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Good evening uh and welcome to uh our tonight's uh from the uh Duke's Club. Uh It's a pleasure to see you all joining us tonight. And uh I would like to, to thank uh you our advanced um cancer uh speakers for uh joining us tonight. Um Just quickly before we start um uh a, a quick advert about the Duke's weekend. It's uh gonna be the week and starting the 15th of September. And uh you will, will receive an advert about this. So please book in your study leave for, for the weekend and there will be some uh weekend courses as well that we have advertised before the TM and the CME Cadet courses. So, um without, for a, I would like to introduce Johanna to introduce our speaker and start the wear. Thank you. Hi, everyone. And um thank you for joining us today. Thank you more for the introduction. Um I'm particularly happy today to introduce our three speakers and I want to have a special thanks to War and Helen Mohan from joining us from Australia at a particularly early time as it's 5 a.m. in Australia. Um And I think it's quite exciting topic today. Um And obviously Elaine Burns from um where I am at the moment at Saint Mark's. Um I think the topic today is very exciting given that um everyone has a particular interest in robotic. Um And it's about robotic pelvic exenteration, how, what we can learn from fellowship, the challenges on the learning curves. Um But also we're going to look, look at some interesting uh videos um and learn more about um up and coming studies and also um a talk for the challenges by Elaine Burn. So, without further ado, um I would like to start with Helen Mohan, um who is now a consultant at Peter Mac in Australia. And uh she has been very supportive and she was one of the previous Dukes uh committee member. She was the previous um advanced cancer uh rep and she has been very supportive with everything so far. So without further ado Ellen, thank you so much. Uh Thanks for the intro, Anna and thanks for the invite. I'm just gonna try and share my screen. Um OK. Can you see my slides? Yes, great. OK. So I'm just going to present a little bit on where we're at with the evidence and the data for robotic pelvic exenteration. And then SATIS is going to take us through some of the technical aspects and um Elaine is going to talk about the barriers. Um So just some disclosures, I'm faculty at the International Medical Robotics academy and the study that I talk about in this tu ropes is supported by proxy. So why consider robotic exenteration? I think one of the key things we're at the dawn of precision surgery. Um And as medical oncology has moved towards more precise tailored targeted treatments, surgery has also um began to head in a direction towards increased precision. Um and some of the potential benefits and the hypothesis behind why we would consider pelvic exenteration robotically. Um is that compared to traditional minimally invasive approaches, the extra um wrist movement, et cetera with the robot potentially gives um better um precision and access um deep in the pelvis. Um As I'll talk about from the initial series suggest that there may be reduced blood loss. Um And the big kind of unmeasured long term outcomes, things like um large incisional hernias and also the more short term outcomes like the functional outcomes and rehabilitation are all things that we wonder whether um adopting more minimally invasive approaches may be beneficial for. But what does the data actually show? Where is the evidence currently? So I think it's really useful when we think about robotic pelvic examination to think about the ideal framework. Um And as you know, the ideal framework is used in looking at integration of surgical innovation and basically divides surgical innovation into a number of phases of adoption from the very early kind of initial reports to it becoming more mainstream and established. Um So, in terms of the data, so the the first kind of um snapshot kind of um systematic review um from 2018 from the Pelvic Collaborative um included just four studies with 37 minimally invasive um exenteration. And that includes both laparoscopic and um open. And they did show a longer operative time but did show less blood loss and a shorter length of hospital stay. Since then, there's been quite a number of uh series from um various centers in the world. So there's probably about um 10 to 15 centers internationally that are doing a um a kind of that are kind of early adopters of robotic pelvic exenteration. And one of the um leading centers in terms of numbers would probably be Tata Memorial Hospital in India um with a CLA and um in their first series, they showed 100 and 24 minimally invasive exenteration and 59% were total. Ex the rest were posterior ex sense and 23% were robotic. Similar to a lot of other series. They started with soft tissue exenteration as their primary focus and they benchmarked their data against the Pelvic database of um of pelvic exenteration and demonstrated safety and feasibility. Basically, they've subsequently published a um a comparative study where they compared oncological and perioperative outcomes in um 97 open versus 61 minimally invasive um exenteration, 17 of which are robotic and again, the results are quite consistent, longer operative time but fewer wound complications and less blood loss. Um Another group that are um that have led the way in terms of pelvic exenteration are Quenton group in Bordeaux. And they've used the ideal framework to publish their initial series. So their initial series, they published as an ideal stage two A evaluation. Um And it's interesting, they've actually demonstrated um better outcomes with robotics. They've showed reduced overall morbidity and reduced blood loss and reduced hospital stay. Um However, it is a little bit more expensive with approximately 1000 €658 more expensive per patient. Again, they focus primarily on soft tissue accentuation. And then here at Peter Mac, um we recently published um beyond te resection. So, exenteration and any beyond te resection with our initial series of 24 patients and demonstrated very similar results to those other studies of feasibility and safety in selected patients. Um And again, MD Anderson in the US um has published similar data basically showing that it's safe and effective. So there's been a more up to date um systematic review in the EJSO this year and that now included 11 studies with 2009 patients. So much larger systematic review than the previous one. Um And they've shown no difference in overall or disease free survival, no difference in recurrence and no difference in lymph node yield or or zero resections. I think noting no difference in our zero resections is is, is good because the initial thing we need to establish is safety and efficacy. So for oncological safety, I think that's an important point. It did have a longer operative time, but less blood loss and shorter length of stay, which I think is very clear when you read the individual case series that that was likely to be the outcome. Um they also showed a reduced rate of pelvic sepsis as well. Um And but in that study, again, the numbers are still small. So if you look at the numbers, um only 58 of the minimally invasive exenteration included in this series were actually robotic. So, 22% of their minimally invasive exenteration and 3% of all exenteration. Um We've just done a systematic video review looking at the current videos of pelvic exenteration just to try and see the distribution of what kind of um organs being resected. And again, the