Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good afternoon, everyone. Um So, uh thank you for being here and welcome to our robotics and A I session. So we have about an hour. Um We have two brilliant speakers. Unfortunately, our second speaker, Vick Nesh couldn't make it today. Um So we'll have some extra time to talk robotics and training in some of the um the interesting difficult aspects perhaps um we can explore today. So it is my pleasure to introduce our first speaker um Mr Christina Fleming, who is a consultant, robotic colorectal surgeon um in Limerick and has been heavily involved in asset for the past few, well, past few years, past many years, um previous Vice President um naing a lot of asset papers to robotics. So um please give a round of applause for Christina Fleming who's going to talk to us about robotics and surgery. Perfect. So, hello everyone. And thank you, Matt for the kind invite to come and speak today. Um As you can see from my introductory slide, I'm a robotic colorectal surgeon. I'm involved in the robotic surgery training group in Ireland. We probably most importantly, I'm a past um asset VPA national rep and I'm very fond memories of the many years I've been involved, was involved with assets. So it's really great to continue to see the organization going from such strength to strength. So perfect. So, just a few, um, financial disclosures relating to um, robotic surgery. And also, um, I have my little boy here with me today as well. So if you hear any noises in the background, he's prod me very good, but hopefully it won't be too much of an interruption. So over the course of the next kind of 13 to 14 minutes, I'd like to just go through, I guess, um what my experience was as a trainee specifically in robotic surgery and how that role has now changed in my current practice as a consultant who practices robotic surgery and developed into a trainer role. And a few thoughts I have on the future of robotic surgery training, the different things I think we can do to improve the landscape moving forward and some of the potential obstacles that I think we do have an opportunity to overcome. So I guess bringing you back to the beginning and how it all started. So in 2017, I was an ST five and the previous year in 2016, um the colorectal surgery group in Limerick commenced the first robotic colorectal surgery program in Ireland. Um And this was in about March of the following year, they um convened a introduction to robotic skills course for surgical pr s who were interested um in this area of surgery. So this is the first time I had any exposure to robotic surgery platform. And that was um the Da Vinci platform from intuitive. And instantly I could see there was something in this. Um and I suppose like all of us, you get a little bit distracted by this new shiny toy. Um But also I think I could really see the ergonomic benefit of it. Um And from the point of view of visualization as well. And as somebody who was always interested in being a colorectal surgeon and operating in the pelvis, I could really see how this could overcome the complexity of straight stick operating in the anatomical limitations of the bony pelvis. So this was my, I guess journey through um her surgical training from then. So in ST six, I actually worked in the unit in Limerick with um Mr Colin Pierce and Professor Cavin Cy are now my consultant colleagues. Um And during this year, they had, I guess they were approaching their 1/100 case by the time I entered the unit. So there was opportunity for training. Um and something certainly that Mr Pearce would very much have embraced at that time. Um So the first thing you had to do was complete your simulation and then you were, you know, do your basic robotic skills course and then start as first assistant to really understand the tech that you are using and the obstacles that can occur. Um at the bedside, which is very important when you're working on the console and you can't understand why something isn't working out properly. Um During this time, I got some early console work. So starting to mobilize the left colon um during the anterior section or dividing the mesentery and they were probably the two main mainstays of what I got to do. Um on the console, it also gave me an opportunity to do some research. And with research comes an opportunity to learn because you have to read the evidence to know where the gap in the evidence is. So I guess when I went into ST seven, I was in a job where I didn't have access to robotic surgery, but I did have an opportunity to continue on doing research. There was a simulator in the hospital so I could continue to do that. And I had reached the level required to complete the er CAD colorectal surgery course. So I could still continue on my robotic surgery training journey without actually having clinical opportunities on a day to day basis. And it was at this time um during De Ali's presidency that we all started thinking about more broadly, I guess, um how robotic surgery was going to influence training, how trainees were going to get opportunities in robotic surgery. Um and how as it might have a role in bringing that forward as well. Um Josh Burke and a rouge ali were very um important in that process as well. And we got on to some of the work later on. And then I went into ST eight and this year with Professor An Brannigan and Mr John Connely in the ma hospital in Dublin was a very um fruitful practical console operating robotic surgery training year for me, um particularly focusing on colorectal procedures like um ventral mesorectal pexy And then from a general surgical point of view on abdominal wall surgery. And I also completed the or si abdominal wall course during this time. So, following on from my training in Ireland, I went to the beautiful France and the beautiful bordeaux um on an E SCP robotic Colorectal surgery fellowship. So this was heavily focused on rectal cancer. Um So this video clip um is something I looked at every single day posterior tmu dissection. And I think it really demonstrates very nicely how the um visualization benefits offered by the robotic platform. You can clearly see the um hypogastric plexus nerves falling down inferiorly. Um and the measle rectum in the superior aspect of the screen. And this is probably why we get better functional outcomes following robotic surgery for rectal cancer. This was a high volume fellowship. Um also during this time, because of the volume of procedures that were there for training opportunity, you also developed a role as a trainer. So when you learned to do a step in a case, then it was your responsibility to train the more junior person how to do that step while you advanced on to the next level. And I think that kind of culture and ethos of training in parallel with each other is something that I really saw the benefits of and something that I've tried to embrace now in my consultant role as well. And it offered a huge opportunity to collaborate with other colleagues in other countries um who have, who have been a huge technical support to me in establishing my robotic colorectal um practice. So I think I had a really good experience, robotic surgery training, both of my training and fellowship. But if I reflect on maybe some of the things that weren't available and could have made that better, I didn't have a curriculum. So I didn't have, you know, a pathway to certification, which also meant at the end of it all, I had no proof of my proficiency. And whilst I did have a log book and I did CT but I didn't have anything that specifically mentioned robotic surgery and that actually becomes very important from a clinical governance point of view when you start your consultant practice. So looking