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this meeting is being recorded. Hi, everyone. And welcome to the scalpel in Trocars Webinar series. So this is the sixth webinar. Uh, and we have Mister Carb in today with us. Thank you, Mr Carbon, for joining us. Uh, So Mr. Corbyn is, uh, is a fellow at the Royal Sorry county hospital specifically in robotic pelvic, your oncology, Uh, and his main interests, including your oncology and robotic surgery. Uh, thank you for joining us tonight. So initially, we're gonna start with an introduction to robotic surgery and the robotic systems, and then he will talk about an overview of prostate cancer and the management of it, and then we're gonna go a step by step. Um uh, regarding the robotic prostatectomy and the post operative management and what we need to know as junior doctors. Great. Hi, Mister Carr. Been. How are you? Yeah, good. Pleasure to meet everyone. Thank you very much for the introduction. Uh, t o. Uh, with this, I think I'd like to start my presentation as, uh, as possible. Uh, I'll share Mace for me. We can now see your screen. Great. So, uh, so today we'll be discussing about, uh, a shorter, brief introduction to robotic surgery with specific emphasis on robotic radical prostatectomy. Uh, I'm Danny Darlington Carvin and one of the robotic surgery fellows in pelvic oncology. Uh, in the royal Sorry hospital. I have nothing to declare. I'm not, uh, part of any robotic companies. Uh, the topics for today will be under the following hips. Uh, one is robotic surgery and the basics, and we'll be covering the advantages and disadvantages of the robotic surgery. Uh, we'll also be going through parts of the robot with steps of robotic radical prostatectomy. And it's post operative care. Uh, we'll also touch base with some of the future surgical platforms in robotics as well. So, first of all, the basics and the history robotic surgery was originally intended for warfare surgery. So that can do so that the surgeon can be safe while operating on injured soldiers. Uh, and somehow we didn't pick up predominantly. The reason was because of the slower Internet connection. There was always some delay, uh, in reciprocating the moments in the robot, and therefore this did not pick up. There were initially several prototypes of the robot like see us and the s up systems, which are just an extension of laproscopic systems and the Da Vinci system. As you know, Well, uh, was FDA approved for human use in the year 2000, and since then, millions of surgeries have been performed using the Levinsky system. The version, which is very commonly used nowadays, is the multi port seven c x A system. And we have the same system in the royal story. Hospitalized? Well, uh, but the the intuitive surgical's have come up with the newer version of this, uh, UNC system, which is the single port system, which is very much, uh, more common common use in the US than in the UK Nothing so coming to parts of the system. The report has three parts from left to right in this image. The left is the surgeon console, and the middle one is the vision coat. And the far right is the patient port as the names in play. Uh, the surgeon console is the one, uh, through which the surgeon controls the patient port. So the patient, the surgeon will be having plenty of let controls and hand controls called the Masterton Troll, through which he can operate on the patient patient console part. So all these three systems are interconnected through wear rings. This is a picture showing the robot in use. As you can see, you've got two surgeons here working simultaneously. This is called a dual console where we attached to robots together. This is very much valuable for teaching purposes. You can also see the vision cart with the display, which tells you the, uh status of the surgery and the number of instruments used and the lives left for these instruments. The right one is the patient card with the patient on table. Uh, the patient card is attached to the patient through, uh, instruments called ports, and we passed the robotic instrument through these ports. And, of course, you will need a better state assistant to help you. During the surgery, the message assistant will be switching the instruments, helping you, uh, with his laproscopic instruments. So the main advantage of robotic systems are the economics, because the surgeon you can see is completely at rest. His a sitting position doesn't have any strain to his shoulder or the neck, as in laparoscopic surgery. And, of course, you have the three dimensional and magnified vision, which is which makes the surgery very You seem to do so coming to laproscopy versus Robotics. I would consider this as a comparison between chopsticks and endo wrist. So, uh, in laproscopy, you get a straight long instrument with with with only two degree of two or three degrees of motion, whereas in the endo wrist. So all these are instruments with the indoor is technology. So indoor is you get plenty of joints with more than seven degrees of moment. So you you get to do a difficult step in laproscopy very easily in the report. But your robotic procedure depends also on the laproscopic and robotic skill of the assistant. In addition to that, a robot proversity were magnified and three dimensional vision, and several Sally's approving it to reduce the learning curve associated with any operation. It also releases the blood draws and thereby promoting early likable. So far. So in our royal sorry hospital, we have even started doing a day case prospect. So the patient comes in the morning, gets the operation then which is of