majority are a soft tissue, extensive bladder, some of these skulls prostate. Um There is some with unblock side walls and um more advanced structures. Um But essentially what that has brought us to is to set up a study called ropes, which is robotic pelvic surgery, looking at robotic extended resection for locally advanced and recurrent pelvic malignancy. And the idea is that we will move from ideal to a which is basically single center individual series to ideal TB where we've got multicenter prospective observational data. Um And this is an international study with all of those centers that we've mentioned and the UK, with Elaine at Saint Mark's being instrumental in getting us set up in the UK and Dina Hardy um in the study design in Manchester. Um So the structure of the study is we have an initial um defi to try and see what people in the study are doing currently and trying to find parameters for the study. Then we're moving on to a prospective observational study and which will then hopefully evolve into an ongoing registry. Um So the initial defi basically the aim is to establish current practice in robotic pelvic is intubation and beyond te resection. Um And these are just some initial kind of preliminary results from the first round. So um the total number of robotic beyond te resections per year. Um So you can see that very few centers are doing very high volume. So, and this is selecting the centers, these centers are basically the centers that do robotic pelvic exenteration and you still only have about a third of them that are doing more than about 26 robotic beyond TEME cases a year. So it's still, it's still relatively early in its adoption, patient factors and planning robotic approach. The most important factors that they cited were um tumor factors and preoperative imaging. Um And I think what's interesting is looking at the anatomical structures that are resected, the majority of centers um are either performing or would like to perform soft tissue exenteration robotically. And there is a little more hesitation with um vascular bony and nerve resections. The next phase of the study is the prospective observational study which is moving us into that stage two b of exploration of the ideal framework. And the aims are basically to establish safety of a robotic approach, to establish efficacy and to establish considerations in case selection for robotic approach and barriers to robotic adoption. Um As part of that, we will be looking at um patient outcome measures including problems. Um Secondary objectives are to assess the acceptability of a robotic approach to the surgical team. The um including the wider theater team and learning curves in robotic beyond Te and Pelvic. So the methods will be looking at basically preoperative decision making operative findings and strategy, clinical outcomes and then functional outcomes including problems and abdominal wall morbidity. Um We're just about to close the first round of the DEL I and move on to the next round. Um And um the aim is that we're hopefully going to be up and running for data collection by October. Um I'd like to thank um Elaine Burns in particular for her help and Dina Hardy for their help in the UK and the support of the Pelvis Evan Qu us to let us present this recently at Pelvic and my mentors. Um and the leads on the study with me, Mr and San Harriet are head of unit. I'd also like to thank approx me for their support of the study, which has made it feasible. And thank you again for the invite. If you are interested in your center to participate in the study, do drop us an email and we can get you involved. Thank you so much, Helen. That was going to be my last question. How are we getting involved? How can we get involved in this? Um It might be worth putting that at the end of the talks as well. Just is interested. Thank you so much and thanks for this great su review of the studies and this exciting new study on um Robs and how things might change in the future. Um I want to invite the next speaker, Satu Warrior and he's a consultant from Peter Mac. And um it's, I'm looking forward to all the videos and all the different techniques. Uh You're gonna share with us today. Thank you very much. I think we can see. Yes, it's all up and running now. I think you're still muted. C Very good. Yeah, I can hear you now. Thank you. Yeah, thanks for the invitation to talk and a fantastic talk by Helen um disclosures on screen. So as as Helen has set the scene, um normally we're using robotics to remove the meso rectal envelope. But today's talk is very much about the technical aspects around doing beyond TME and that, that involves taking adjacent organs uh gynecological urological organs and sometimes soft tissue. Uh we know the compartments um There are different compartments that can be removed. Um And the focus I guess of some of the technical videos is are pretty much on the posterior and lateral compartments, which are a little bit more challenging for surgeons. It's an example of a exenteration where the right uh internal iliac artery has been taken with a total pelvic exenteration. Uh And whilst the, the photo looks good, um you can see that it's a big cut um with a high potential for abdominal wall mo morbidity and um potential for complications. And this is a patient. I'll show you a um video of later where they've had a fairly extensive resection including excision of the sciatic nerve. But you can see the incisions are, are less, less obvious and abnormal morbidity is less potentially. I think it's impo important to establish from the start that having a program which has mis um uh approaches requires a team. Uh you need case volume, you have to be selective in terms of picking winners. And ideally you want access to robotics as well. From uh our unit point of view, our uh consultant group has, has changed with um Helen uh joining our group. Um and a very welcome addition and we have other supportive people uh involved um in terms of taking on uh more complex cases. I I think it's important to have the team um have a shared mental model. Uh incorporate video reviews, try and work uh as a team to reduce your cognitive load and time management is important. But this is beyond the scope of this particular talk. I th I thought I would give particular mention to Amrish Rajkumar who gives me a lot of um help and reduces my cognitive load in theater as particularly helpful from a technical standpoint. Now, because you're talking about training in uh robotic exenteration as a trainer. I think it's important to state. Uh It depends how the fellow would come into a uh program. So it's different having a robot novice versus an expert, a competent robotic surgeon where the aim is obviously to get them to an expert phase. Uh We look at um teaching and I think majority of the uh teaching in a robot exenterated case would be component operating. It's really important uh to have mentoring during the case. And for the mentor, it's important to manage time uh in a busy theater where the case will happen and will go long anyway. And, and future future role of there certainly is a role of simulation but form formalizing cognitive simulation in these cases, as well as um using tele mentoring, as Helen had mentioned, proximally for more advanced uh robotic exenteration will be important. Uh It just uh very quickly on the data that part of which um Helen has has presented. Uh we know R zero is the the strongest predictor for survival and the data is varied in terms of survival. Um It's already been presented, but Pelvic collaborative