at my current practice and role, I'm now a consultant surgeon. I do a lot of robotic colorectal surgery. I also deliver the undifferentiated general surgery um call cover as well. Um But specific with regards to robotics. Um when I started as a consultant, I did have to get a certificate of equivalence from intuitive just from a governance point of view to demonstrate that I had actually um achieved what would be I guess considered the same as a consultant who was trained in robotic surgery. Because the difficulty with training in robotic surgery up to this point is that it had all been industry driven and it had all been focused on consultants. So there was no pathway or certification available for trainees. So a huge amount of valuable training wasn't being recorded or awarded. Um In my actual role, I'm really focused on focusing on trying to expand the surgical indications for robotic surgery. The more we use it, the more efficient the theater team becomes and the more training opportunities we create and then from an educational point of view, we're an approved E SCP fellowship site now. So we're hoping to get our first uh fellow in the summer months. Um We recently published an E SCP guideline on training in robotic colorectal surgery. I think that went online in Colorectal disease last week. And we have established a na national advisory group to really put a structure on robotic surgery training in Ireland. And I'll come back to that again later on. So I think this is probably a short summary of some of the more maybe traditional procedures and emerging procedures that we commonly perform in colorectal surgery um robotically. Um And over the course of the next two slides, I'll probably just focus on three procedures. The first being a robotic anterior section, which I would really view as an index training case in robotic colorectal surgery. And then um robotic mesh rectopexy. I think the robot was actually just designed to do this operation. Um And again, it'll just demonstrate how it really overcomes the angulation um when you're operating low down towards the pelvic floor. And then finally, um a robotic pelvic ext with vaginal reconstruction. Then this is a really good example of how now that we're used to using robotic surgery, how we're increasing the surgical indications for its use um and particularly in multivisceral resections. So um robotic anterior section, an index training case in colorectal surgery. Um It's very, this very much lends itself to a modular approach of training. So, you know, when the opportunities maybe aren't as numerous, there's certainly an element of the case that everybody can do and you don't necessarily have to do all of these steps in the one case. But if you can do each of these steps, you can put together to do the, the full procedure. And before I show this video, I just want to mention Darra Walsh, we're very um uniquely um blessed to have a medical illustrator um employed in our department who actually has a, an office in the operating theater complex. And this is hugely important for us from the point of view of training and from the point of of augmenting our training images and 3D printing and all the other fantastic things that he he he does. So this is actually a case I did um part of with as an SPR when I worked in the unit. Um And you can see my consultant trainer is showing me where the um left colic artery is. I had done the posterior and inferior dissection made a window to divide the I MA and we use this for training purposes um with some onlay art as well that Dara has done. I certainly didn't do any of that, but just to demonstrate um where everything is. Um And then as we come down to the retrovaginal dissection again, I'm a little bit off the plane here. Um So my trainer is very much bringing me into the correct plane using the arrow and the pointer. And that's a really important element of robotic surgery, the dual console element. Um It really, really supports training and learning here. Again, I go to do the transection but the Nova dac and immunofluorescence system is obviously built into the da Vinci. In all cases, I'm a little high. The perfusion isn't excellent going up to the um the stapler here, so I can move that, move that um down a little bit to ensure perfusion of the, the distal stump. So I think all of those little adjuncts that the robotic platforms bring are very important from the point of of training. And having you know, an anti resection is an index case with the modular approach also lends itself to that um this case, II mean I think the robot was built for this from the point of view of robotic surgery because eventual me recopy is a quality of life operation. There is no room for error and if error occurs, it needs to be very minimal. So we need to be sure we have the most optimum tools to perform this operation. Um On the right, you can see um a dynamic MRI for this woman who is 40. Um and she was, she was a very small radiologically, very small rectocele um but was having a lot of issues with fecal incontinence during sexual intercourse. So this is obviously a big problem for her. So um we decided to perform a ventral mesh rectopexy and you can see here we're operating down and anteriorly in the pelvis in a plane that is very, very thin in a young woman. So you can see the plane between the vagina anteriorly and the rectum posteriorly um is very, very thin but very, very clear using using this um system then with regards to mesh placement at the level of the sphincter. Um There's a couple of things to consider. Firstly, we're actually looking up an anterior um and we only use biological mesh in this setting, which is very difficult actually to get a needle through biological mesh. But the ended instruments really helps that. We also have a dual instrument here where there is a scissors. So you can actually, after suturing cuts straight away because when you're putting on a lot of sutures that takes a lot of time off of your surgery and then we just, um, hitched the rectum up to the presacral fascia here. And we have done a Delphi, um, with um I think there's about 25 pelvic floor surgeons throughout the world in the US. And Europe who participated in that it was performed by Ta Keating when she was actually an intern um in her group in the matter. Um And, you know, cer certainly the surgeon reported benefits of the robotic platform for performing this surgery um are undo doubted. Um And I saw recent evidence as well that the mesh erosion rates are slightly lower in robotic surgery um when this procedure is performed compared to laparoscopic. So, going on to the next procedure and I guess this is really where we're marrying index cases from different specialties to expand the surgical indications in robotic surgery. So, again, this is a 42 year old woman who has a large low anterior rectal tumor that's invading her vagina. And um right down to the um the um retrovaginal space, right down to the pelvic floor. Um This woman really was keen not to have a stoma. Um And from a body image point of view was quite keen to have um you know, a neovaginal orifice of some description at the end of her procedure. So from an oncological point of view, she required what we describe a posterior pelvic accentuation which is a combined low anterior section with at and BSO. So we did this case robotically. Um So I guess one thing to think about is the hardest part. One of the hardest parts of the anterior section is maybe the anterior dissection because you don't want to injure the vagina. And one of the hardest parts of a ta is the posterior dissection where you don't want to injure the rectum. But actually, when you're taking these things out on block, um that reduces the complexity of the