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Our final speaker for the session is MS knew her Yassin who is a consultant colorectal surgeon at the Royal Wolverhampton Hospital. She's a council member of the Royal College of Surgeons of England and she's part of the future surgery group and she is lead for robotic code erectile surgery for her trust. And she is the first female National Proctor for Robotics Colorectal surgery in the UK. So please can we give her a warm welcome? Thank you. Thanks for the kind introduction. I missed most of it because I was saying hi to Prof Cahill. So sorry about that. Um So thank you to Martin and thank you to um asset team for the kind invitation, but for a fantastic program, it says you've been an inspiring morning and I hope that you have um uh plans to stay and enjoy the rest of the congress. So if I was to put one slide up and this is the only slide that I put for my talk, it'll be this one, this slide shows you guys yesterday in all of your wealth from Twitter. Really? Um With all the sessions that you've had as a hands on session including the robotics, one with CMR that Dina was alluding to earlier with regards to the VR simulation. So if we talk about robotics, and if we talk about innovation, if we talk about the future, the future is you guys and the future is right here right now, not waiting till tomorrow. So, um if you want to take any message today, if you want to make any change, be that change yourselves, but let's go back to robotic surgery. Well, let's start with minimally invasive surgery because robotic surgery is essentially an extension of laproscopic surgery, mixed with digital innovation and all the other acronyms that you heard earlier. Why do we do minimally invasive surgery in the first place? I remember being a senior S H O in Yorkshire and having just passed my mrcs, I was asked, um, fill in for a registrar in the in the rotor because um, she was pregnant and couldn't do the night shift and that was my first lap appendix. I'm not going to tell you what year that was because I still consider myself as young quote unquote. Um And the massive difference between doing open surgery, laparoscopic surgery has certainly improved outcomes for our patient's. We know that they might not care so much about length of stay, but they care about having less morbidity, less pain and returning to work early. So there are many benefits of having options of doing minimally invasive surgery. So that's the laproscopic era and the laproscopic era has been ongoing for 30 years or more, but it does come with slight disadvantages. So, although better than open surgery, there are limitations such as having a two D camera. But when we're operating a body, it's a three dimensional thing. And also the economics you're standing up, but you're actually facing the wrong way. So eventually you get fatigued and they're straight instruments. Many papers have quoted chopsticks, but actually they're a bit more than that because you get a numb thumb. I don't know how many of you I can't see very well because the, the lights are quite bright. But how many of you have done laproscopic surgery in by the end of the operation? You think my thumb is quite numb because I've been squeezing so hard on this straight instrument. And of course, if you've had a good night, the night before your operation, you might see your enhanced tremors on that screen. So there are slight limitations. I wouldn't call them disadvantages yet, but I would call them limitations to laproscopic surgery. So then when you think of an extension to um laproscopic surgery, you think of robotics because that is minimally invasive surgery and it caters for the limitations that we've just mentioned. And you've heard in the last couple of talks. So what you can see here, I'm not sure if my laser pointer will work. So that's the trainee and that's myself, then we're doing the initial part of robotic operation with the setup and essentially it's laproscopic surgery. But look at the posture, you know, the economics are not quite right. And then eventually, what you see is that as a human being, we have joints, we have, you know, the shoulders, the elbows and the wrists and with laproscopic surgery, these don't exist, but the robot caters for that. So you can see here that the economics are much better, the person sitting down. And this is my urology colleague, where we're doing combined operations together. And that in a setting where you're sitting down and comfortable and you've got better vision. And again, in the setting of the robotic theatre, this is the theater in Wolverhampton, you can see that the trainee or the first assist is sitting down and comfortable. The whole atmosphere is very comfortable and welcoming, not the mayhem that we used to have with open surgery, but also what you see here in the corner is an F one. Do you see F one's in theater is very rare. So this is an anatomy lesson where the F one can see high dimension, high, three dimensional, really amazing vision and a new way of teaching anatomy. So it's about education, training and passing on those skills to the current and future generations and the core technology, regardless whether it's an intuitive or other platforms for robotic surgery. The most important thing gives us that better vision So it's three dimensional and high definition vision, but it's also 10 times a magnification. So you see uh surgeons in the, when I, certainly, when I go in Proctor, they, everything is magnified, you know, they think we're too zoomed in. But actually, that's the benefit of the robot if you can see something so clearly, are you likely or less likely to injure it? And then of course, there's the end of risk Axion where we have our own