showed longer operative time, less blood loss, shorter length of stay. So there are potential advantages. The initial series were small. And initially, when we started, it was very much uh to establish uh feasibility of a robotic Beyond Te platform. Uh So we did a case series that uh Helen has alluded to. It's a little and you can see here the, the tumors abiding the the right uh lateral compartment. So, uh using a vesica to, to, to um get out onto the side will expose the external uh iliac artery and vein using sharp dissection. And as we do that, um we're able to preserve the obturator nerve and take the lymph node package. But importantly, um uh keep the tumor away. We're doing a proximal ureteric uh division here and clipping it and taking uh branches of the internal iliac artery. Uh If you do that, technically, uh it's important to realize that you will have to come across the bladder or the distal ureter. We've done a um hysterectomy vaginectomy and are adopting an anterior to posterior approach for the rectum. There are some cases, we adopt a transanal approach uh to divide the rectum. The vagina is closed, colic clonic pouch is placed in the pelvis and then where the ureter has been removed. We'd perform a bo a flap and that is sutured in. Then following that, that is tested um in a pelvic drain, it is placed in the pelvis. So it's a fairly straightforward um lateral compartment operation. This one involves uh more posterior uh involvement. There's, s four involvement with um potentially a vaginal involvement as well. So, dissecting out the back, normal T MA plane and then down onto presacral fascia. This is anterior into the vagina um opening the vagina is um reasonably good with a mccartney tube. Um Down at this level, it's uh the ureter is out of play. And then once you've stripped the presa fascia, you're down onto bone, the fenestrated bipolar um technically is very good for taking small vessels and we're using a Masonic bone scalpel to uh divide the bone. And you can see as you get beyond the bone, there's definite give the separation as you get into the um post um sa called fat. And the important thing, technically here is not to go straight down. It's actually to hug the bone where there's a risk of button holding the defect uh is closed. And our preference is to use gluteal based uh flats for closure. Uh I have included this, this is a um combined, this has been published as well. It's combined T ATM E ultra low with a seminal vesicle involvement. Um Here, the T ATM E um it's con uh slightly controversial but it's used um as an adjunct uh for the procedure. As you can see a normal TME plane, we're trying to get up onto the seminal vesicle um from a transanal approach. And what that does do, it does facilitate um easy preservation of the patient's anatomical, right, seminal vesicle um and take a wider peritoneal reflection on the left side which um we u routinely use for complex cases. ICG through the ureter uh stents catheters, but it does um does stain the urothelium. The similar vesicle is um taken by taking the vast defer and you follow that down to the pre uh formed a pre diss area from below. And as you can see, the final dissection is complete. Uh using the VESIcil, there is a false grain from the second uh operating light, but you can see it looks different. Uh And this patient did particularly well. The operation took uh four hours as a combined synchronous operation and the patient went home day four with clear margins and recurrence free. And he had alluded to our early series. But as, as a mixture of um uh rectal cancers, 80% 45% were restorative. They all had adjacent organ structures. And um of the resto non restorative, the majority had peroneal flaps. Operative time was um was long, but there was some blood loss and some cla and three morbidity. Uh Importantly, the R zero resection uh rate was 95%. Uh our, our conclusions from this. It's robotic B on team is feasible. It should migrate to Multicentric studies and certainly uh with ropes, there's an opportunity to do better and be more collaborative. I've included uh another case. So this is a 73 year old um female exsmoker. He's had long course chemo duration and an ultra low with adjuvant uh capsid been at is at an outside institution and surveillance imaging revealed a metastatic deposit in the left pelvic side wall and she has re received repeat uh need event. Chemo radiation is felt. The involvement was um piriformis um nerve roots uh sciatic nerve uh which would involve uh taking a proximal interno iliac artery and vein. So bear with me. So I'd say redo in case. So adhesiolysis is required. Um the robot is particularly good for that. It's a lateral um dissection on the conduit ICG through the ureteric uh catheters. Again, just facilitates easy um identification. The conduit is um divided at the pelvic brim which gives us access to the goal vessel. Uh The ureter can be viewed on, on screen. A ure catheter removed, it's ligated. Then um once we have taken the round ligament that, that allows access to the external um vein, um immediately we're looking to try and get on bone and you can see the um bone present and this is dissection anterior to the internal iliac artery as we prefer as we um uh here we're um floating the common iliac artery of the psoas muscle. And that's purely just to get um control, the lateral uh margin is defined by your normal um uh the external vein, the obturator nerve is importantly preserved here because we're planning to take the um portion or the sciatic nerve. The obturator vessels are preserved for are taken for convenience. The external vein gain is dissected off the uh underlying mus muscle structures. And then following that the internal iliac artery, um you can see the impact of radiation here. It's pretty stuck. And I would argue that a vision uh in a robot case is probably easier than an open case. Um Unless you're routinely using loops uh with the steady platform, internal air cay um at its origin is taken and the dissection continues, there's posterior branches, the main trunk and the superior gluteal artery is probably an early um main trunk and we see the superior gluteal artery later. And um that's Amra just pla placing clips, the assistant, we continue the dissection really to get exposure of the vein. And that allows um the operator to um sling the common iliac vein. The external iliac vein is, is slung as well with the vess loop. And following that, you can see uh the pearly white fibers of the uh lumbars trunk coming down from a medial view. And here we're floating the external common iliac uh vein, uh completely dissect out. And that's important just to uh find the obturator nerve that creeps in, particularly if you're trying to um take the nerve higher up. Um approximately completes your lymphadenectomy. It also allows access to the uh internal iliac vein. And this maneuver is particularly important. So you to get, we're here, we're only able to place one proximal um good. So the superior gluteal artery is sacrificed. Um And that, that sits between L5 and S one anatomically majority of the time. Um There is a risk of um buttock pain or buttock ischemia if you take it. But um uh this patient had no, no sequelae. Um that allows for distal um di um division of the internal vein, which um means your vascular, um the artery and vein are clear of the nerve. So it sits uh posteriorly alone here. We DM I cutting the local anesthetic is placed prior to um resection. And whilst we use a little bit of diathermy, the majority of the di uh division is performed uh straight