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Ok, great. Thank you very much for joining everyone and welcome to this um series of webinars on digital surgery. Um I'm really excited that tonight, I, we've got some great speakers um as you'll have seen when you signed up, this is all part of um a series of, of um webinars that are trying to promote Oscar, which is um a national audit, which I'm hoping everyone will um learn more about digital surgery tonight and then sign up to take part in. Uh and we're really keen that you're involved in this. So it's, it's really when we call it a digital surgery collaborative, we really mean that um and we hope that everyone um will join us as, as collaborators in this cos there's huge potential for us all to learn here. Um So as I said, we've got some great speakers tonight. We've got um Miss Nura Yasin, um who is a consultant colorectal surgeon and honorary associate clinical professor at the University Hospitals Birmingham. Um She's also a council member and lead for the future of Surgery, robotics and digital Surgery at the Royal College of Surgeons of England. Er, and we've also got Er, Mr Ben Cha, who's corrected me. He's Mr Cha, he's a consultant urological surgeon at Geyser, Saint Thomas, er, and lead for urological cancer and clinical robotic surgery there. And he's also an associate professor at King's College London. And then, uh, me, I'm Andrew. I'm a general surgery registrar in Surrey and I'm a researcher at Imperial College. So, um, should we start with Miss Yasin? Um, who's gonna give us an excellent talk on all things digital surgeons? Thanks very much, Andrew. And it's a great pleasure being uh with you both here today. I'm just gonna try and share my slides, which is the first um technical challenge of a digital surgeon. Let's just uh try that first and hopefully you'll be able to see my slides so I can't see you anymore. So, do shout out if you can still see my slides. Looks great. Great. Thanks for that, Andrew. And uh good evening to you all. Thank you for joining the first of the series of webinars that are organized by uh Andrew and the team. And I'm excited to hear about the Oscar study, which I hope that Andrew will tell you about um uh again, towards the uh later end of this webinar. So thanks for the kind introduction. Um And hopefully by the end of this talk, you'll, you'll think differently that we're actually in a digital era and we're perhaps all practicing digital surgery. So, before embarking on, on what I do and what we do at the college, I think it's quite important to think of digital surgery as the bread and butter of how we should all our practices within surgery. So we need to digitally define the patient in all their aspects, not just focus on the anatomy and the pathology. We need to think about the surgical field also in a digital way, the surgical problem, think about the task at hand and think about how to operate based on all of this information that is provided to us. Um and not just focus on the surgical technique and anatomy. So when we think about the patient journey, you can think that in your everyday practice, we go from electronic patient records to most information be being on some sort of digital platform or other. And then we think about how we used to consent patients and how um perhaps in in various parts of the country that digital consent is being used. These are two examples of companies that um uh provide digital consent these days. And uh uh although I don't use it at the moment, I know, for example, um Ben that um bows have digital consent and that standardizes how we speak to our patient, how we provide uh the information to our patient, regardless of, of where they are in the country. So these are good examples of good practice as a colorectal surgeon. When I think about the technical aspects of an operation. I think what do I really need? I need precise dissection, which is nerve sparing most operations. We think about removing things, but we should really be thinking about what can we do uh for preservation of other organs around. We need to think about the articulation of stapling devices. How we want that to be precise for the transection and for the anastomosis that we really need good blood supply uh and other aspects to be in the optimal position so that we don't have morbidity associated. So this uh then brings us to computer-generated modeling and and that side of digital surgery that uh can help us improve um the preoperative planning for our surgical practice. And then we can think about the other adjuncts that can be used intraoperatively uh or in the perioperative period such as 3D reconstruction or intraoperative ultrasound. We uh spoke about briefly just now the use of um um in the signing green as a dye, whether it's the highlights um vasculature or even the lymphatic drainage. And of course, the use of augmented reality and uh A I which I hope will be covered in the next webinar. I'm just sorry to interrupt you. I've, I've just seen in the chart that there's some, some people may be having difficulty seeing your slides as, as far as I can tell, I think I can see them. I just wondered if anyone else in the in the chat is able to, to say whether whether or not they're able to see I can see them nicely. Excellent. Thank you. I'll carry on and hope that the rest have better wifi so they can see my slides if that's ok. Perfect. Thank you. Thank you. So, um I'll just go back a slide to just show the flow again, talking about the technological adjuncts that we use and again, an adjunct or a tool rather is um the use of robotic surgery. Again, in this digital era, having an improvement uh to the previously limited laparoscopic surgery. We know that minimal invasive uh is helpful for our patient in combination with enhanced recovery programs and other programs. But what the robot affords us as a robotic surgeon, I can say that that stability uh filtering away the tremors, high definition uh 3D uh vision and that magnification as well as having that endo wrist action that allows us to work uh in type spaces and perform complex operations uh in a simplified way using such tools. But what it has also given us if you can see this is my previous trust, uh not my current trust, a different way of training. So within the console, we can teach anatomy to medical students in a completely different way compared to how we used to just use books in the past. And then we used online uh platforms and now we can use this digital technology. So I actually think that we're not using just robotics, we're using systems and we're using digital surgery as we do every day. So in my practice, um I'm an intuitive uh or da Vinci surgeon. So I use the preoperative planning using the 3D model, using the intuitive learning and prior to that simulation and also an app called my Intuitive app that shows me all my uh numbers, then we can use interoperative guidance and we, we spoke about the vasculature and preoperative mapping. Um and using those adjuncts again for postoperative analytics that help with the learning curve, but also help with teaching and training colleagues as well as trainees. Um And then of course, uh simulation training is also part of digital surgery, but it has improved remarkably over the years and the models are so realistic that they can emulate what happens in real life. So it's it's very important to look at the whole picture of how we can improve the whole journey for us as surgeons. And uh inadvertently, of course, that will reflect on how we uh train uh our current generation and how we deal with our patients. And then we can think about the analytics to continue that professional practice and improvement. As a proctor, it's important to be able to uh have effective communication and feedback back to uh the surgeons. And then we can see from these uh digital signs of of um robotic surgery that one can look at each arm and each timeline and review them back and see how that practice can be improved. Of course, um I use the Da Vinci robot and, and Ben, hopefully we'll talk uh about other platforms uh later, but