case actually as opposed to increasing the complexity of the case. So this is our standard posterior dissection for um the um TME and I think we can probably already dissected the vessel there. Have I skipped? Yes. So we've already done the vessel. Um And now we're doing some lysis is the tumor was lying a little bit um close to the ureter on the right side. So that's the ureter there. We're just dissecting that out very clearly. This is anterior dissection in front of the uterus. And as you can see here, we've continued to that down inferiorly. Obviously, we're leaving the bladder inside you. Um as it wasn't involved in the tumor, we're now dividing the mesentery because we're going to deliver the entire specimen um transanally. So here we're doing a, a low intersphincteric dissection um because we do want to do a delayed coloanal on this lady. So we're not, we're not doing an APR, so we are maintaining the anal canal. So we started the dissection. Now we're just going to close the lower rectum. And once we have that done, it will start to do the anterior vaginal dissection, which here you can see we're just uh disconnecting the vagina inferiorly and I will deliver the entire specimen on block um with the anterior section and the T HBO, it's going to divide that for the moment and we'll come back to how we actually manage that. Um afterwards. So now at this point, we're going to create a neovagina using the small bowel. So we're going to pedicle that um in its position. Um So maintain its blood supply from the um the mesentery of the small bowel. And we just did a side to side stapled anastomosis to continue the continuity of the small bowel. And we're just going to open this up along its anti mesenteric border and to um clearing all out and then um invert it to or event the, the small section here and close it and then we'll invert it um before fashioning it um at the new vaginal orifice. So that's what it looks like. At the end, we just put some swabs in to maintain its shape and also to reduce hematoma formation. So I'll see, you can see the small bowel anastomosis just above it as well. So it's still on its pedicle. We've delivered it now um And are suturing it in place to the new vaginal orifice. Um And that will form essentially the, the new vagina at the end of the case. Um So this isn't a functional issue, this is just a structural reconstruction. Um But from a body image point of view in young patients who have cancer, this can be very important. And now we're just looking at the perfusion of both the um colonic proximal clonic chondria and the um the neovagina at the end. And as we can see, there's some good um and good perfusion there. So we're going to delayed coloanal anastomosis. So we literally just sutured the colon in place. Um And now we're just suturing the um the neovagina to the protein reflection to prevent a prolapse. Um Then four days, I don't actually have the four days POSTOP um video, but we come back and we actually just remove the redundant element of colon and perform a delayed hand Coloane anastomosis. So I think that's just a reflection of maybe some of the really useful areas for robotic applications in colorectal surgery and also that it's really expanding, it's facilitating multidisciplinary operating um and the benefits in training. So looking at future directions, I mean, we have to embrace somewhat element of technology. We're living in a tech generation. Um And this is part and parcel of surgery. Currently, it isn't actually the future and the digital surgery era is here now, we're not waiting for it to happen. Um But how we embrace it, learn about it and implement it is um probably where we're falling behind a little bit. And I like to think of this as a continuum. Each element of these types of ways of performing surgery are all still important in a certain place. Um So no one is replacing the other. And I think it's important to say that and when we talk about digital surgery in particular, generally, we talk about the five pillars of digital surgeries. So looking at advanced instrumentation, enhanced visualization, robotics, connectivity, data analysis A I and machine learning. But I think we have a really good opportunity with robotic surgery as a vehicle to actually learning and delivering digital surgery. And it's probably something we're not tapping into enough at the moment with regard to the future. Obviously, um Josh Burke, um he led the report on the future of surgery, technology enhanced surgical training. And I think one of the key message I would take from this executive summary of the report is that there needs to be collaboration between patients, trainees, trainers, industry and educational stakeholders to support the development of a technologically enhanced surgical practice and surgical training. Um And then Charlotte is obviously, look, you know, looking at this with all of the key stakeholders involved as part of her phd in her role as the R cs Hee Robotics research Fellow. And I think um I would hope reinvent will identify as what each subgroup probably perceives as the obstacle to progress. But then all of the other groups will probably have answers to how to overcome them and actually putting all of that together in the right people in the right place. And I guess from the point of view of actually, you know, delivering robotic training in a very structured way, in an equitable way. And this is something that we were very interested in and asked it during my time there. And I was doing Martin King's presidency and that we delivered this Delphi process looking at, well, look how could we practically do this, um what's important, what's not important, what should we maybe leave for specialty um associations or what should the college take more of a role on? Um So, you know, a preprocedural core curriculum is probably something that could be standardized, pan specialty. Um But even in the short time since we did this work, I think my opinion on device training in particular has massively changed. And, you know, there isn't just one show in town anymore, you know, obviously intuitive and the Da Vinci platform was very much the leader in the field at that time. Um But now you know, there are three platforms in clinical use and practice. And I think looking specifically at platform agnostic training, you know, today is, is is very relevant. Um Helen Mohan who is a past president of Acid as well um is the current of Clinical Research at the International Medical Robotics Academy. And they're working with a lot of really interested people in robotic surgery training at the moment, aim, you know, trying to develop these platform agnostic training pathways um and supplying some fantastic hydro models to do so. Um And we're really looking forward to delivering the first one of these in Ireland on the 27th of April in my um home hospital in Limerick. Um at a national level, obviously, you know, I think probably the College of Surgeons in Edinburgh and um obviously, the surgical community in Wales have very much embraced a national approach to surgical robotic training, um robotic surgery training. And we've kind of started this as well in our CSI. We're a little bit behind the curve. Um So we have a national advisory group. These are the members I sit as the general surgery specialty lead. We have training representatives QA um the director of the surgical training programs. And I suppose what we our overarching aims are to develop somewhat of a hub and spoke infrastructure for develop for delivering robotic surgery training to have a structured curriculum so that everybody has the same access and a a very clear pathway to certification. Um But really, we're very much at the early stage of this challenges