scissors to cut through the, do you know of? And once we've got through the nerve with um using sharp, sharp dissection very much onto bone, uh the procedure in this particular case, taking the gonadal on the right side. So, um doing a very similar uh procedure on the right, uh we're coming across the bladder on purpose and this, we mapped out pretty um carefully beforehand the vagina. Um So again, just stating, you have to come through the ureter or you have to take the bladder, the medial aspect. Uh Here, we're taking the um nerve roots lower down. And the important thing is probably to stay on the midline on bone. And by doing that, you can take the nerve roots that you want to give you um access to the peri for mus muscle. And the peri for mus muscle can either be taken partially or um completely in order to get your margin and uh from a functional sequelae, that's the hip flexor. So it they will um have some impact from taking the piriformis, gives us access to the sciatic nerve as it's um closer to exiting the foreman. And again, it's sharp division with local anesthetic. And then that is finally, um the specimen is is free and that's extracted. It's quite a big specimen. Uh There was a little um a small um bleeder that was reinforced um with some robotic sutures and then the hemostatic product placed at the surgical bed. And that, that is the operative bed on, on view with the our left ureter on display internal artery which has been divided the uh common internal external vein on view, the obre a nerve on view all preserved. And following that, the reconstruction is performed first uh vagina and then um the bar or flap as as demonstrated previously uh is placed and closed and then uh tested. Yeah. Mhm Yeah. And the specimen as seen, um you can see the ureter, the artery vein and the uh present in the specimen. I think that might be the end. So the, the blood loss was about 200 mils uh T four N zero. There was e extra colonic vascular invasion, important invasion into the sciatic nerve and all margins were clear. And whilst this video um shows this is in the fairly, in the early postoperative phase, the patient has a left ankle brace, so they'll lose dorsi flexion because um that's dependent obviously on the sciatic nerve. Um they're able to walk um with a frame and they're disease free at 18 months. Um So she's, she's very happy with her result and um free of pain. I'll show you another. This uh particular video is a more recent one where we have got a metastatic deposit that we're resecting with partial nerve resection and piriformis nerve um resection. So we've already um divided the internal iliac artery in this particular case. And this is the internal iliac um vein. You can see it again in 3D platform using the fenestrated bipolar um to help isolate the internal iliac vein uh which is divided uh clipped and then divided. No. Yeah. Following that, the um dissection is continued um laterally lateral boundaries um formed with again, with dissecting under the common external iliac um vein. This was particularly fibrotic given the, the radiation which was used in the past. And again, it probably shows the, the platform you can see the radiation impact, um superior gluteal artery is um divided again in order to get access um to the the vein, again, you have to float the vein in order to get the nerve um on view. And here you can see Amrish placing uh two clips on um superior gluteal artery, it divided. Um And in this particular case, I I do this is a posterior branch of the uh external common junction. It's probably an early division of the superior gluteal vein which um is taken. And still, despite that, we haven't uh really freed up the uh common external junction. Um And this shows by o operating uh at the back we're able to expose and what you actually have here is um and it's Japanese definition, but we've probably got a two, a um uh modification. So you have a second ipsilateral um internal IAC vein, which is coming off. So you can see the two veins which have been divided in order to clear the vein properly. And following that um allows us to get onto the, the nerve. I don't know where a section to defining that was defining the medial boundary, the lateral um operating then continues. Um We did the same uh uh operation on the right side. Uh Again, there's an on block hysterectomy which is performed in this particular case. All right, I'll just forward some of this. And here again, the nerve um is being divided and, but we've chosen to um preserve some of the nerve fibers because we don't need all the nerve fibers to try and get a lateral margin. Um And that can be again, some mixture of cautery as well as sharp dissection. So I should say the fenestrated bipolar technically is quite good. And there are at least two, there's two vessels infero um internal pudendal uh in inferior inferior gluteal artery which you encounter um down below in the inferior gluteal vein is particularly important. And then following that, the dissection of um is right on bone. This will need to be edited a little bit more this video. Um And it's a fairly recent case and then again, the proximal margin to get down on to bone, to take the piriformis muscle on block. And by staying immediately, we can take the the nerve root out and that's just further division of the nerve as we continue. Um again, there's a lot more footage that needs to be worked through. Yeah. And to continue, I might skip to the end just to show the. So I'll pause that video. So you can see the obturator nerve is present. The scalloping represents the nerve roots. The piriformis muscles been excised completely the ureter whilst it's it's is bit up was fine. Um And the internal veins have been divided, the ex and the internal iliac artery um has been taken as well. So estimated blood loss uh for the case was 50 mil initially, I was ready for discharge at day seven, I was awaiting a rehab bed and it was an R zero. Patient did get a secondary collection, required antibiotics and I just reiterate the importance um of having a collaborative um uh prospect um ideal two B prospective study again. Thank you. Thank you very much for um some eye opening videos and technically challenging and very exciting at the same time. Um Thank you very much. Can I remind everyone to please post their questions if they have any? We'll address all of them at the end of the three presentations. And it's a great pleasure to introduce our next speaker, E Lane Burn from Saint Marks who's going to talk to us about the challenges um addressed Thank you, Elaine. Thank you Anna and thank you for inviting me. I'm not sure quite how to follow those uh videos. They were absolutely awe inspiring and please do join the rope study. It's vitally important. I'm going to attempt to share my videos. It bear with me disappeared. Ok. Ok. And just please let me know that that's working. It should be full screen and you should see them at full screen. That's um so again, I'm delighted to talk, I've got a few disclosures. Much of this talk was actually, is part of Shas Mohamed's MD. So with her per I have shamelessly stolen it. And so thank you, Shaz without you then I could not have known where to begin with this talk. Um So I'm here to talk about the challenges and barriers to an introduction of robotic pelvic exenteration surgery. Crucially these, so these barriers came out from an interview study, which was the first part of a different Delhi study, which is designed to look at the barriers to the actual implementation on a grander scale rather than on an individual patient