there are plenty of uh soft tissue uh robotic platforms as well as orthopedic ones. Um beyond the UK. In the UK market, we have the three biggest players at the top there and there are some others that are in the pipeline. So I've used some examples from their own websites. This is the CMR uh digital platform and have, they also, they also have clinical registries and they use um virtual reality for training as well. Um So that's also another part of this digital era. And this is Hugo and also with their own touch surgery and digital platforms that also helps uh in how we can um use the surgery in a different way. So we at the college are also embracing the future and uh we're looking together at how we can change the face of surgery. So the future of surgery, if you haven't heard about it before was commissioned in 2017. And there are two reports in 2018, the future of surgery commission and the, the training aspect of it, the PHOS test and uh reports, this focused on identifying uh key areas um of technological development that uh will uh be looking at for the next 20 years. And there are four areas highlighted. So m invasive surgeries, one of the highlights imaging, virtual reality and augmented reality as part of digital surgery as a whole, big data genomics and A I as well as specialist interventions. The training aspect of of the future of surgery reports. The FO test has actually looked at seven key areas of how we can um implement um digital surgery and technology into training. And these are the seven areas here and I would really urge you to read both reports because they are relevant and important uh when they were published, they are now and they will still be in the future with regards to the themes that came out from the very report. So we have these working groups under the overarching umbrella of the future of surgery. We have the robotic and digital surgery group, which is the radar group that um Andrew has mentioned. We have the I hub uh that has been running successfully for the last year. And the genomics group who um have run two events so far are and are uh putting a group together to continue this work in the future. So the I hub, we've had uh plenty of events from the fantastic group that run the uh I hub led by Ryan Kirsten who's um a plastic surgeon in London. Um And they've run plenty of uh workshops and an A I webinar and we've had combined webinars as well and a future of surgery webinar series about the H I hub itself about training in robotic and digital surgery. We've had a recent one a few weeks ago about uh patient and public involvement, which is really important and I hope you join us for the next webinar series for the Radar Group. Our key themes are focusing on everything to do with robotics and digital surgery. The focus so far has been on robotics and the digital surgery group are, are being set up at the moment. From the robotic uh surgery side of things, we've focused on research and data and we've had various um studies running. Uh We've also focused on training and on our network development as a whole and also with our patients and public awareness and policy. So from the uh policy side of things, we are um collaborating with all the stakeholders including Knights and N HSE for the network development. We're delighted to have a large network and always looking for that expansion. We have a network uh meeting this Friday. Uh And I'm delighted that Ben will be speaking there as well. Um And you can see here that the research uh outputs. I'm not gonna go through all of them uh within this webinar, but we've had plenty full of research outputs from PPI projects, systematic reviews. We have had two trials, the mastery trial um and the Rain course uh which is still recruiting, we've had a few publications but do uh join us for more information on those from a training aspect, we as a college have various elements to the college. So we accredit robotic centers or centers rather and robotic courses. Um And we're also in close collaboration with all the um trainee networks. And we're thinking about how we can have a um an equitable way um to, to provide platform agnostic training. So look out for the seventh edition of the BSS, which is coming soon. This is Matt Harris, who's the rad uh the radar equivalent of the trainee group from asset. So he's the chair and uh we're currently updating the BSS and other courses within our learning packages to as robotic uh uh modules and the fundamentals of robotic surgery to that. And of course, last year we published the um good practice guide uh at the college, robotic assisted uh surgery. Um and we will be updating this soon. So to summarize, we have a great network um in the radar network, we think robotic and digital surgery. It's not just the future. Um It, it's very important that we keep up with the technology and we make sure that we have governance, we have training and that we uh cater for our patients in the best possible way. And hopefully this webinar will generate some questions and there will be some answers from studies such as Andrews and beyond. I'll just stop sharing my screen. Uh So I can see you and happy to take any questions. Amazing. Thank you so much, Miss As that was a, a brilliant talk, really enjoyed it. Um So while we're waiting for any questions to come in, uh on the chat, and I'm pleased to ask them cos we've, we've got um a good amount of time here with some excellent speakers. Um Mr Cha, should we start by having a, a quick chat about how um what your practice as a, as a digital surgeon is, is like at, at guys in Saint Thomas's? Yeah. No, thanks very much. Uh Andrew, can you, can you, can you hear me? Ok, great. Now, he's very nice. New, has covered the um the whole of sort of the breath of digital surgery. Um, very nicely there. I mean, I suppose I was, I was going to speak really about as she did to some extent as well. But, but what I actually use on a day to day basis of these digital things, um I'm lucky that I get to play with three different or sometimes even four different type of robot a week. Um And I know, you know, I want to support, you know, really encourage everyone to get stuck into the Oscar program because that's going to give us some, some data in this area. But in terms of pre op the 3D modeling really lends itself to kidney surgery. And so we work with a company called Inner Site when I go and speak in Italy. The Italians have got all kinds of companies that are doing a sort of virtual world headset 3D modeling where you can drop in and out of the arteries, the veins, the tumors, the kidney of itself. So we use that, we're actually part of a trial called VISP, which is an RCT looking at whether using a 3D model is going to help you with kidney surgery. So that, that's nice that the patients love looking at that. Um And also it's great for the trainees to show them that those models are so detailed that once you start the case, actually, I don't look at the CT, I look at the model, the model has got answers on it that you can pick up. Um having started and looked at the anatomy that is very good. Um And in many ways, it is much easier for your mind to digest than constantly flipping between axial coronal and Sagittal views. Um We also have professor I work with also printing, actually not the inner sight is mainly about a 3D model that is on a screen, but you can, we actually have some printed models for that as well. So we're looking at one of our phd here is looking at whether that is better or the same or equivalent for the surgeon and planning to actually physically have that for prostate to have a prostate with a blob where the tumor is. And we're being able to sort of orientate it to how you're looking down the screen at any particular time. And of course, we've been stuck with Epic, which was a bad thing to start with because no one likes change that's forced upon you. But actually Epic is great at doing all of that digital consent and we record every case that is done in robotics across the trust and that consent is taken on the Epic platform. We've got a Da Vinci CMR and a Medtronic or five