and barriers obviously as is published on this previously. And I see that there is another up to date survey that's circulating at the moment because it's really interesting to see how a lot of these things are changing. The consultant learning curve probably isn't as much of an issue anymore. Lots of people are returning from fellowship totally proficient thrombotic surgery and it's their primary method of operating now. So I don't think that's probably as much of an issue. The same probably could be said for expense because now there's a competitive market, whereas there wasn't a competitive market, probably around the time that we started looking at this, it will always take additional time to introduce a new technique, a new technology. And there will always be that fight between using the robot and acquiring skills in another way, be it open or laparoscopic. And I think getting the balance right on that, we probably haven't fully addressed and, you know, equity in health care access that's not just relevant to robotic surgery that's relevant across all elements of medical care. So to summarize, I think I went a little bit over time, but um just to look at the past with regards to robotic surgery training, this was always very industry driven training, it was very unstructured, it was opportunistic. Um and depending on where you trained geographically, you know, that really dictated your learning opportunities. But I think now, you know, we are increasing the surgical indications, more and more surgeons are actually using robotic platforms that obviously increases training opportunities. There is a big push to develop a core curriculum, which I think would be very important from a training point of view. But very importantly, there is increase in college leadership in robotic surgery training. And I think it's very important that we do transition to the colleges actually taking ownership of this as opposed to allowing it to be totally industry driven because unfortunately, when it is industry driven, the trainee isn't as important in um stakeholder in that um relationship. So for the future industry partnerships will always be important, but it's important that the power differential in that industry um relationship is actually um balanced and that trainees are placed centrally in that. Um I think widening access, having regional solutions, which is what we're trying to do um will really help. And I think using robotic surgery to deliver digital surgery models of care um is a really good opportunity because they are now present in many hospitals. So I think it's something that we need to just push on and embrace. So, thank you for listening. And I think we're going to have a panel discussion at the end for questions. Thanks. Thanks Christina for a, a brilliant talk. Um We look forward to discussing it a bit more at the end. So it's an absolute pleasure for me now to introduce our next speaker, Mister Chris G. Um Chris is an orthopedic consultant in Glasgow. He's also an associate medical director and is very heavily involved in medical education and advancing the standards of medical medical training. So we're very much looking forward to his talk on um uh robotics in orthopedic surgery. Thanks Chris. Thank you very much. It's an absolute pleasure to be here today and it's been great to meet so many trainees in surgery across the spectrum. And I'm delighted to have the opportunity to talk about passion of mine, which is orthopedics and specifically robotics in orthopedics. A few disclosures. So as part of my role running the teaching program for the registrars in the west of Scotland, I have to get educational grants to support that. So none of those are really relevant today, but I do do some consulting work for Manuka. Um And I'll start off talking a bit about where I work and, and what we do in terms of NHS Golden Jubilee and robotics. Um and then give us sort of an overview of robotics and orthopedics. Um And then going into what I know most about which is robotic joint replacement, uh surgery. So this is NHS Golden Jubilee. It's funny hospital. We don't have an A and, but we do have a hotel, a conference center and spa on site. It was a private hospital built 2530 years ago, that didn't really succeed and was sold to the in Scotland and has been used as a center for high volume procedures basically ever since. So we have thoracic surgery, general surgery, endoscopy with a national training program for endoscopy ophthalmology where they do 30 per cent of Scotland's cataracts arthroplasty, where we do 25 per cent of Scotland's joint replacements. And then as a national hospital with those hotel facilities, we can treat people from the borders, from Dumfries, from Shetland, from the Western Isles, which means that we're a center for some low volume, high complexity work particularly on the cardiac side where we do adult congenital work. And also last year, I think the team achieved 40 heart transplants. So it's a mixed bag, but it's all about high volume and good patient outcomes. And that's where orthopedics comes in and where robotics come in. So last year, the highest volume Mao Robotics Center in the UK. And we're just about to hit 2000 cases of robotics, which is quite high in the and it's a great place to work. Obviously, it sometimes looks like this but mostly it rains. But obviously, I chose the pictures carefully to make it look as good as possible. And it's always been a place that pioneers new technology and innovates. And on the top left there, there's Professor Fred Picard. So he performed the world's first computer navigated knee replacement. And I'm proud to say he's one of my colleagues, a lot of the technology we use in robotic orthopedics today is based on the work that he did during his phd that brought computer navigation and now robotics and arthroplasty to life. And by having robotics in orthopedics in the NS, it's a fantastic opportunity for us to train. And while it's traditionally seen as something you learn as a consultant in orthopedics with our trainees, we now provide a free cadaveric robotic course for all our new trainees every six months. And some of our trainees get the opportunity to certify. And occasionally we even get the opportunity to train politicians on how to use a robot. So um very much our department is of the mantra of no training today, no surgeons tomorrow. And we're delighted to be expanding the number of trainees and fellows that we have within our department. And with this interest in innovation, navigation orthopedics, we are involved in the computer assisted orthopedic surgery society. So if you're interested in joining the QR code next year, there's plans to put on a conference all on robotics and computer assisted orthopedic surgery. So I think that would be included in your membership. So just a quick plug there for a society that I'm involved in so on to robotics and orthopedics. Um you can see here from this graph on the on the right that the number of publications, the amount of interest in robotics in orthopedics is really taking off and it's not just joint replacement surgery, which is what I do, but actually, there's a lot of evidence for the benefits of robotics in orthopedics, particularly with spinal surgery. If you think about how small the pedicles are in the thoracic vertebrae and you're trying to thread a screw down that kind of narrow pedicle. And if you go too far in then, you know, there's this big blood vessel just behind the vertebrae, you probably don't want to put a screw in. And there's this thing, you know that the vertebrae protect the spinal cord, you probably don't want to put a screw in there. So if you've got technology that can allow you to place those screws more