basis of robotic surgery. In particular for advanced colorectal cancer. These were really the broad sweeps of the barriers that were identified by most surgeons. We're now in the process of getting ethics to discuss this with patients as well as with industry. So first one, I'm going to try and run through one of these, each of these areas. One of the crucial things that have been identified is really the lack of time, time and training time for these procedures as is artfully demonstrated, you know, they are long procedures and you're adding additional time with robotics procedures and there's a learning curve to go through during that time and you need access to theater. So, one of the things that we lack most to surgeons is time and that's so applicable in um advanced colorectal robotic cancer surgery. I'm not gonna run through all the evidence because it was beautifully outlined earlier by Helen. But the evidence is an issue in colorectal surgery. You know, Helen outlines that we're talking about 284 extended resections um including a mixture of total pelvic exenteration and posterior exenteration, which have a very different morbidity profile. And if we look at pelvic exenteration, the colorectal and robotic there is an increasing number of publications. So I think the evidence is coming and Helen and Saha's rope study will be vitally important in this. Hm, I'm not sure we have them there. Um However, you know, we're still at a very, very early stage of adoptions. We're still innovators in this area. We're still learning how to do these procedures. What's the optimal way of doing it? What's the optimal procedures that we can do? The rope study will help inform that. But there needs to be a greater body of evidence and the evidence needs to understand the challenges in pelvic exenteration surgery. This is one of the biggest studies. It's excellent by the Tata Memorial Group. Um But it contains a very small number of robotic events of 17 in total. And actually, if you look at the difference between the open and the minimally invasive surgery, there was much more total pelvic exenteration in the open group. So we're not necessarily comparing like with like they're all retrospective studies and they're all carefully chosen for robotic surgery. They're leaving out the awful Groy big tumors. So case selection is really important. There may be ways that we can begin to discuss like for like and we've worked with UK Pen to develop a coding system or a procedural lexicon for this type of surgery in order to allow us to begin to be, ensure that we're doing like for like comparisons. And this will allow us to really understand the and understand which procedures are important to be, continue to be open procedures and which can be carried out by robotic. And this may vary by center. So s excellent results, but that is maybe not replicas through other centers. Now, I felt left out because had a beautiful video. So I'm going to play my beautiful video and this is one of the side walls. And the reason I'm playing this is really not to just have a beautiful video which we all love as surgeons, but it's really to highlight some of the challenges. This is a gentleman who had a locally advanced rectal cancer and so far I've only done locally advanced and the current because of the concern around the fibrotic, especially around the vessels, but a locally advanced which was abutting the side wall and had nodal disease within the side wall. So we opted to do an pelvic clearance with a TN. So an extended resection rather than necessarily a pelvic exenteration. You may say a soft tissue exenteration. We have a slightly different approach from sati in that our first step is that lateral mobilization of the whole side wall. So the vascular package is um easily controlled and you have space on both sides you can see that actually, the robotic platform allows you to go down nice and easily as far as what I hope you'll see soon as the obturator nerve and um L5 S one to optimize attention and open the space continue the dissection to sure why that's happened. Um And that was Mohamed's reporting, you can begin to see L5 S one and the obturator nerve coming into view, but it's still a very confined space. And in a second, you'll see the ves sealer coming in. And when you see the vesicle, you can actually see that it, you know, it takes quite a lot of the space up there. It is, it's a reasonably big instrument, it requires some dissect, you've got hinges on the back of the instruments and I worry about the way that they can catch off you and the major vessels. Um And you have skeletonized your vessels and you have the robot and perhaps one of the concerns is around control of that, the video goes on. But for the sake of time, I'm just going to move on. So when we go back to the barriers, we've identified some in terms of technical factors. But let's go through each area from, um we talked for lack of evidence to infrastructure and oncological safety and technical challenges and training system. So these were the ones that were really highlighted when we talk of infrastructure and one of the big problems is lack of access. It's the number of robotic platforms, certainly within the UK is exponentially increasing. But having them at the right site, having them accessible to the colorectal surgeons at the time when you, for example, have a urologist, that's all technically challenges. One of the challenges we face is we've got ICU on one side and robot on the other side and bringing those two together means that we have to very carefully select our robotic procedures currently. And that is a barrier to further implementing our robotic program governance and oncology. You know, this is an exploratory procedure currently within the ideal framework. So there is an important governance issue with this. There's an issue around whether we consent them and what we say to the patients in terms of the innovation in this area. And above all, we need to make sure that we're maintaining our zero resections. These are expensive operations in the UK I lose between 20 60,000 for most pelvic exenteration each time because of the problems related to the tariffs and the coding system. If I'm adding in into an expensive innovation and adding in longer time, who's going to pay for that? How can we be certain that that's adding value for the NHS team team is vitally important in these procedures. Sati mentioned it as well and the importance of his assistant. Um but team and creating that infrastructure within your team, creating the ability to do those slightly longer operations and um allow this in a safe and controlled manner when you're sometimes bringing in patient nursing teams who are used to robotics, but perhaps not used to exenteration and bringing those together and allowing them to be trained in both sides of the coin are vitally important. So I don't like to just bring challenges. I like to bring solutions. And these were the some of the solutions that were really offered by the people that were interviewed by ZA infrastructure and cost. I think as we are seeing a massive increase in penetration of colorectal robotics with that, we're now seeing sort of three main robots on the platform. Two of them have challenges and lack of energy devices, Humalogs, et cetera, but you know, five years time, the instruments will probably be equivalent and it may be that we can begin to use other platforms beyond the sort of market leader. So competition will help bring in some of the infrastructure will help bring in some cost and probably