da Vinci two cm two Medtronic and a CMR. So all of we have to use a platform for recording that is essentially robot agnostic um because otherwise, it became too difficult with, we were recording on this system and versus that system. So we still do that. But the hard core, the database for the trust is using proximity, which is one of my consultant colleagues, Nadine Hat Haram, she's CEO of that and that is in all the theaters and that almost automatically starts recording every case. The patients don't seem in my experience to be worried about that. The main likelihood thing is they're going to say is can I have a copy? Can I have a picture? Can I watch the case? That is possible? And of course, if you're going to consent them for recording, you have to, you have to give them an option. It's not something we would do uh for everyone. Um Obviously, uh the intuitive hub, which does the XI and the, and the sp recording the touch surgery app you've alluded to new has as well and the versus connect. So each system comes in what they will usually call an ecosystem that, that has a digital platform that, that links to a robot. Um I don't know about the Chinese robots which is uh the edge and the other um robot which are rapidly appearing at lots of meetings doing literally remote telesurgery all the time. I don't know if you've seen that Andrea that these guys are, are doing operations from anywhere in the world to anywhere else. So with patients in China sometimes but also in Africa. So that is very digital. You're literally talking about a 0.130 2nd delay for the for the sound, the motion and the diathermy to go there and back and that's 10,000 or even 15,000 kilometers. I mean, it's just mind blowing, but back in the world of the NHS, what do we actually use in digital? In the case? I'll be using ICG. I'm sure colorectal does that a lot as well. Newer um for looking at perfusion of, of perhaps the ureter or perhaps the kidney tumor or perhaps isolating where retroperitoneal fibrosis is um we use a drop in ultrasound probe of course, which gives us a a heads up real time screen. So those are just some examples of things that we're using not every day, but, but most, you know, most cases I'll use the ultrasound for a partial. Um And then afterwards, it doesn't stop that the to give a plug to the medtronic system, they've got an amazing system that within about 20 minutes of us finishing the case, literally undocking the robot. I get a message saying that the video has been uploaded. So that's separate to the whole proximity thing which we use in our trust. But the, and then about a half an hour later, I get a message saying that it's been segmented. Now that means that the, the software or the hardware and software combination of Medtronic has, has segmented the operation without human intervention into eight or 10 parts. And it currently does that for radical prostate, for partial nephrectomy and for for gynecological hysterectomy. So we want to look at the excision of the tumor. You literally click on that and it literally starts as the incisions start, start chopping out the tumor. If you want to look at dorsal vein ligation for the prostate, it does it and the anastomosis, it does. It, it's, it's absolutely incredible. And that's very, very clever because once you get to a point in digital surgery where the machine knows where it is, then the next step is actually controlling the instruments because it, if it knows what it's doing and what you're doing, um, if you just mess about for five minutes and you know, you're kind of swabbing stuff and burning a few things and tying a little bit of bleeders. It knows that that's kind of great time. That's no, that's not a forward step in the operation. And that is also very interesting because it can tell you whether you're an efficient surgeon. If your grade time is 40 minutes a case, you're literally spending far too much time not moving forward. And I think more junior, you know, the fellows, you will see that if you let them do a whole case and, and you stand back, they will do that. Some of my colleagues who are extremely efficient doing three cases. A list, they have very little grade time. It's 55 minutes max, they know where to move on. So my final thing was what do we do with these, all these videos? We review the cases. The SCP is the surgical assistant. I didn't realize this. I spoke to them. They review the cases. If chain has got a crazy retroperitoneal partial nephrectomy, they'll find the last one I did and they'll review that whoever is going to help me the next day. I mean, incredible dedication that you know, from the surgical assistant, but I will review the cases with the fellows. You will never think to start the camera. If you have a complication, you're too busy trying to sort out the complication. So the only way to find complications is to video every case because no one is saying it's bleeding, it's bleeding, start the video. They're saying it's bleeding, it's bleeding. Give me a suture unless they're sort of slightly weird. Like my friend Demy in Australia who used to do that as well. So give me a suture and start the video. And if you have the sections of the operation that we have for some of these more standardized procedures that we have in urology, the trainees will be able to tell you, you know, I did the anastomosis and it took me 40 minutes in the first two months and then I can do it in 30 minutes. And now I'm aiming for 25 by the end of the year. So you'll get that set of data. We were talking earlier about the medica legal aspects. Now, to my knowledge, none of our people have ever sued on the basis of their thing being recorded and far from it, it's been used as a defense to see that we've actually done the right thing on occasion. So I think that the whole breadth of this is all under the banner of digital surgery. But, you know, as we go on more and more of these things are going to be integrated into each other. And I would, I would urge everybody to try and look at ways of recording cases because that's how you, it's a brilliant learning resource, let alone doing talks and teaching and training. But it's, I could have showed you a whole load of gory complication videos, but maybe we'll save that for another another video session to illustrate that. But recording the cases, I think is a key part of the future of digital surgery. But thanks for asking me to give you my, my nine sense. Absolutely. Thank you very much, Mr Cha. That, that's really interesting. So maybe if we just take a a few minutes just to chat around some of those points that that came up. So um obviously, as Mr Chain, you, you both operate on robotic platforms. Um I don't know if you could talk a little bit about um before you, you started with robotics, how, how you felt that um sort of laparoscopic or, or open surgery um may be um doesn't have, well, it, it can have the same sort of digital analytics and things, but there, there may be other challenges, for example, in open surgery, we don't use a camera. Um and, and maybe relate that back to what has been the most noticeable digital improvements uh as robotic surgeons as you both are Miss Aston. Do you want to maybe talk on that first? Thanks, Andrew. Uh I mean, I think we say we're robotic surgeons, but I still do um emergency general on call. So I'm a surgeon that uses a robotic platform electively. Um You know, in, in the digital era, I don't think uh you know, Ben, you mentioned N HSA. Few times, I don't think every hospital can say we're robotic surgeons. We only do that and we don't do emergency surgery, laparoscopically are open. So it's the right tool for the right patient at the right time, I suppose. Um, but you know, the, the limitations with laparoscopic surgery, think about the surgeon, think about the patient, think about the team, um, for the surgeon, the longevity is gone, you know, the backache because of the poor ergonomics and standing in awkward positions trying to reach um areas we when you've got straight instruments, endo wrist action. Uh So I think robotic surgery for me is like doing open surgery. I've