hand instead of a straight instrument, you're able to be both a scientist and an artist. Um And there's enhanced economics where you're sitting down comfortably and you're in control of all of your instruments. There is a pathway for training, but that pathway that interest you have focused on the consultant. And why do you think that is why is industries focus from a robotics point of view on consultants rather than trainees can't see hands up? It's because say that again. So exactly. So it's a, it's almost like who's gonna partake those skills to the next generation. And that was the lab co program. I don't know if any of you uh young enough or old enough to know about laptop. But that was the laproscopic training program in the UK to train consultants to become laproscopic surgeons. And that was Ethicon lead. But there were certain trainers and the people need to submit their videos, etcetera. But once you reached your capacity of having this many trained surgeons in across the UK and Ireland, then it had to be self sustainable and then the surgeons had to then train the next generation. So absolutely, you need to train the consultants. But it's a very old fashioned way of thinking because I learned laproscopic surgery alongside my consultant who was doing his lap, his lap co program. And what's really important to note here is that these steps, although this intuitive program of training focuses on the consultant, we can certainly emulate that. As you heard from Josh's presentation about the future of surgery and the fastest report, let's see if this plays. So just in the background, you can see just the atmosphere in theater, just training people, even how to put a various needle, etcetera. It's just a very relaxed atmosphere. Um But what's really important when we talk about the robotic ecosystem, it's not just the technology, it's not just the platform, it's the support education training that goes with it. And what's really important regardless of your platform is to make sure that there's the elements of online education, there's assessment, there's support when it comes to technology, either working or breaking down and also the ai side of things. And and with regards to learning such as what Dina had alluded to, there are many ways of proctoring doesn't have to be face to pace. Can it be via proximity or other platforms that are coming out in the market at the moment. So when you talk about digital surgery and robotic surgery have to look at your overall picture without knocking the microphone and the overall ecosystem. So the indication as a collect allow and general surgeon for me would be anything that's in the abdomen. The traditional way of thinking of robotic surgery was just focus on the pelvis, that's the most difficult area of the body. And therefore, that's what the robot has been built for. But that's absolutely wrong because we as colorectal surgeons are patient's come with Myriads of ailments and regardless of the etiology were hopefully able to answer their queries or sort out the issues without being too super specialist, which is the European model, the UK model is super specialist. So you think, well, how can I use this tool to cater for my patient's? Um and that would be by offering not just colon rectal um surgery but also other etiologies. And my example is colorectal because I'm a colorectal surgeon. And this high um the fourth generation uh of intuitive, I'm sorry for using intuitive as an example. But that's my uh current platform that I use has actually completely transformed the way we do surgery. So instead of thinking, where do I doc, am I going to have clashes, etcetera with the improvement in technology, we're now able to access the whole abdomen in a single docking. So if you can see the the super pubic approach here, if you doc here in a straight line, you'll be able to access the whole abdomen to do a subject or colectomy, for example. And then with uh swiveling around to the pelvis, you're able to do a pan proctor if you so wish. So it has made docking and all the other things that people used to worry about a lot easier and therefore access to further indications in the abdomen and the pelvis. So this is a video or just showing the anatomy, I was just pointing to the Euro to their, the vision is so amazing that not only able to teach the procedure, regardless whether you're doing the operation or not. This is a patient who has had um chemo radiotherapy. The planes are really sticky, high B M I and there are what is able to give you that arm regardless of how heavy that anatomy is, is give you that vision in the pelvis where you can actually see the nerves and hopefully preserve them. So this was the initial experience. This is the right hemicolectomy where you can see the anatomy is very medial. You can see here that the pancreas is very, very much visible and the duodenum that's D three, you've gone round the corner of the pancreas and you've gone down D two and D three. And again, you can, if you so believe in central venous ligation CME, that's an operation that can be performed much easier robotic compared to the laproscopic approach because of the economics and everything else we've mentioned, you can see here the end of risk being able to use an instrument like your own hand to be able to access that vessel and control it compared to the straight laproscopic instruments. And again, the vessel sealer is one of these energy devices that you can use to facilitate the procedure. And you might remember the old fashioned goldfinger. Again, you can use this um retractor here is called the tip up just like a gold finger to go around the transverse colon medicine tree. So hopefully this is wetting your appetite, not for lunch, but for uh surgical