drive forward better technology specific tariffs. You know, can we lobby for robotic surgery as an innovative procedure which we think helps let the stay looking at all the initial data coming out. Can we reduce the tariff that's um increase the tariff that's associated with it and use that as one of the levers? And I think the rope study is an excellent first step. Perhaps we should be looking certainly nationally and perhaps internationally for Clinical Registry. And so we're auditing both outcome in terms of perioperative outcome in terms of adverse events oncological outcomes. So we can answer that oncology question, but also cost because that's the only way that we're going to be able to really drive through the penetration of um advanced colorectal cancer surgery. What are the technical challenges? Well, one of the technical challenges is bringing very difficult surgery with robotics and putting them together. And I truly believe that that can only be delivered within a pelvic exenteration unit. I believe that we need to have the expertise around us in order to deliver us, radiology, oncology, nurse specialists, the ability of those multidisciplinary team members, urologists, et cetera to manage patients complications and manage these patients through their entire journey. We know that the complication rates are about equivalent. So therefore, I believe that they should be managed within a pelvic accentuation unit. I'm gonna cut, these are some of the technical challenges that were identified. So t has really talked about lots of them, but the robotics is not an absolute panacea. It is a really stable platform. You actually the current sort of market leader has good energy device. It has perhaps a little bit big the energy device, but you know it is reasonable and the bipolar and the scissors are usually a reasonable amount to do these operations. They've got good stapler, et cetera, but there are limitations. It's difficult if you're working in different, in different quadrants, you know, at the end of a long operation, having to drop the splenic lecture sometimes is tiring. And so we need these robots to begun to be even more adaptable to allow us to fully benefit from them. Many people identified the loss of haptic feedback as a real concern and also navigation issues just being absolutely sure where you are in what is a difficult space and perhaps a concern around losing some of those key landmarks. And that you have, for example, within the pelvic side wall with those more focused and procedures, we don't perhaps have the same global overview without taking a step back. There was real concern around the management of bleeding and I think there has to be work about smaller and more effective energy devices. There was a concern about the ability of the multidisciplinary team to be ups skilled. We are quite lucky in that our reconstructive urologists do a lot of prostates and bladders. So they are robotically trained. But that has, you have to think about that across multiple specialties. These procedures are each bespoke we saw from point of view. And sometimes he was keeping, um you know, the majority of L5 and other ones, he was dividing it completely, you're planning each individual procedure. And because you can't just routinely do the same operation each week, then that leads to problems with training and learning curves and sometimes they are big tumors and they, unless you're doing a perineal extraction, then you may end up with a reasonable sized extraction site in order to remove them. So again, I think as um robotics increases, some of those elements will have to be overcome. But training, training is a real issue. It's a huge concern for most trainees that I have met coming through. Um not necessarily in advanced colorectal cancer, but in standard colorectal cancer procedures where robotics has taken over many of the current laparoscopic procedures and that's leading to difficulties with training. Um As many surgeons are on, they're still on their learning curves. So therefore, aren't able to train as effectively as perhaps before. And that is a real issue that we have to be aware of because not only do you need trained as a robotic surgeon, but you also need trained as an advanced cancer surgeon, bringing those two together can lead to quite a long learning curve in terms of the particular issues that were concerns for the interviews that we spoke to. It was around choosing suitable cases. Which ones do you start with? We have had a slightly odd learning curve because we can't do, we can do posterior exams but not necessarily a lot of bladder work because of sort of concerns around lack of intensive care, but we can do side walls. So it's it's a slightly funny mix, but each of that is solutions which are applicable to each individual center. How do you train the wider team, not just the team and theater, but also the multidisciplinary team and who trains. So there aren't many people doing this in the country as Helen show from the number of centers contributing data from ropes and the number of cases happening in each center. So how do you get proctors? I think one of the other challenges is really perhaps just speaking to the fact that this does need to happen in centers that are focused on complex rectal cancer. Um because you have to be able to, to my mind effectively do these open, especially if you're going to go out into the side walls to know the anatomy inside out. And those training pathways do have to unite for surgeons. What training solutions. Um I think on a sort of micro, micro level, I think two consultant operating definitely takes the stress out of it. Definitely they long procedures, the amount of burden and strain during the procedures is high. So bringing in two consultants training the whole team, I think in these procedures and having a standardized team makes a massive difference. And I think we need to be looking at international Proctors. I think the associations and I know the robotic steering group as well as the AC P Advanced Cancer steering group are looking at this. But we do need a greater role and greater push from AC P GBI in NHS England in terms of standardization of how we do it. And we need to bring in that training from an early stage so that the trainees coming through are able to achieve this cy and to do all that fundamentally, we need to go back and have time now going forward, there will be solutions. And this is the one Jordan Fletcher who um has produced these sort of work. He's done a huge amount in segmentation and how we can use imaging to help our understanding. And we could see that this sort of work could be put on to a sort of tile pro model and to allow us to have more um visual help us with their navigation. Now, clearly, this is not good enough yet, but I think there will be a future in this. And Jordan also kindly supplied the next video which is back to proximate, which Helen has gone through for this show that, but basically this is a CME it's not a pelvic, but you can see how you can have a proctor in one country and a surgeon who is proficient in the procedure um and has had some experience but needs further experience beyond um that could have an international pro to help them decide um go through the procedures and really benefit from that. So I think we are going to have to harness all our levers in order to overcome these barriers. Part of that is going to be developing our professional networks. And I think, and he are really driving that through our rope study where we have that space to allow us to um communicate