got my hands back, but in a miniaturized way. So using those um uh endos really vitally, you have the advanced energy. So you're not worried that if there's bleeding, you're gonna have to open, you have ways of controlling that. But the adjuncts are what, what are really important, the digital part, it's not just the tool, it's what happens with it before and after. So like Ben mentioned, you know, even before you embark on the journey as a trainee, you start with your simulation training and I don't mean training as in resident, the new terminology, I mean, somebody who's new to that platform regardless where they are in their uh experience as a as a surgeon. Um You look at videos, you know, I'm impressed that the S EP looks at your videos been, that's fantastic. But, you know, in the past, I used to look at, read a book before looking at an operation, the Kirks manual and then moved on quickly from that to looking at um web search when that existed. I don't know if that predates your, your era Andrew. But you know, those were all the laparoscopic videos uploaded there and then moving on after to robotics, I've got a couple of gurus that I follow on, on youtube and they've got, you know, Mark Solomon legend in America who, who splits an operation to so many steps think golly are there that many steps so that, you know, so that's all part of digital and as technology improves, we need to think we need to move with the times our patients no longer come with paper uh information, they come with their apps and say I've looked at this and I found uh that procedure. Can you tell me more about it? So I think it's part of upskilling that we need to become digital surgeons rather than stay uh where we were before because the world is passing us by. Yeah. A absolutely. It's, it's really good and interesting to hear you talking about um the, the video review and, and Mr Jam as well having the team V review, the video cos I, I'd say that's, you know, we talk about robotic and, and laparoscopic or open surgeons. I'd say, you know, reviewing a cases video or a similar cases, video before you operate that, I'd say that's definitely sort of becoming a digital surgeon and, and using um the, the, you know, modern technology that's available and, and yes, it, you know, you, you may not have as much um data available to you as a robotic operation, but, you know, using your video from a laparoscopic case or even an open case if you're using um cameras in theater or, or glasses to record it is, is, is certainly uh interesting ways to, to not miss out on, on the the operative data that that is available. Mr Cha, do you have any, any thoughts on, on this? Yeah. No, it's, it's funny how we've, I mean, I have been in theaters where we've literally had pages of books printed out and stuck to the walls where we were doing something tricky like a, you know, a reconstructive procedure which is rare. But I mean, as no said, I mean, quite recently, I've started doing some retroperitoneal approach with the single port and there's a couple of people who put great videos on. I would literally my prep for the case was whilst they were at the patient, I'd watch a couple of those videos and just get myself into the OK. I know the ports. I know, but I just, and see how it, how it looks and it's, there's a little bit of mental preparation that goes on when you do that. It's why I think sometimes people don't understand why it's urging someone just switches the order of the list. That is quite impactful because your mind is sort of prepared for the, for the other. Um, the other case, you know, there used to be a thing where you could on sky sports where they'd kind of follow one player and they just watch a football game from the perspective of one player. What I'm going with this is that from the assistant point of view, if you watch a case, but only from the assistant point of view, which that's also really useful. So you can get quite a lot out of these videos. You can look at the timings, the efficiency, the gray areas, the moves that didn't do anything, the complications, of course, but if you just look at the assistant moves, you can see how a good assistant works. People have looked at this and seen that an assistant could be worth as much as 30 minutes in a two hour case as to how in terms of your, your your timings. So someone asked on the chat there, Andrew about whether we've had any, any resistance. Um I think people are always a bit resistant to change if they're very set in there. Ways, obviously working with predominantly relatively young people in theater helps because old people who are my age and older, you have a way of doing stuff. We, we, we have a phrase that we said, we talk about old fashioned robotic surgeons. Um which I mean by that is people who have done it the same way since they first started, they were taught that way and they didn't want to change. That's their way. They've sorted. Whereas the people coming up behind me have never set themselves into doing it just one way. So, Raza and Archie Fernando, they are constantly reinventing their techniques the whole time because they never got to that point, which if you imagine the person who did 1000 hernias and they only did it one way. That's it. They don't get to that point because they do 50 then they read something else or see someone's video and they change and have a go at that and if it doesn't work, they go back to something else. So I think staying fresh, staying fluid and infusing the team about changes is important. Yeah, absolutely. And, and I think that's a really good point that you, that you just made there. It, it really is a, a, you know, a team that's delivering the, the care and, and there's, you know, having more information and data around um these operations gives everyone the chance to, to really get to, to, to know what their role is going to be in, in the operation. Um I just had another question um thinking about not only the video that, that you get from, from the operations. But um you both talked about the apps that are available that come with, with the systems that, that you often use. Um How are you looking at the data that comes off those apps and, and how's that leading to changes in, in your practice? Min? Maybe we could speak with you first. Um Sure, II think we don't really know how to use data. Let, let's be honest, you know, it's captured in many ways and it goes up into some cloud somewhere. And you know, at the moment, the um if we're going to use the robot as an example, the robotic companies own that data, but it's actually our data. So we need to invest the time into understanding what's actually being captured. It's not just a video, what are the other metrics that are being captured? What's really useful? Um Again, I'll use the proctoring example because I can see exactly what I've done in console number one, if you've got a dual console as an example and what the other person has done in console number two and all of the arm movements you can see with all you know, the graph that I showed earlier with the different colors. So then look at your own videos alongside the person that you are, you know, helping along their journey. And that is the vital bit of trying to improve the learning curve. Um Watching good videos as prep for an operation is fantastic. But then looking at your own videos, helps your own learning curve and, and, and helps you um uh teach better actually. Um It usually the bleed can be stopped five seconds before it's actually happened. When you look at that video, you can see where the error uh has happened. And of course, there are other human factors as well. I just want to use an example that's not robotic. Um And I'm not sure if Ben is there or not, that's why I'll just keep chatting for a bit longer. You are excellent. I was gonna use the labco example and of course, um uh urologists have pioneered uh everything before colorectal. So hats off to the urologist. Um but labco was the Colorectal uh program that trained consultants, not trainees on how to use lap, you know, the laparoscope for, for, for colorectal