accurately, then you absolutely, you should use it and the evidence would support that joint replacement surgery. It's all about how can you be accurate, how can you reduce your risk of complications of revision surgery? And increasingly they're looking at options of using robotics to assist in arthroscopic surgery and even in trauma care as well with fracture fixation and how you put the bits of bone back together again. And there obviously benefits with robotics and orthopedics. So you can develop pre operative plan. I'll show you some examples of that. We know it's more accurate. In theory, there's less soft tissue damage debatable. It's not as minimally invasive as going open versus laparoscopic when you do a knee replacement. It's still very open. But potentially, there are reasons why there'll be less soft tissue damage, potentially improved, implant, survivorship. So, fewer surgeries, if you think back to the green surgery talk we were hearing today, the best thing we can do is not operate on patients. So if we can reduce our redo rate for surgery, then we can reduce the green footprint for our surgery as well. But it's also a fantastic tool for providing data And I'll show you some examples of that, but it's not foolproof. It's costly. Currently, it's mostly in the private sector. I'm fortunate enough that I work in an NHS institute where we have access to robotics, but that is not where things are mostly in the NHS. It's a work in progress. I think we're behind general surgery, colorectal colleagues in terms of the amount of access there is to robotics. Some of the some concerns around how long the surgery takes. Although with experience, you definitely become time neutral or if not quicker because it's so reliable that you just, you just go through the steps, you don't have to go back, cut twice, check twice. It's just you follow the steps of the operation and you get the same outcome every time. And in terms of patient reported outcomes, the evidence is debatable. There are also potential complications from using robotics. You make additional incisions into the patient and as much as it's very accurate, we don't actually know what the target is that we should be aiming for. So if you think about the dartboard analogy with robotics, you'll hit the balls eye every time. But what if you actually needed to hit triple and 20 we don't actually know exactly what we should be aiming for yet. But you know, this is one case and you don't need to worry about all the different um technical um data points here. But this is the data that we're collecting or part of the data that we're collecting for every single operation. And if you think a million mao robotic cases have happened globally so far, each of these data points, there's a million of them and that's where it becomes really exciting because robotics actually gives you the data to use machine learning and artificial intelligence to understand what the target should be for patients. So, I've, I've built in a little bit of audience participation. I've not done anything like this before. But um could everybody in the room just stand up for me? Would that be OK? Or just stand up? Excellent. Right. Thank you very much. That makes this bit work good. Right. So I want you all to stay standing if you drive a car. OK. So most people drive a car right now, if you drive a car, stay standing, if you use satnav. OK. So most people will use satellite navigation. Now stay standing again. If er the SAT NAV has ever kind of got you out of a tricky situation, you know, you've avoided a car crash or you've avoided roadworks because of that Satnav. And it's got you to work on time or it's got you way of going. Ok. So that's good. Um, and also to stay standing as Satnav sometimes failed you as well. Occasionally, you know, you, it hasn't picked up the fact that there's an accident and you've kind of wishing you'd not gone the route that Satnav told you. Ok, good. So, and when that happens, stay standing. If, uh, if you continue to use the Satnav, after it still stops working on you that one time. Ok. Good. And then the last one is, um, stay, uh, sit down, er, if you, er, have a driving license to drive your car, right? So the point is that robotics doesn't take away from the fact that you need to know how to do these operations, but robotics and navigation is exactly that. It's the same as your Satnav. It helps you understand the route, the path to giving each patient that best possible outcome. And it relies on data. So some of you might use Google. So Google relies on other road users and their data to give you that best information. That's what tells you what the traffic is like. And some of you maybe use ways for example, and that's actually real live data from other road users telling you what the accidents are. So it's all, not just the navigation but the data that comes with it. So this is what I use. This is the mao um robot by Striker. It's probably the most comprehensive orthopedic robot that there is um it's based off a CT scan. So all our patients get a CT scan before and you get a preoperative model that tells you what you want. So you know, more before you start the operation because you know more you can plan your cuts more carefully. And we also have uh involved in this that actually stop haptic technology, which essentially creates a barrier that stops you cutting beyond where you should be cutting on the bone. And because you've got that model, because you know more the robot knows what exactly the shape of that bone is. And then postoperatively, you can start to collect data on your patients as well and you can bring this all together with data analytics and there's evidence out there and it's a growing body of evidence that shows that it's definitely more accurate that there is some evidence, it reduces soft tissue damage. And there's some evidence that implant positioning and outcomes are improved as a result of that, there's cost effectiveness analysis, which is really important for the NHS, which is starting to suggest that it does reach the required quality parameters to justify its expansion in the NHS. But long term follow up is something we love in orthopedics, big data, big numbers. And the longest follow up for robotics is the Australian Joint Registry. And you can see here that robotic assisted partial knee replacements are increasingly common and obviously non robotic. So, and you can also see this divergent graph of implant survivorship which shows that there's a statistically lower rate of revision surgery if you do robotic, partial assisted knee replacement over non robotic. And while it doesn't look like very much, this is about 25% reduction at five years in the number of revisions that are performed for patients. So it's quite a significant reduction when you think about the number of joint replacements that we do. And again, you can see here for total knee replacements that not technology assisted is now less than half. So more than half of the joint replacements going in in Australia have some form of technology and robotics is easily taking that over. And again, you can see the graft diverging here showing a change and a reduction in revision rates. So I've got some examples and I'll just go through those. So just to talk about hip replacements for those non orthopedic surgeons in the room, we want to restore a hip center. We want to restore the offset which is the distance from the anatomical axis of the femur to the center of the hip. We want to restore the leg length and we want to correct the combined the correct combined anteversion to reduce the risk of dislocation. And you can see from this case here that we were able to restore that leg length and restore that offset through robotic