with each other to help us overcome the various different challenges. I think we do need the evidence to not only demonstrate equivalency but superiority and outcome and also to look in detail at cost and to show cost effectiveness. We need to use a existing technology such as segmentation, but also such as um proximate and that sort of tele mentoring, we need to liaise with industry because we have to get the devices and the technology that's going to enable us to expand and keep pushing the boundaries of what we can do with robotic pelvic exenteration surgery. And in order to underpin that we need to not not be a talking shop amongst ourselves. We need to lobby patient groups and really lobby key stakeholders, use the association and use the different areas that we have to lobby the policy makers in order to help rule out robotics robotic platform um between ropes and robo comp. I just want to put a shout out to shad of study which is going to proceed as a defi with surgeons patients and industry in order to look at these um more global barriers to the implementation of colorectal cancer surgery. And finally, just another good. Well, we have frontiers 2023 as far as the marks and it's focused on colorectal cancer with a further side parallel meeting on I BD. And there will be robotics featuring quite highly in that. So please do sign up or come in person. Thank you so much for your time and uh I think you'll agree, we have lots of challenges to overcome. Thank you so much, Elaine for such a detailed outlook of all the challenges and who we need to approach and what the future kind of um direction should be to address them. Um Can I um remind everyone to please um put your post, your questions on the app? Um And oh, sorry, one of the questions has already come up. So, um for the observational phase of the rope study, which poems are likely to be used. So we're going to use EK five D and we initially had three proms included and we're just going to have a consensus with the participants to see if they think that's excessive and because we needed to be deliverable as when we needed all the centers to be able to participate. Um So I think the priority one is EK five D because we can do some health economics with that as well. Excellent. Thank you. Um Helen, could you pause your, the details for the ros on the um questions? So if anyone is interested, they can contact you for the study. Um In the meantime, I have a question for all three of you and um it's regarding the training and we've seen some fantastic videos and obviously the learning curve to achieve that. As Elaine mentioned, you need to be both proficient in open advanced cancer surgery, but also in your robotic skills. So what would your advice be for, um, a fellow who wants to endeavor in such, um, to basically get all those skills and become a proficient surgery, a proficient surgeon for the um, advanced cancer. Do you wanna go or do you want me to? I think, um, obviously fellowships will form part of the, um, the jigsaw puzzle. Um, I'm not sure. I think it'll be more than one fellowship and also understanding that it depends where you're going as Elana had alluded to, um, if you're going back to a, um, a supportive um hospital that is already doing exenterated practice, then having two consultants is probably a little bit easier to integrate into practice. Um, uh, if you're going back and trying to take it on as a, um, single surgeon with people who are novices around you, then that's a bigger challenge and then you probably need to upskill to a, a higher level before consultancy. We have had, um, I've had one fellow from Chile who was, uh, is pretty advanced and, um, had spent three years with us and he is competent, but still, if he were to, um, they're still waiting on trying to get the appropriate platforms um, into Santiago into his hospital. But if he were to um take on more complex cases. He'd probably use tele mentoring still um beyond um Telep proctoring. Beyond that, there, there are opportunities I think as the access increases. Um As for example, at said marks, um if they um obviously they're doing a lot of exenterated work, if they're robotics aligns with that, the numbers will increase the surgeons skill set up, the opportunities for fellows will increase, which will will I improve that fellowship experience as well? Uh From a training point of view, I think uh sorry, last thing is just training point of view during the fellowships. It's for me uh part of it when we're training is teaching components but also managing the theater. So it may do a lot of smaller components of an operation to give um a fellow an opportunity to do uh components that I think they're capable of doing. But it's understanding if you can, if you can do all the uh requisite components of an operation, you can put it together, but you do need pro you need competency and then proficiency in robotics in general, which may involve more than one fellowship. Yeah, just to echo that aa like as somebody who I guess recently transitioned from being a fellow to a consultant, I think the key, key things are trying to get your total volume of robotic work as a fellow as high as possible. So um like one of the things that was an advantage of Peter Mack was I could do a very high volume of general robotic colorectal as well as open um advanced cancer work. And I think as Elaine said, you need to be able to do the open advanced cancer work to fully understand the anatomy and to be kind of fully across it. And then you can um you know, begin to do components of the extended resections and obviously, like I'm in a very lucky situation because I'm working with is an ongoing mentor in my consultant practice, which is obviously, you know, the ideal situation to have a mentor. Um But definitely, um I think getting your general robotic skill set and your um advanced cancer skill set as high as possible is key. I just got that saying you should just go to pe for your fellowship for four years. Um um I think, I think this is a challenging area and I think we have a challenge especially in this country in delivering robotic training for sort of standard colorectal resections. Um In all honesty, I think that should be the focus right now. In terms of these, there will be a small number of senators internationally for the next sort of five years who are delivering these procedures. They will hopefully do it in high enough volumes that they will be able to train um fellows. But although the roll out is likely to be reasonably acute, I think um it will be relatively limited to a smaller number of centers, but smaller and probably, you know, 30 centers probably internationally doing it in any reasonable volume. Um And I think the current focus should really be in achieving good training for the trainees coming through in standard robotic resections. And then when you're in a unit that supports the service as a whole, actually the transition, although it's daunting is not as bad as it could be if you're not in that sort of supportive unit. So I think the initial focus should be getting a standard colorectal training. And I think it's going to be very difficult currently for fellows to come by profession in robotic pelvic surgery to go to either an exenteration naive center or a robotic Naive Center. It will be achievable in the long term. But I think currently it will be difficult. Thank you, Elaine. And um a further question just cause to you, Helen, cause you've recently um kind of transitioned from a fellow to a consultant. Do you think that there are any adjuncts