surgery. And, and that adoption from open to laparoscopic surgery took years. But that Labco program was really important because, you know, the wet lab, et cetera, then you had the mentor or whatever you wanted to call them those days. And then you, you went back to your unit and recorded your own videos, sent them back for analysis and, and you got signed off that way. So what happened since it's quite peculiar that we've stopped doing that? And then we, you know, obviously, uh training became in house now that we've got robotic platforms. Why aren't we back to a labco style uh program for trainees perhaps. Um the, the, the consultants are being trained by the companies. There's some investment in that. These are my views. They're not, they're all college views. I'll just, you know, I'll just say that from now. So, um, so I think it's important to think that, you know, we've had good examples in the past. Why aren't we using them nowadays? So, quite like the idea of your video assessment Andrew because I think it's uh it's bringing back good practice that has been shown to be positive. Previously brilliant. Thank you. And, and Mister Cha, how, how are you using the, the data that's coming back to you from your operations? Um Well, I'm, I'm probably beyond the stage where I'm getting home nervously each uh Friday night and sitting there and rewatching everything. Um unless something weird happened. Um But I would encourage the fellows to, to, to do that. Um And we're lucky with the assistance. They are, they are good and they, they are much, you know, incredibly dedicated doing that. Um We, we always um the recording has to be almost automated and I'll tell you why because two of the occasions in the last 10 years where we had a problem and we really needed to look at a case once the disc it was on a disc and somebody broke it and it didn't work. And the other one, they forgot to start the video on a key one where we then had a major complication and a bleed and a conversion and we didn't see it. So, um, from that point of view, things like the, the Kinect and the Medtronic App are automated. Um, and the intuitive hub can be automated so that it records all your things. So II use the intuitive app to look at how many cases I've done of each type. I use it for my annual, what would you call it? Appraisal? I suppose, audit that tells me, you know, bend it 80 prostates, 100 and 10 kidneys last year or whatever. And so that's all on that because it's, it's not made up figures. You've got the dates and the times if you work in two trusts, it, it, it, it, I looked at it today in preparation for this and it says that I'm still in the last year, I've done operations in five different places. Um, so it, it's all on there so you can use it for your, for your appraisal, your, your regal and your, and your appraisal. Um, it's, um, really useful but I think as n says, not used enough for that sort of telementoring that proctoring the ability to perhaps watch somebody else doing an operation and feedback to them. We don't do that enough. Why don't we do that enough? It's a great point. I mean, it was done with discs being sent around and yet here we have the platforms to do it. And yet I should be able to sit in this clinic room that I'm in at the moment and have one of the senior fellows started an operation and say, Ben, could you have a quick look at that? And my friend in Canterbury who's done 100 I've done a few 100 or something. Should be able to just dial in and go. Ben. There's a bit of a weird anatomy. Have you seen that before? And I go, yeah. Why don't you do this? Why don't you do that? We don't use that nimble ability to connect as much as we could do because the technology is there. We can, we've got so much linkage and yet we don't do that. And actually if we really want to allow people to go from a novice, they can do the operation, but they're not, they're not very slick at it to the next stage and that independence that a lot of trainees are looking for and it doesn't just have to be robotics. It could be anything. Then this technology think is perfectly placed to help people get to that next step, which was sit in the coffee room. But really, that's not really helpful because you're not helping the operation and you're not even viewing the operation, sit in the coffee room watching it in lifetime, making the occasional comment. Maybe that is actually more useful. Brilliant. Absolutely. That's, that's fantastic. Thank you. So my last question for this part of the webinar is um talking about consenting patients to, to have a, an, a video made of their operation. Um So, so I just wanted to ask you about sort of what, what your approaches are to that. Um Whether you do it at the same time as, as when you're consenting the patient for the operation itself or whether there's a, a different process. Um And, and what your experience is of, of how that conversation's gone with, with patients that you spoke to, to about this. So as you want to start. Yeah. Sure. II feel a little bit of a fraud because I haven't recorded for a while. I have moved trusts uh recently. Um And the reason for that is an it issue rather than any other issue. And I, I'm definitely missing those videos because um that repository is so important. But previously, it's just the same consent form for the operation that then says medical photography, videography, um not necessarily for patient, for the, for the records, but for educational purposes, if it's part of the records, it doesn't make me nervous in any way because it's not, you know, we're not in America it and, and I'm sorry for any Ameri American audiences who listen to this. But you know, the Medico legal side of things, I think shouldn't be the first thing we think of when we talk about patient care, when we talk about and training. Um It's how we want to use the tool and how we want to use that digital part of um of our technology for, for the, for the benefit of the patient at the end of the day, if we improve our skills and we upskill, that's also for the benefit of, of the patient. So it's a, I think it's an easy conversation. Um It depends how, how one says it really uh but it should be done at the same time of as consenting for the operation in clinic, not uh on the day of the operation itself. Brilliant. Thank you, Miss. Yeah, I totally agree. It's, if you make it very matter of fact, we record all the cases, there's also a bit on there that says that we're going to record your case. That's what we've been doing for the last five years. I mean, no one goes really, I'm not having my case recorded because immediately I'm going to say, well that this will be useful because we might find things that we didn't, we didn't expect. I mean, I'll give you two examples where, where recording the case directly helps me. One is the other day I found a diverticulum of the small bowel, which I knew I wouldn't know all about, but I looked at it, it looked weird. I didn't quite know what to do with it. So I took a video, a clip of the thing that we were recording and I sent it to the colorectal surgeon on a different site and said, what do you think? He said, yeah, fine. Do this do that? Gave me immediate advice. The other one was we lost a needle. It pinged off as someone was taking it out of the port and we couldn't find it and we spent a while looking for it and then we suddenly had the idea, why don't we just go to the point where it was in the needle grasper and go frame by frame and we'll see what direction it fired off in. And we revised rewound the video frame by frame and we could see that it flicked over the back of the liver. We look over the top, there's the needle cool off X ray, everything, everything's fine and that's just from recording. It gives you, it gives you the ability to, to, to do these kind of things. So what is more, I suppose more worrying for the patients potentially is that in urology, maybe that other specialties aren't really into this. We still quite a like a lot of live surgery as in we go to meetings where you now that's a different kind of consent and that has to be taken very