procedures that can be performed robotically and both will just go back. One, both Dina and Profit Cahill. I was just going to show you um I C G here have shown the benefits of I C G but actually blood supply is really important. We all talk about anastomotic leaks and prevention. Well, blood supply is something that we used to uh use the cut test. I don't know if many people still experience what the cut test is, but just to see a blood supply in a way that's not measurable is not in, you know, the year 2020 23. We need some other way of actually saying to the patient that we have done our best in being able to sleep at night is using that technology such as I C G So before the transactions, you're able to give a small amount of the dye and that just shows up good blood supply before the transactions. And then after the anastomosis as well, this is an integral Pauriol isoperistaltic anastomosis for a right hemi. And again, suturing is made far easier because we are you able to use that in the wrist motion um and being able to use um intricate procedures, being able to do them robotically and integral poorly rather than having to have extraction sites that are in the upper abdomen causing more pain and therefore more complications. And hopefully you'll get to see the, yeah, the I C G here showing that the blood supply is still fabulous for this, right? Hemi in Estima assis, there are other complicated procedures that one can do. Dina mentioned uh over cycle officially for diverticular disease. Well, they can happen for cancer as well. And what's important here is that these are transferrable skills and we learn from each other. So if there are urologists in the group, we've learned a lot from the urologist on how to um perform a partial cystectomies with or without the need for urology to be in the room. Um and also how to close that bladder by essentially closing the fistula, but making sure that you use all your robotic skills to perform that in the most optimal way. And you have to be flexible as a surgeon because it's not everything's textbook not every B M I is low. This patient here has a mass in the right iliac fossa. So the book tells you too doc in a certain way and actually, you can't for this patient. So you have to just lateralize your port and docks slightly lateral so that you're able to move away from the pathology and have a wider surgical field. Similarly, this patient here has a high B M I. So a low um docking would be quite difficult to be able to reach a so called promontory. So it's a trans abdominal and one of the ports will be where the ileostomy is for this subtotal colectomy. And again, patient's with high B M I and uh uh co morbidities are able to have these procedures robotically safely with less POSTOP complications. And these are other cases that one can do robotically again in a minimally invasive way such as are you l pouch formation for this patient who had a subtotal colectomy initially as an emergency laparoscopically, that was in the initial, I've had a couple of years of laproscopic surgery followed by, by 2.5 years of robotic surgery. So what one then can do is take down the ileostomy, use that as a port and then you can do your docking for your robot without creating too many extra sites for docking, perform the procedure for a completion proctectomy and then follow it by an idea anal pouch again, the use of I C G is really important in seeing that vasculature for the small bowel and using it. Uh, see exactly where to use the elongating procedures on the mesentery prior to performing the pouch surgery. And I'll anal patch anastomosis. And this is a case where we've had a combined procedure. This is a partial exenteration. Uh, the patient had a really aggressive cancer, um, and had a defunction in Colostomy. Previously, you can see that that was there. Um And just through this kind of docking, we were able to access the whole of the pelvis where she had um an on block resection of small bowel anterior section, partial cystectomy anti HBs. Oh and the extraction because she had a bit of a paris normal hernia was all via the colostomy site. She was able to go home day three. So this is what the robot can do for your patience and it is patient centered care that we should always focus on. There are other procedures. Um Certainly over the COVID period, patient's have gained some weight, had high B M I and therefore experienced some incisional hernia. So this patient here had a previous um anterior section and extraction was midline, developed an incisional hernia and that was repaired robotically and was able to go home the same day. And this patient, he had developed a paris normal hernia, which was also fixed. The benefit of doing robotic sir for hernia and abdominal wall reconstruction is you can actually close the defect. Most laproscopic surgeons find it quite easiest to suture at the ceiling if you like. So um makes it a lot easier to do that robotically. And you can choose whether to put the mesh in as an ipod. Um In this case, it's the sugar baker because of the paracetamol hernia. So the possibilities are endless and that's what robotic surgery allows you to do. There are many benefits, but we talked about data data are lacking and that's a call for everyone to join the research. Josh has said it, Dina has said it and profit Cahill has said it that if you're interested in research, this is your calling now because data are required for us to continue this good work because at the moment, it's all anecdotal, it's small center, uh not many randomized control trials. And again, the patient's of the focus. So in little old Wolverhampton were able to have a multi specialty, a robotic user group from Thoracic to dining on Gynie Benign, obviously colorectal and