that you found helpful or you used? So 3D models or proxim me or anything else? And then same question to Elaine is S trainers if that would make your job easier to train someone. I definitely think like in terms of when you're in terms of setting yourself up before you go on fellowship. So if you're going on fellowship, where you're going to have access to robotic training do as much simulation time as you possibly can beforehand. Because the further along the learning curve in terms of the generic technical skills are at the start, the quicker you'll progress once you get on the robot. Um And even, you know, I think as well try and focus on wherever you whenever you're in a center where you have a robot available and chat to the kind of trainers and that about doing component operating, even if they're not comfortable, um kind of training you to do the whole case, start building up components and just the more hands on you get the better. Um I do think tele mentoring and proxy and things like that are actually useful. Obviously, they're funding ropes. So that's a declaration of interest. But um I recently did a Thomas as a consultant, um which is the first one that I've done as a consultant and I had sati on proxy as a mentor because he was at another site in Melbourne. And it was really very useful for having somebody to trouble shoot the set up. And the and just for like general robotic stuff, it's quite helpful to have an extra pair of eyes sometimes just to give you that additional support because there is a difference when you transition from being a fellow like operations that you could do in your sleep as a fellow suddenly seem a lot more challenging in your first few months as a consultant even though they are things that you um were very comfortable with as a fellow. So it is nice to have that additional kind of mentoring beyond just your fellowship years Cation. What's your input on the? No, no, I think, I think that jumps are important. I, I do notice um we do have a robotic colorectal um uh a designated robotic Colorectal um fellow as well. Um And I, I do try and get them to do simulator training in between uh cases. And you do notice uh certainly early if they're robot naive the improvement in their performance. So that that's a um having access to simulation and using it is very important. Um We have done it, the proximate thing. I, I have um tele mentored as, as Helen had explained, I think it's a really important adjunct, particularly if you haven't had a high volume of robotic. Um Obviously, Helen has had a high volume but um there are other um centers, there's a regional center that had picked up robotics and I have been tele mentoring um them as well and that's been quite supportive for them. So I think that's an important adjunct and in terms of um 3D modeling, et cetera for the future, I think that will be very important. We have utilized it for retroperitoneal lymph nodes in the, in the past. But the ideal um situation for us would be for the more tailored complex type type work that Elaine had alluded to so that adjunct um for operating will be great as well. And then I would very much count myself on the learning curve of advanced um pelvic exenteration surgery. But what I have found useful is um developing networks of people that you can troubleshoot problems because um you know, sati learned in isolation really how to deliver a lot of these things because of his background of and knowledge in the advanced cancer and translated those over. But he has gone through a learning curve himself. He's faced a lot of challenges. There are simple things between saying to people exactly. How do you put your reports in for doing that? On the right side, I struggle with this. On the left side. I don't, you know, I'm OK, I use two rights. I use one left and creating those networks where you can have those conversations informally and saying, you know, this that I struggle with and it's nice sometimes you hear other people saying, actually I find that difficult. I tried this and it worked or I tried that and it didn't work. So I think those networks are crucially important and we've tried to build that through Pelvic in the UK, through UK Pen. And I think there is a real role in terms of robotics. There are clear leaders like and you know, memorial like Peter Mack, like MD Anderson, who are doing a really high volume of these things. And you know, the rest of us on our learning curve could come through and be really helped by that on top of everything else that we've already said. And the last question for me, how you mentioned stakeholders and the patients, Elaine, how do you get the patients involved in such a technically challenging operation or what is needed for that? How do you kind of simplify that the terms needed for them to understand it? Because I think it's something fancy and everyone likes it and everyone will say, oh yes, it's a Robert and it's probably the best thing now. But how, how do you kind of, how do they approach this kind of idea? A bit more easily? So it's challenging because to my mind, it is still an innovative procedure. Um and I, I do tell patients that we are now starting to use the robot for this, but it still is innovative. Um So I have told them about that. I don't get them to fill in a separate consent form or anything like that. I include that as part of the consent, other centers don't necessarily do that when they're doing sort of more advanced robotic surgery. I don't know what the right answer is, but I feel more comfortable if I have done that. Um other centers have had dedicated governance structures in place in order to um introduce these. And I know certainly in Sydney that they've had a carefully monitored governance structure because they've considered it a new technology. Um So, first of all, I think we have to inform the patient about what it is, what we're doing. And um I would like them to be helped to guide some of the research around this, which is I think one of the reasons why Helen included problems, why we're hoping to include patients in part of the sort of more the wider to see how we can um get their voice in all of this. What is important to them? Is it getting their tumor right? Is it going home a few days early? You know, what are the issues? Is it not having the cut up and down the tummy? What are the issues that are important for them and what can robotics deliver for them apart from being a nice tool for us to play with and perhaps giving us slightly less shoulder and back pain and neck pain and increasing our overall length that we can contribute to the NHS. And we do have to answer as to whether we're actually delivering value for patients or whether it's something for us. Thank you and Helen probably you mentioned this um or have you included any patients on the defi for the ro study? No, we haven't. For this phase of the study. We do have patients later on once we've got um the study up and running these patient involvement. But for this phase, we just wanted to get a snapshot of what the group are currently doing. Really. And so we've mainly just included experts in the initial defi great. Thank you, everyone. Um It doesn't seem like there are any other questions. Thank you. Both from Australia. Have a good morning. Um Thank you for your time and for all the exciting videos and the exciting study. Looking forward to all the results from the ropes, Elaine. Thank you so much for um highlighting all the challenges and thank you for your time again today. Thanks Kelly. Thank you. Bye. Yeah, thanks. Bye bye bye bye.