specifically, which is we're not just going to record your operation, we're also going to broadcast it to 500 of our closest friends sitting in an auditorium, um, who have, have a cup of coffee and are willing to, to chat about it. Um So that if you're doing that kind of work, you need to have a specific form that says what, what will, what will and won't be shown at what point the recording would stop. If there was a complication, you need to have a patient advocate. We've got some e urology guidelines on that so that consent is different to the, we're just going to make it part of your medical record. And probably if you're going to use part of the patient's record to show in a talk, you should also consent them for that because you don't want their cousin who is also a junior doctor. Then sitting there and going, hey John, I think that was your case. I saw that they would be upset about that quite rightly. You would, wouldn't you? And, and that would, that has got potential. So if I'm ever gonna use a patient's complication or thing, I would, I would ask them more and then put that in our electronic notes. Fantastic. Thank you very much. So um I'll just move on to the next part of the webinar is just AAA few short slides um trying to explain um what's going on with Oscar and, and what we're, we're hoping to achieve um with this collaborative audit that I hope um everyone will be able to take part in. So if I do this, hopefully everyone can see that and that's looking good. So Oscar, so obser observational study of um camera assisted surgery recording. So it's a nationwide audit um collaborative um with hopefully everyone on, on this webinar involved um of surgical video recording in the United Kingdom and Ireland. Um And what this really comes from is is the fact that we think that as, as as we've discussed that there huge potential um in digital surgery and, and a huge component of that is is digital surgery. And as you can see in the video here, this is a robotic cholecystectomy. Um As we've alluded to earlier, to, to be a digital surgeon, you don't have to be operating robotically. There's many different ways that, that you can take advantage of all, all of these new technologies that are available to us. Um But we're particularly interested in surgical video in Oscar and there's a number of reasons why that is the first is um for the medical record. So there's a paper here that has said, uh operative notes do not reflect reality in laparoscopic cholecystectomy. And, and you can very easily see see how a video of exactly what happened in the operation is a really good objective measure of, of exactly what happened in the operation. Now, it's not comprehensive necessary, you know, things can happen off screen. Um But you know, an operation note that was written after a long operation where everyone's a bit tired or, you know, you weren't, you don't, you know, fully remember every single tale of every single bit that happened in the operation. Uh We think having the video it now that it's so readily available in many cases, um would be a really helpful addition, not replacement for the written operation note, but addition to the medical record, the next visit as we've talked about extensively tonight is education and training. The um idea that you can go back and watch certain parts of a video um after a case to see how you've done something well, or how something could have gone a bit better or as, as we were discussing um earlier in to prepare for another case and to get used to a particular approach or way of doing an operation. Um or if you're new to, to working with a new, a new team, new colleagues uh that can really help you uh anticipate and prepare for that operation. And then also it's, it's a really important data source. So when you, when you have a large amount of video available from an operation, you can do really interesting things uh with that data. Um So the example that I've got on the screen here is some work done um in Los Angeles by um Doctor Andrew Hung who's um been looking at surgical gestures in, in prostatectomy. Uh And he's done this really nice piece of work where by assessing the gestures done in, in the operation, uh you can make a prediction on a patient's erectile function. Um six months after their operation um from immediately looking at the video once they've, they've come off the table. So that's fantastic being able to try and um give us a, a deeper insight into our postoperative outcomes ahead of time. Uh And then hopefully, then that can feed back into education and, and, and learning um to try and improve those outcomes in, in the next patient that you operate on. So then this brings us our interesting video to, to this paper that, that we published in e cinical medicine um earlier this year, looking at the adoption of routine surgical video recording in, in England and Wales. Um And so I'll just talk to you briefly through what we, we found. So we asked 100 and 40 NHS trusts, um and which almost all of them um replied, um and we found that on the whole, not many, er, trusts are recording their, their procedures routinely and we're, we're interested in routine recording for the reasons that we talked about before, you know, no one's thinking to press record when things go wrong. Um So we found 22 trusts are recording and um of those 17 trusts gave us estimates of the, the average number of, er, percentage of consultants who, who were recording um within those trusts and, and the median for that was, was 20% which we think is, is probably not entirely accurate. And that's, that's quite a big reason why we're doing Oscar because we want to know exactly what's happening in theater on the ground. Now, we, we asked also about technology and, and just under half of, um, the NHS Trusts really interestingly said that they had technology available uh to record their operations and, and that's a big discrepancy with the amount of, of places that are actually recording. Um And so that's another thing we're interested in is if, if you've got the technology there, what's holding you back from, from making use of it. Um And then we also asked about how they're storing their, their, um the, the data that comes off um their, their operative video. Um And as we've heard about earlier in this webinar, there's a variety of different approaches to it and there's a number of, of third party providers. And actually, if you're going to record all of your operations, that's going to be a huge amount of data um that an NHS system may not be able to, to deal with. So it's important that we're aware of all of these solutions and the pros and cons of, of different ones. Um And, and how we can, can use them um to benefit, you know, our patients and us as surgeons. Uh And so we've got an interesting webinar coming up in a few weeks about um what solutions industry are offering. And I'm, I'm hoping they'll, they'll be able to speak a bit more about that. So do join us for that one. We also asked about consent. So, um asking about whether we should be consenting patients for recording uh as part of their routine care, which we've discussed tonight. And um around 20% of, of trusts in England and Wales are doing it as, as part of routine care. Um Another about third of trusts had an additional consent process, which is, is good because obviously we, we need to be asking patients um for consent for a lot of the recording that we do. I say a lot because there are certain instances where the GMC permits recording of um intracorporeal views without consent ahead of time. Um But as we discussed earlier, it, it, it's more likely that you're going to have a, a better sort of consent experience with, with the patient if you're discussing this ahead of time, as Miss Yasin said in clinic ideally, um and at the same time as discussing the operation, if it's sort of like an add on bit, you know, and just before the patient's, you know, being wheeled into theater, by the way, do you mind if we record it? It's, it's not really the right way to, to be approaching consent for this sort of thing. And then also what are we consenting um