course, a major operation and it goes home by. If you mean this again is a endodontist technology, which almost mimics the human hand. And as you can see, all these instruments are very minute and smaller in size for precise manipulation, so advantages and disadvantages of robotic systems. So, first of all, the advantages you get less blood loss with early recovery, and robots have been proven to shorten the learning curve for the operations. And unlike Laproscopy, there is very less musculoskeletal damage to the surgeons. It also provides better oncological and functional. Consider patient's. The main disadvantages are the costs of the robot system and, uh, need for a dual console for training a surgeon and, uh, availability of the robot and training officer. Gin is not Saturdays it in many of the centers worldwide. Yeah, sure. So coming to steps of robot assisted radical prostatectomy Uh, first of all, I would like to discuss something about how to manage prostate cancer. So it prostate cancer. The disease will be classified as localized to the prostate. Locally advanced, that is, uh, involving the lymph nodes and met aesthetic. So we do robotic prostatectomies mainly for cancers, which is confined to the prostate. Two. Of course, there are centers which do surgeries even for locally advanced. But this is always clapped with radiotherapy, your hormone therapy. So as long as the primary modality is offered mainly for localized prostate cancer, So coming to steps of prostatectomy, uh, the patient is put in a steep reversed in the best position where baby, baby, keep the head and down the leg end up. So this position is mainly, uh, put to bring the bubble above so that you get some space in the pelvis to operate on the prostate. So in order to connect the robot to the patient, you need pro course. Pro course need to be placed in the patient supplement. The first trocar will be in the midline, and subsequently we infuse carbon dioxide air into the carbon accident to the tummy to create a new mop atonal space, and all the other ports will be in seven ash. Oh, sure, In the pictures, all the low ports are robotic ports and the purple and green ones are assistant ports, so the robot will have four ports and the system will be helping you through two reports. One is a fireman port, and the other one is a 12 millimeter port. Among before robotic ports. The middle one, the umbilical one will be for the camera and the other three will be for the instruments. So there are plenty of instruments which you use in robotics surgery. You can use scissors here on the right side and the left side. You you get to use bone apples. Buy paralysis is bipolar forceps our progress from the left side. So these are other instruments which have specific purposes during the operation which will discuss slating. So finally, when you go inside with the camera, you are seeing all these three instruments with your camera and to your rights here to get the scissors and the left side, you have the bipolar forceps. It has culturally, you can pass country through these to coagulate Tissues and scissors also can be used as a cold cut and forgot rest contestant. And the other instrument in the four left is the progress up what we call as a retractor. So in robotics surgery, you you don't need any assistant much. You operate in three arms. You don't operate in two with using two arms like in laparoscope. The advantage of robotics is you are producing three arms 12 and three so you can control all three arms simultaneously. So coming to steps of robot assisted radical prostatectomy with pelvic lymph node dissection, the first step will be a proceeded dissection or dissection of the seven physical, and subsequently will will. Some centers we might Amit. Some centers might do a pelvic lymph node dissection and other steps will be bladder drop bladder division and posted a division of the prostate dissection of the prostate. Subsequently, the steps will be now sparing and, uh, other steps will be posted. Prostate medical division, docile wane division and we divide and ligate the docile been complex for a by epical dissection. Then we debate the urethra and finally and estimates the bladder to the urethra. We removed a specimen and close the skin incisions. There are some pictures I would like to share the So when we go in with a camera, first you do the posterior dissection. And subsequently this is the bladder, which is attached to the anterior abdominal wall. I hope you're getting the, uh, remarks. Uh, so this is the bladder wall, which is attached to the abdominal wall, and we dropped the bladder down so that's called the bladder drop. Once you drop the bladder, you go well below into the bladder prostate junction and insist the bladder neck that is exactly the junction of bladder in the prostate. And then you go behind the prostate and dissect between the rectum and the prostate to to create a space out. So this is the most beautiful part of robotics, which you cannot do much in open operations called Nell sparing. So I'll give a brief orientation of this picture. This is the prostate, and, uh, and this layer is a denonvilliers' facially oh, that's the rectum. A lot of studies and cadaveric studies have proven that the nerves which are responsible for continents and erections run through the postal lateral aspect of the prostate. So we try to preserve Postrel lateral tissues as much as possible to preserve the nerve nerve structures. And depending on how much level of preservation is done, the nerve sparing is called extra facial, inter facial or intra facial nerves. Bone so extra facial you