urology and able to cater for our patient's. But what about training? So Josh has said it all, I'm not going to repeat what Josh has said in the first test report, but please do really, it's really important and what's important is for you all to take part today and rather than have industry drive training, I think what's really important is for all of us to collaborate and, and get together to make sure that we drive training and make sure that we've got equity of access because that is quite variable across the UK and Ireland. And what about recovery plans which were mentioned early in the presidential uh session? Um And sustainability was also mentioned, there are very good examples across the UK of how robotic surgery was used to allow for these recovery plans. This is the group from Norwich. Um and one of the audience earlier asked about cost, actually, this was the same day discharge colectomy. Now this rings alarm bells unless you start continue to read the article because you think, well, what happens to the patient's once they are discharged? Um And what's really important is to have those follow up protocols in place is to have a very robust eras program to make sure that you've got safety netting for your patient's because it's not just about length of stay. This is the team here in um U C L. This is the Mako robot and they've just completely the 1000. Not just I think that was December 1000 operations. And this is the example of a surgical hub where high volume centers are able to train uh and also perform uh these surgeries and be part of the recovery plans. I don't know if anyone seen this um on either Twitter or linkedin. Sure, you've all got social media accounts. I was impressed by the photo this is the most diverse surgical photo I've ever seen. So it's fantastic that the guy's and ST Tommy's um, uh, team have completed the hit whenever I hear hit. It's about exercise. But actually that's surgical hit lists where they've performed eight prostatectomies, robotic prostatectomies in one day. Um, and prior to that, they had 17 other lists where multi-specialty from Gynie, two G eye etcetera where, uh, they've performed these hate surgeries before. So when we look at this picture and you think, well, why can't we do this every day? And again, previous speakers have alluded to workforce. It's not just about us here in this room, it's about who else is required to perform any operation or to look at the surgical journey and surgical flow. And of course, trainees are in the center of it all and you're all here today because you're interested in the shape of surgery and your future. And here's an example of how training is a leading from the front is James in the in the audience thought I'd embarrass him. So this is the Birmingham team and they performed the uk's first Net Zero operation in Solihull. I do want to ask a Neil and the team if they cycled to work or not, but we'll, we'll hear about that later when they talk about the sustainability later in the afternoon. But it can, it can be done. We just need to collaborate and learn how we can do it together, not just be the first to everything, but be able to collaborate and see how others have done things before, whether it's training or whether it's sustainability or recovery plans. Because we've got fantastic examples across the UK. And of course, it's not just the medical field. So we can uh there are actually better examples outside of the medical field that we can learn from. Of course, the robots are different, but here are examples of how robots can help with sustainability in general. So we should be looking at how we can learn from other uh societies and examples of positive practice. This is a good paper and it just puts you all into perspective and we can actually see that not every operation should be done robotically, that that is an important thing to consider and also think about cost effectiveness and how we can bring that cost down. But most importantly, this is a journey that's still in progress and we're all here learning together how to improve it for everyone. So um again, a plea for education training as well as sustainability and making sure that we do this together. So if I was to put a final slide, I love this great from Barack Obama. He says that change will not come if we wait for some other person or some other time, we are the ones we've been waiting for. We are the change that we are seeking. So it's important guys that if we want to see robotic training in the center of what we do is that we actually start to lead from the front, such as what Josh was talking about earlier, start, start to make sure that we have pilots in the UK that have started these programs of training. How do we emulate that? What do we learn from that practice and make sure that it's translatable across every region across every dean arri in a cost effective way and finally have some fun surgeries. Fun. So this is some fun with socks. Uh Every time somebody wearing funky socks in theater, I make sure I take a picture. Some of them are mine and a little plug at the end. SGB I, we are holding the Congress in Harrogate this year in May and we have a robotic session, robotic training sessions called the Robot Start uh robotic workshop. Amongst other sessions, including to EDI sessions. One is coming out at the Congress and the other one is about race, ethnicities and beliefs. So thank you for your time and um happy to uh ask to answer any questions just before lunch. So I'm afraid that is all we have time for um for our research and surgical innovation plenary. Um So we will begin again in whole one a at 1 45 for an inspiring leadership session. Um Just before we go, can we give a big round of applause to our fantastic speakers.