assistance. Combined, anteversion is a harder one. But you've got this femoral anteversion in the in the femoral neck in relation to where the knee is. Um And you can see that the acetabular also has an anteversion angle and in patients with spinal pathology, which often have when they have a um when they often have arthritis of their hips, um that can change the position of the cup, whether they're seated or standing and that can have an impact on dislocation rates. So, if we have improved accuracy of our implant positioning, in theory, we'll have a reduced dislocation rate, improve leg length accuracy, improve long term survivorship and better function outcomes for our patients. And you can see the studies here showing that if you aim for a target with robotics, you're much more accurate than if you um have a go yourself without. And this is a case from Friday patient. You can see you get this 3D model of the hip tells you that they're one centimeter shorter. And the femoral heads actually been pushed out due to osteophyte inside the acetabulum, which is why their combined offset is increased. You can plan exactly where you're gonna put your cup. So you can have an inclination angle, a a version angle. It tells you how much bone you're taking away you can make sure you're not going to ream too much or too little. And it even gives you a sort of a, a mock up X ray of what your hip replacement will look like afterwards, which is fantastic. The knee replacements, what I do more of, to be honest and for knee replacements, we want to get a well aligned knee and a balanced knee. So we talk about the gaps when the knee is straight, our extension gap and we talk about flexion gaps when the knee is 90 degrees and what you want square gaps, because that's in theory, what's going to give you a good functioning knee. And traditionally, we would talk about the fact that we've got people who are varus with bow legs, people who are valgus with not knees. And that's all there is in terms of alignment. Well, actually, increasingly we are wondering, well, why are 20% of our patients still unhappy when we do these knee replacements? Some of it will be expectations, some of it will be patient selection. But actually, when you look at patients' knees, there's a lot more to them and there's a lot more complexity than straight varus or valgus. And there's this classification that looks at joint line obliquity. And there's huge variation in the population in terms of what their alignment is and what their joint line obliquity is. So, rather than always aiming for a straight knee, the patient's never had a straight knee and they've always had an oblique joint line. If you can, if you can reproduce that, then potentially your patients will have better functional outcomes and better long term survivorship. So, this is a young man and I treated recently, he'd had multiple ACL surgeries, I think three in total, including with a carbon fiber ACL, which is a horrendous implant. So you open up the knee and everything's black from the carbon fiber, terrible arthritis in his knee. You know, there's a screw in there, there's a wire in there. You know, do I know if I'm going to be able to get past them with the operation? So I get a CT scan and then he starts to see actually, he's got a lot of bony destruction as well. Um, and do I actually need even, you know, more complex implants to fill that, that hole in the bone that's been left from his uh previous ACL reconstructions. And I can get a plan like this that actually shows it's not too bad when you look at it in a sort of 3d structure. I can see that my implants aren't gonna hit the, er, hit any of the screws. So I don't necessarily need to think about taking that metal work out either at the time, which could be quite destructive, increase the length of operation, increase his risk of complications. Um, and you can see again, the scale of the kind of changes in this bone, but I can plan the operation, um, see what my cuts are. You don't need to know these numbers, but they're different from what you would normally necessarily plan if you're doing a standard knee replacement or what you think you might be doing if you're doing it manually. I mean, to be honest, you're just guessing cos you're just putting jigs on and hoping for the best. But, um, with this, you get a very accurate um judgment and you can tweak your uh various angles and resection measurements to and get a balanced knee. So these are the gaps between the bones in flexion and extension with the implants in place. Um And that's kind of what we aim for, which is about one mil, which essentially should give you a well balanced knee at the end of the case. And by knowing more and cutting less, I'm able to use less complicated um implants. I can avoid having to take metal work out, avoid another operation and improve the outcomes for this young patient who will probably at some point in his life have another surgery and I've kept things nice and simple for him and you can see his joint line obliquity there. Another pe teacher, previous ACL uh injury and reconstruction you can see is about 1415 degrees, quite significant valgus I use maker avoid having to take out the femoral screw cos I can plan to see it's not in the way. Um And this is a pe teacher, high demand, high expectation with a forgotten joint score of 100 which essentially is, he doesn't know that his knees replaced the vast majority of the time, which is fantastic. And what about this 39 year old, same age as me? Um, he's had significant problems with his patellofemoral joint. He's had surgery not necessarily performed that well. Um But you can see he's got horrendous arthritis of his patellofemoral joint. And most people would plan to do a total knee in this patient or just leave him disabled at 39. But through robotics, I can do a more minimally invasive resurfacing of his patellofemoral joint, leave the rest of his knee alone. And when he, when he comes to his revision operation, which is inevitable when he's 39 you know, he's got another operation in the bag and we can get things nice and accurate. And you know, for this 39 year old cos II know them well, I know that they've um had a fantastic outcome and they've got that quality of life back with their young family. And then this is a patient from Wednesday. I filmed my colleague Mr Oley. So I'm very grateful for him for letting me film him. And you can see this lady's got patellofemoral arthritis and maybe a little bit of the medial oa, but we weren't sure. So we have a plan to do a medial unicompartmental knee replacement and patellofemoral replacement. You can see we've got some resection measures there. Um in terms of how proud the implant plants are the flexion extension, er, the size is the rotation of the implants. Um And you can see the kind of plan that you get here. So this is just the, the tibial plan for the partial knee replacement. You can see how it fits on the bone. You can make sure you've got the right size before you start. Uh You can make sure your reception depths are great. You can see what the slope is of the natural tibia in relation to your implant. Um And then you can see again the same thing with the femur, you can plan to get your patellofemoral replacement and your uh medial femoral replacement both in the knee. You can make sure the implants aren't in contact before you start and you can kind of identify any problems before you really get there. We arthroscope, the lady and found that she had a medial femoral condyle osteochondral lesion. You can see there on the right and her patellofemoral arthritis on the left. So we plan to do that by compartmental replacement with Mao as Mr Oley with the trainees on the left doing the operation