dissect out of the denonvilliers' facia. You can see the plane out of the pink layer denonvilliers' facial, and they checked out of the lateral prosthetic facial asthma. So this is a lateral prosthetic facial. So you go out of this and remove everything in one go so the patient will lose his prostate. The patient will lose his dinner and bless aphasia along with all the nails. Mel fibers. So this is done mainly for a high risk disease where we don't want any cancer to be left inside. Inter facial nerve sparing somewhere partly with partially in between extra and intra facial nerve sparing in inter facial plane we go between the lateral pelvic fascia and the prosthetic facial. The prosthetic facia is the one in the gray color, and the lateral elevation is the one which is chicken. So you go between these two planes. So we kind of preserve half of the nerves and half of the nerves go out, uh, into the prostate. So patient be left with some some part of the nerve favors so that he gets some some amount of continental erections. So this is done mainly for intermediate risk disease, Uh, where you kind of have a bargain between cancer control and preservation of structures. The inter facial nerve sparing is the dissection done on the prosthetic tissue. So it is the dissection just over the capsule of the prostate. So this is then mainly to remove only the prostate so that you get all the nerves and other structures into the patient. So the patient retains all the important structures which are essential for continents and erections. So this is done mainly when you are very much sure that the disease is not out of the prostate just confined to the prostate. So this is done mainly in early prostate cancers. So this again, this is an interpretive picture showing the prostate here, and you can see the nerve bundles here. Can you see this? These are the nerve bundles, this bright ones with the artery to the know. So all these things can be beautifully seen in the robot. You cannot see these such a view in open surgeries. So here the surgery is going and exactly on the prostate, and he's kind of releasing all these bundles into the patient so the patient will be left with all the nerve bundles getting an early continents and erections. Hopefully, this is an intra facial. No aspirin. This is again a screenshot of some of the surgical videos. So this is the posterior dissection explaining the posterior planes anterior to the dinner. And, well, especially, this is a prostate. And we go anterior to the rectum and anterior to the dinner. Blefuscia to preserve as much nurse as possible. Uh, this will be the final, uh, appearance of the pelvis after we remove the prostate. This is where the prostate was. And we have preserved all the nerves on either side of the prostate with all these arrow heads are nerve nerve fibers. Once you put the category inside, you bring the bladder from below into the urethra and stitch it the blend of the operation. So I'm going to show a short radio clip of the operation. Uh, I would like to thank my mentor, Dr Puneet Ahluwalia, who kindly agreed to share the videos with me. Uh, let me run the videos. It is. It's kind of annotated video. You can go through this. So first is once we go in with a camera, we make an incision in the posterior peritoneum. So this is the rectum. Sigmoid and the rectum. This is the bladder. Here they make an incision just below the lower part of the bladder and the peritoneum and the pouch of Douglas, and we get the vast difference in the similar basic load. So that's the same basic. Okay, so once we do that, some centres proceed directly for the bladder drop and some of the centers do lymphadenectomy. So we have a normal Graham called break anti nomogram, which is an online normal graham available in the, uh, website. Uh, it was devised by doctor brick anti Europe. Uh, there will be some perimeters, including age staging, grading and PSE levels based on which you can calculate the risk of finding cancer in somebody's lymph nodes in the pelvis. So if the risk of having cancer is more than 5% in brigantine am a grown, it is ideal to do well in for elective. So in this patient, probably his risk was more than five. So we went ahead and processed did a bilateral infinitum independence. So I'll be showing the right sided notes first. So the area of decision will be medial to the externally ago. A tree Obbo. It goes up to the bifurcation of the camellia country and immediately it goes up to the medial umbilical ligand. So that is the external iliac artery. And the this is the X l e a grain. So the dissection proceeds all over the Exelon way. Sorry. It's so uh Okay. Yeah. So we defect all along that the rain Here we are dissecting over the rain and you separate the lymphatics and the limb from these are all the lymph nodes which are separated from the leg pain. Yeah, Let me show you a video. Sorry. Okay, the this is the fourth, um, there is a progress which holds the median umbilical ligament here. What you What you see here is the median umbilical ligament, so that forms your medial boundary of limestone dissection. So this is the advantage of lapresse robotic surgery in laproscopy. You cannot, uh, simultaneously manual three instruments. So here you are doing scissors, bipolar and the progress at the same time. The depth of the defection will be up to the operator now. So once we find the operator now we know we are in the maximum depth of our dissection. So here the surgeon is going lead immediately and dissecting somewhat of the in floor. So he has created a packet of lymph nodes. He has discipline, packet of lymph