patients for when we're recording this video? Is it just for the medical record or, you know, as we've talked about there's a number of other benefits and, and we've mentioned specifically education and, and research. Um And so we don't want to miss out on that cos if you've, if you've recorded a, a really good case, that would be great for teaching, but you haven't consented the patient for, for that use originally, then it can sometimes be harder to go back and ask, ask for more consent to, to use the video more widely then talking about access. So obviously, if we've got these really important pieces of and, and data available and, and they're really beneficial for everyone, we need the right people to be able to access them. And as we've discussed, it's important that surgeons can access them for um you know, their own quality assurance of their surgery. Uh and then also to, to educate and train themselves and others. Um It's also, you know, if a patient has, has their operation and it, and it's, you know, them being operated on, I think it's quite reasonable that that patients are able to, to access them. And I don't, I don't think that's something that um the NHS has, has done well enough up till now, there are a number of means for patients to, to make um requests about their own data within the NHS. Um But as you can see here, only around 20% of, of trusts in the Eng in England and Wales had a specific policy that facilitated patients being able to see their, their videos. And then again, are, are we using them for the right reasons? You know, if, if um we, we see here less than half of, of um the trusts are using video for nonclinical purposes. So education and research and so we're, we're losing out on a lot of valuable information that that could be doing a lot of uh of good. Then again, the governance policies, we, we talked briefly about this um e essentially um the governance around surgical video is based mainly around um medical photography policies which um are good in that we have something available that's that we're able to point to, but we think that we could probably do this a bit better and that we'll be looking at um some more work to do this within our group uh in the near future. Um Because we think a video of everything that happens within an operation is very different from taking a photo of a specific view or, you know, a few photos at, at certain points throughout an operation. So we, we found that that most surgeons don't record their operations, but there is um some variability within the NHS and that we need to make sure that that the policies are in place that everyone feels safe doing it. And that's patients surgeons and, and obviously the, the, the governance um side of things. Uh and, and with the aim of all of this to, to be able to increase the availability of, of surgical video for all of the, the reasons that we've discussed cos it's, it's such a valuable resource um in, in digital surgery. And that really led us to, to Oscar, which um is, is why we're, we're holding these webinars to, to try and um encourage people to learn about digital surgery and then also to take part in this because your data um in Oscar will be really valuable in helping us answer some really important questions. Uh So we're wanting to do an audit of all patients undergoing any surgery. Um And there'll be 21 week data collection periods, one in November 1 in December case collection. I'll, I'll run you through in just a minute. It's um via redcap. So it's a secure server um which means that it's compliant with um all the, the requirements um for, for audits that are registered in uh locally registered audits. Uh And it's similar information to E log book for. So for those of you who um keep a log of your operations on on e log book, the data entry will be very familiar and hopefully very straightforward and very easy for you to, to contribute to. And then you can obviously um be credited with collaborative authorship as, as part of this. We'll then also look at 30 day follow up um for patient outcomes. Um So looking um for things like complications length of stay and then also for, for video use as well. And there's a QR code that you can use to sign up. We have um we're taking a collaborative approach as, as, as I've said. So there's a team structure and um so we have um a steering committee which then leads into the writing group and the advisory group um and then a number of regional leads. So we're being supported by uh a number of um surgical specialties societies as you can see at the bottom of the screen. Um And so the regional leads from, from those societies are going to help us by, by disseminating um Oscar, we're looking for local leads so that people whose um primary responsibilities are uh to, to register the audit within the hospital, er and, and um identify people who can help with um data collection, local collaborators and also data validation afterwards, um data validators. Uh And then we'll make sure that, you know, everyone who's, who's taking part, who, who could be audited as part of this study is, is aware. So making sure consultants whose operating lists we're getting data from, are aware and, and they can also take part and they can sign up and, and also receive collaborative authorship. So, the timeline of, of, of the study is that we, we've launched um Oscar um last week and we're, we're starting the, the webinar series this week and we've got uh two more webinars coming up over the next two weeks, er, and then data collection on, on the 18th of November, um the weeks commencing the 18th of November and the ninth of December, er, with follow up data time, uh time to complete data, follow up in, in January. And then we'll hopefully have um the data all validated and analyzed early next year and we'll have results available early next year. So what do we need to do now? So, before Oscar, um we need you to sign up obviously, and then you'll receive an, an information pack um via email. Uh and then that includes details of how to, to help you register Oscar locally as, as part of local audit uh registration and then uh to, to please publicize Oscar and, and get um all your, all your friends involved at work and, and, and really get as many people contributing to this as possible because hopefully we've kept the, the barriers to entry nice and low. Um and, and it's something that everyone who's, who's used to logging operations in their E book, er, can pick up very quickly and, and take part in er, and get a, a publication for, for hopefully not too much work. We need to organize the, the data collection and I'll talk you through the redcap very shortly and, and creating an orchid account is just so that we can keep track of, of authorship during the those data collection weeks, it will just be to log your operations on redcap as you would with the book. And afterwards to make sure that there's, there's um 30 day follow up data included and then afterwards as well, we want you to present your, your results locally. Um And you'll be credited with authorship on, on um any, any papers and outputs that we, we generate from this. Um Obviously audit is, is something that's required by all of our training programs. So, so this is a nice way to try and get a bit more um get, get, get a bit more dunno juice out of the orange for, for doing your audits. So, thank you very much. I'll uh just walk you through the um way we will collect the data now and just while I share my, my tabs, Miss Yin or do you have any, any comments on that or anything? It's OK. If not looks good, exciting times. Thank you, Andrew. Thank you. So I share this. OK. So um this is e log book something which I think uh most people will be, be um quite familiar with. Uh and this is really just to show how similar our data collection will be. So we've got specialty up here. So, mindset to general surgery, um we get the patient's hospital number, uh date of their operation, date of birth. Um and then CPOD urgency um as, as we talked about before patients A SA uh responsible consultant. So we won't ask for names um in the red cap as