and you can see that hole in the femur that I just showed you arthroscopically and this is the set up. So there's Nathan one of our trainees doing robotic arthroplasty. You've got the robotic arm and the robotic array on the left, you've got arrays in the femur and the tibia that communicate with the camera on the right. There's a screen for the surgeon to look at and there's a screen for the mao product specialist. So someone from the company that's highly trained to understand how the, how the robot works. Um And he's mapping out the bone. So he's taken all of those green points and those green points match the CT scan. And that shows that what he's looking at and what the robot's seeing is within 0.3 millimeters of what it thinks it should be seeing. So that's highly accurate if you think about it in terms of what you're wanting to achieve. So then you can take the knee through a range of movement and you can with your implants kind of planned provisionally in place. Um And you can capture it at different different stages of uh flexion and you're capturing these poses as it goes through. Um Just seem to have paused there for a second, carrying on. Um And this will give you what the kind of balance of the knee is. Um If you like with a graph which you'll see in the top right in just a second. Um And this gives you the gaps are between 1 to 2 millimeters there, and then you can adjust the positioning of the implants to get the best outcome for your patients, you then go on to prepare the bone, having done that balancing and you see that haptic boundary there. So that's protecting the back of the knee. I believe there's some, er, uh, some clockwork at the back of the knee, you probably don't want to put a sore into and also the M CL, which is protected. So if that, if that sore blade touches that haptic boundary, it will just turn off, it will, it will stop. And if you try and force it, it will not let you go through past that boundary. So it really is very well controlled and actually makes it really fantastic for training because your trainees got that haptic boundary keeping them safe. And you kind of saying, I guess, um and again, you can see it here, you know, soaring through the back of the knee, protecting the protecting the bone, you've got that haptic boundary, which is fantastic. Um For part of the operation, you can bow it out. So you can see this thing that says orientation control. So you're burring the, the pegs for the implant very accurately again, and buring buring out the rest of the bone. And again, you can see Nathan plugging away on his, his bicompartmental knee replacement. And again, you can see the kind of interop uh final pictures here and you can see some of the data again that we can collect and then we'll follow the patient up, we'll collect their proms scores. We'll bear in mind their asa obesity, their frailty scores, their age, everything. We collect all of that data and we piece that together. That's what will give us our answers. So in summary, robotics is more accurate, potentially better implant survivorship, as we've seen on the Australian joint registry, potentially better function for the patients as well. There is a need for more research and follow up required. Um I think it will be the future for orthopedics and particularly arthroplasty in the spine and it's not a consultant only procedure anymore. This is something you can learn during your training, which I think is fantastic. And you know, as I said, at the beginning, we're delighted to have so many trainees now joining our department when historically, that actually wasn't the case. So any questions, I guess? Fantastic. Thank you so much for that brilliant talk. I know nothing about bones. So it's great to see how the robot works. And it's really fascinating to see the differences between general surgery, robotics and, and orthopedic robotics. Um So we've got a few minutes for, for questions from the audience, we have a roaming mic. Um But what I would like to ask both of you, first of all is Christina, you, you, you mentioned about digital surgery surgery 4.0 Each year we see more and more cool technology coming out. How can we be sure that we are doing this in our patient's best interest and not just using technology for technology's sake. Um Thank you, Matt, an easy question to start. Um Well, I mean, first and foremost, with surgery, surgery always has to be safe. And, you know, I think that's why it's really important. I spoke there about the colleges and their role in all of this and quality assurance. So we were the head of quality assurance within the R CSI in Dublin is a key member of our a national advisory group with robotics. And I think that's very important because ultimately, you know, we have to create a framework which we'll hopefully do now with robotics and that is quality assured, that is safe, that protects patients and protects surgeons for, I suppose, efficiently introducing new technologies when they arise. And unfortunately, we don't have that framework now because what happened is hospitals who could afford a robot, bought a robot and introduced the robot under the governance structure of their hospital, but nobody in the wider surgical community at a national level actually gained from that. And for some reason, everyone is continuing to reinvent the wheel. But what we are, I suppose striving to do is have a national approach and a national framework, you know, for, you know, I suppose managing the industry relationships. Um you know, the the I guess pathway for introducing the new technology into a department and then the follow up, you know, the phase three, the phase four the long term follow up. And then obviously I do think it is the colleges um that have the responsibility to ensure that we deliver this in a more structured way. So Chris, any thoughts? Uh yeah, I think um yeah, you can hear me. Um, I think in orthopedics there's a long way to go in comparison. Um It is most widely used in the private sector and it is a case of private hospitals being able to afford a robot, buying a robot. I think surgeons that then go on to use it robotics in the private sector. Um When they don't use it in their NHS practice. Um I II find it's something that's quite challenging. I don't do any private practice. Um And I think that it, you know, really, we should be kind of thinking a bit about what we, what we're doing there. Um To be honest, I think that, you know, the NHS is the place to introduce these technologies through robust research. There is a, currently, there are currently two robotic uh NIH R funded studies. Uh The racer trials, there's Razr hip and racer knee. Um while they have some design flaws, they're better than nothing. And it's a start um I guess the challenge will be if they show a significant benefit, then you could argue every patient in the whole of the UK should be having robotic assisted arthroplasty. So how do you go about instituting that across the whole of the NHS because the robot that we use costs not, not too far shy of a million pounds, so you can extrapolate that out. It's a lot of money. That's great. Um So we just, we've got a few minutes left and we want to open up to the floor. If there are any questions, we've got a roaming mic. Uh That was me asking a question actually. Um So, um thanks so much for two phenomenal talks. Um, robotics is quite an exciting area. Um Just a question for both of you quite broad. Um What do you think if there was sort of one or two main reasons why there's any push back um for robotics, you know, just being kind of disseminated nationally as, as part of our practice. Um What, what would either of you say it would be the main reason if you had to pick one. Um So there's a lot