you'll see in a minute, but we will ask for responsible consultant GMC numbers. And that's um not to keep track of, of anything other than we're interested in. Is it a particular consultant that likes to record their operations or is it a departmental practice or, you know, how, how um how's video recording practice clustering within different consultants in different specialties and in different regions, supervision code, we will ask about this and I'll talk a bit more about that in a minute, um robotic um laparoscopic, et cetera and, and then emergency time of day, all this stuff that's very familiar to everyone. Um And then the, the operations and, and where you've done it. And so our, our recap's very similar, I'll just log back in. So when we add a new record, we've got the operation details. And so institution is, is very straightforward and we've got a list of all of the, the trusts that um and, and health boards in England, Wales, Scotland, Northern Ireland, and Ireland. Um So hopefully you'll be able to find your hospital here. If not, there is other option at the bottom, which will give you an opportunity to write um in where you're collecting data from. Um And then we just ask whether it's private or not. Um And then the speciality so we can pick um whatever's going on here. Um Hospital number, we, we can put a value in patients age we've asked for rather than date of birth because that's a little bit less identifiable as a, as we've talked about. And then the, the GMC or IMC number um is just helpful as I said to, to look at clustering of, of different um procedures, uh sorry, different um practices. We've got the MC pod classification of intervention um procedure. Again, we've, we've gone to good length here to try and replicate what's available in, in e log books. So there's a lot of different things. So if I just start typing colectomy, for example, if I can spell um all the same things that you would see in, in any logbooks there or, or um prostatectomy. Um as we've, as we've seen from log book, it's all, all the same stuff there. Um So um yeah, confined exactly what's going on um As you normally would um initial approach. So obviously, we, we appreciate some operations start one way and end up another. So if you tick open and nothing, nothing changes. If you tick laparoscopic, for example, this box down here comes up and asks whether there was a conversion to open uh the date. So we're just capturing when the operation was and then a few process measures which will hopefully um be standardly recorded in your operation. So time the patient arrives in theater, time, knife to skin time to recovery and then estimated blood loss. And then we ask about trainee involvement. Um And the reason behind this is because again, if you've got an, a video of an operation, um and um a consultant's performed some of it and a uh um trainees performed some of it, you, you could sort of have some discussion about who, whose video should it be. I mean, obviously there's the patient, there's, you know, if, if it's been done um as part of a um robotic approach, obviously, the the robotic company has their boarding systems. Um So, so we want to sort of get an idea of, of who are the people who are the stakeholders involved in, in operation ownership. Um And if, if you're not a trainee, then um still sort of uh if it's a consultant logging the case, we can, you can still sort of tick performed or training a trainee, that sort of thing then was recording was potentially recording the procedure specifically discussed with the patient. Yes or no. Um Was the patient consented specifically for recording? Yes or no? And was the procedure recorded? Yes or no? So if you click? No, no, that's all the data collection so very similar to log book. If however, the um patient was consented for recording, was it part of routine care or was it an additional consent process? And then if the procedure was recorded, uh did you record the whole procedure or parts of it, what was recorded? So, the operative view or if um your hands are out of the operative view as in laparoscopic robotic or endoscopic surgery, were they recorded separately? Was the whole operating theater recorded as well? Was the recording part of routine care or research? Um What platforms did you use? So we've put here the, the platforms that we identified in that paper before. Um Although there are um others and again, you can select other to put that um there if, if you'd like to. Uh and then was the recording uploaded to the patient's medical record? Yes or no. Um And did the other theater staff who maybe captured in the recording were that was recording, discussed with them. So, the anesthetist, the scrub teams, er, and either, yes, verbal consent. No, er, yes, written consent. No or not asked. And, and that's it. So then we can complete that and then we can save and exit. Then 30 days later, we'll ask you very quickly to let us know about follow up data. So, was the patient still alive? 30 days POSTOP? Yes or no. Were they discharged? Yes or no? Yes. So what was their length of stay? Um And were they readmitted for a complication related to their index operation? Now, if we've also asked here about complications? Um and, and the reason for this is um we, if there is a complication, we're specifically interested in whether the video was reviewed. So, er, and, and specifically within that a complication requiring reintervention. So if we, if we tick um no complications, for example. And um no, uh and yes, someone's rec record reviewed the video, then you get this option. What was the purpose of it? So, quality assurance, eg and M and M or was there some training or, or research done with it? Uh And that's the end of it. But um if this is just gonna give me some warnings, if they have a complication, sort of three or above on in CLD, then if you say um yes to, to the video being reviewed, you then get this option saying the patient had a, a grade three or above complication. Did the primary operator watch the video back before uh following the complication and then you can say yes or no there as well. Uh And then again, what was the purpose? So that in that case, it might be an M and M meeting in education and that's it. That's, that's the uh data collection that we're we're asking for. Um So hopefully it's not too arduous and, and hopefully it's fairly easy for, for people to contribute to this. We'd love to have you all involved. Um And if there's any issues, please just get in touch with me and I would be very happy to, to do my best to answer them. Great. Thank you very much. Any, any closing uh questions or, or comments, Miss Yasin, Miss chain. Thanks very much for organizing it. Andrew. It's, uh, it's great and I'm looking forward to uh, well, you know, thanks to Ben as well. It's been a great discussion and uh looking forward to the next few series and to the outputs from your study. Thank you very much. Yeah. Yeah. Likewise. Well done. Well done. Andrew. Let's, we'll put, put, put some of these thoughts or on the, on the Twitter X thing, we can, we can keep the discussion live on there and I know that we can find lots of people to get involved with this so that, you know, it sounds like you're going to need a few 100 you know, several 100 cases to get to get this going. So good luck with that, I'll get, I'll get all of our teams involved from here. Brilliant. Thank you very much and thank you both for taking the time out of your evenings to speak. It was a real pleasure and I've, I've learned a lot from, from our discussions too, so I'll just put a little quick advert in, in the chat. Our next webinar is um on A I assisted surgery and that will be uh next Wednesday starting at half past five again on Medal. Uh We've got some great speakers. We've got um Mr Hanney Marcus be speaking on uh A I and neurosurgery. We've got Miss Katie Siggins, um, talking about A I and endoscopy. Uh, and we've got doctor um Pietro Macani, um who will be talking on A I uh for critical view detection and laparoscopic cholecystectomy. So I hope you can uh join us all that brilliant. Thank you very much.