of skepticism about um, orthopedic robotics, particularly joint replacement surgery. Um There are a lot of surgeons that will say in my hands. Um I do a great joint replacement with the, with the jigs and I don't need to, um I don't need to improve it. I appreciate their complication rates might not make them an outlier, but the fact is they'll have patients where, you know, each human error adds up and if it adds up in the wrong direction, you know, one degree here and then two mils here suddenly they find themselves in a scenario where they haven't got an optimum outcome for that particular patient. And, um, I, II don't know how to really challenge it, but it's, it's, it's problematic. So there's just that skepticism of, um, and II think some people quite, quite like the thought that they're, they're, they've got good hands. I quite like the fact that a robot can do, do the hands for me within 0.5 millimeter of accuracy. I'm, I'm quite happy to put my hand up and say I'm not that accurate with a. So, um but yeah, that's, that's the biggest challenge is that's that natural skepticism to any new technology. So I think um in colorectal surgery, you've actually moved beyond the pushback phase. So if I reflect on the push back, those that didn't have a robot thought it wasn't useful and those that had a robot thought it was useful and those that didn't think it was useful now they have a robot are embracing it. So, um I think initially that was a big issue and then issues around time. But obviously, the more you use anything, the more the entire team gets more efficient at using it. And I also think from looking at surgery more globally, you know, it's fine to say that, you know, laparoscopy is just as good as robotic surgery, but we're not going to have the same volume of, of laparoscopic practice, our volume of cases in general of surgery in general to train the increasing number of trainees and also our workforce is increasing. There are more consultants, we're all not going to have that volume that's needed for that learning curve. And actually it is easier to do things robotically. It's easier to train robotically. So that is also addressing that specific system problem. We've got time for one more question. I think Mr Breer, you're teed up with the mic. Thank you. Can you hear me? All right. Great, fantastic, talks amazing, amazing work. II was just gonna pick up on the previous question, robotic. I don't think it's only an exciting um field. I think if you think that you're weak, you, you, every week won't involve a neuro trainee and you, every week won't involve robotics. You should sit beside those who used to think that laparoscopy would not catch on. Um But, but II wanted to pick up on, on, on the fantastic book that Christine did with her training. You started robotic head on, on your training fairly early as a registrar. And that's, that's, that's a great opportunity and that's, you know, very commendable. The first question is, how did you manage to fight your way from the patient's bedside? Holding a suction and changing the instruments all the way down to that um site console during your training. So that's question number one. And question number two is how are we going to do? How are we going to allow our trainees, our junior trainees, our sh OS if you in my time, if you hadn't done a lap appendix or several laparoscopic cystectomies, that's an sho you were far behind. How are we going to do that with robotics because we are going to have to do that. So, with regard to the first question, I pushed an open door and actually, I was very intimidated by using the robotic platform at the console because I was very early in the learning curve of my elective colorectal surgery training in general. And I was told by my boss, sit down there and mobilize the left colon. And I actually was a bit intimidated by that. So I just sat down and I did it. So I guess that was probably the culture of maybe a consultant who came home from their fellowship training and started their practice proficient in robotic surgery. And that's the increasing culture that we're working in now. Um So there was no fight, I was probably pushed as opposed to having to jump. Um And with regards to the second question, so this is something I feel also culturally, I really learned working in France. Um And this is because of my boss, Professor Quentin Danos, he was all about parallel training. So from, you know, early stage sho to late stage fellow, everyone had something to do in the case. So, you know, once I was happy with that, I had reached proficiency in mobilization or doing the posterior to in me, then I would train the person a step behind me. So that by the end of the year, the sho was doing the lateral mobilization. And I think traditionally, we always thought that was my, that's my training case. But actually every case now with volume it needs to be shared and each stage of the case or module of the case needs to be given to the right person. And I actually found the byproduct from all of that is everyone is really happy and everyone probably creates a really nice environment for everyone to work and learn. Um And that's something that I'm trying to do now in my consulting practice as well. Um But it's a bit of a culture change and a change in mindset. I think so. Yeah, perhaps we shouldn't fear that much those physician's assistants or surgical, you know, professional surgical assistants who would probably take that place beside the patient and release the trainees to be on the console. So maybe that's, that's a thought to be implemented. And it is also important to do some bedside training because when you're sitting at the console and something is not working, you need to know why. And you know, I know even like Professor Jim K as part of his fellowship program, you know, everyone has to do a minimum of 10 bedside cases. Um And sometimes if you work with a senior surgeon who hasn't done bedside training. You know, there's a lot of frustration as to why things aren't working. But if you've been there before, you have a much greater understanding as to what the challenges are. Do you have any perspectives on that? From an orthopedic perspective? Um I think that there's just a lot further to go in terms of training. But, I mean, one of my ex trainees was whatsapp Me this morning saying how much he misses robotics cos he'd notched the femur and got the implant in the wrong position. And he's feeling a bit sorry for himself today about it and doing some self reflective practice. And I think it's just as you've described, it's an organic process where you have to start off with consultants learning it, then you have people learning it on fellowship, then you have trainees learning it and advocating for it when they become consultants. And I think there's a responsibility for trainers to recognize that that technology assisted surgery will have advantages for patients for sure in the future. And you have to force your trainees to sit at the console. It sounds great. I mean, I'm sure a lot of us would love to have trainer, have trainers that do that and act almost actively kind of encourage learning. Um And uh I think in, in orthopedics, I really hope that we'll just be, you know, a bit behind, but we'll follow that same trajectory over time. Thanks. Well, I think um we can probably all agree that it, it's an exciting time to be involved in, in robotics and um you know, on behalf of everyone in asset, I'm really grateful for both of you coming and, and highlighting what, what excellence in, in robotics, surgery and robotics training um should be. Um So thanks, that's the end of um our session and thanks everyone for coming um up next, we've got our BMA update. Um, so thank you.