lowers, both naturally and immediately. So now the only extent remaining is diesel extent and the beeper extent. So that's the operator now is he? Has the sudden has dissected further. That's the operator now there. So now he's going distantly up to the femoral rain. The female canal. There's a lymph node of clock weight. So once he removes o'clock winners, the dissection is or so that are going to see are better. You know, having our credit artery and the lymph nodes were removed and put it in a We put it in a separate package, I said, Great that. Okay, so that's the vessels and the operator operator Artery Olympic enlightment. So everything is bag separately, and the same thing is done in the left side as well. We have done the left sided in the air, clean floors dissection. So once we do that, the next step will be bladder dropped. So, as I said, the bladder has dropped from the abdominal wall. You go into the space between the bladder and abdominal wall and reach the prostate. That's the vast difference, so glad it was dropped. From now, that's a few big boom. Well, that's a few big bone here. So that's the operator internals and the libertarian immerse ALS. That's the operator know which we saw in the lymph node dissection. So now the bladder is dropped. Our next step will be to proceed into the junction between the bladder and prostate and disconnect the bladder from the prostate. So this is the bladder with the Foley catheter bulb inside. That's the prostate. Here, the surgeon is making the incision in the anti report of the bladder Prostate Junction. So once he goes deeper, yeah, he finds the category inside in the midline into the in the bladder. So that's the catheter inside. So now we are into the bladder, and the surgeon is making another incision in the post year part of the bladder Prostate junction. So once you finish doing this, uh, posted a destruction, you'll end up in into the space behind the process. That is, the seminal vesicles, which was already dissected in the first step, will come into your view. Then you kind of pick it up, and the subsequent destruction will be behind the prostate between the rectum and the prostate. So here the this is the rectum. The surgeon is going between the rectum and the prostate, and the subsequent steps will be so That's the bladder. That's the prostate. And these are all the civil vesicles. All these blood vessels to the prostate run between in these two pills one pill er on the right side and similar pillar behind this in the left side. Here. So you need to clip and debate all these. Let's supply let's support to the prostate to remove the prostate out, and subsequently you need to divide the urethra as well. You had to go find the prostate ureter junction, and divide that. And then the process basically will be out. This is the landless facia. They've got anterior to the renewables aphasia between the prostate and the renewable astasia. So these are all prosthetic blood vessels, which actually we're just debating here with country. So they're supposed to prosthetic pedicle we call any blood supply to any organ is called pedicle themselves. So kind of just they were just pedicles and your process is free. So next become more anteriorly. So this is the prostate here. This is the prostate is a pubic bone, and these two are the pupil. Prosthetic ligaments, right side and the left side. So between this triangle lies the deep venous complex and that also venous complex. So very, very much large, distended veins full of blood. And if you start cutting, you will see plenty of bleeders. Some surgeons try this first and then divide. We kind of cut it first and then take a bite to take switches there. So this is an X step DVC division. Docile, venous complex division. Once you do that, you reach the urethra and you get a debate. The return. You take all the prostate so you can see the Lumen of the veins opening up all the big veins here bleeding and then here decided, is taking a stitch into the open veins. So this Hotaling will take, uh, uh, maybe three or four time the direction of what we're doing, uh, robotics in a laparoscopic surgery. So that is one of the advantages of their listed instruments in the Indo wrist technology. So it's almost done. So now once you finish this, the prostate, it's attached to the your itra. You need to debate somewhere here. That's it. You can see the catheter there. And, uh, yeah, it's a process. It is free. Now it'll be back. We'll put in a separate bag, just inspecting the specimen to make sure we're not going into the cancer. And the next step will be to an estamos the bladder to the urethra. Sure. So Doctor Rocco is one of the Italian surgeons who described this, uh, Rocco Stitch. So many people will be wondering when you remove the prostate, there is a huge space. And how can you bring the bladder to the urethra to fill the space? This is where the Rocco's teach. He described this technique of stitching, uh, the supportive ligaments and structures around the bladder and the urethra so that the farmer could platform for your anastomosis to be done. So this is a step showing media from the dark Oh, stitch. So in this, the surgeon doesn't take any part of the mucosa, but takes around the tissues around the bladder and the urethra so that they both the bladder and the literal, come together with good opposition. So that's the Rocco's dish, and then we proceed with an S m o saying the urethra to the bladder. I think we should do better. So if you can if you closely look into these stitches here. So all these teachers are not regular stitches. They have what we call Barb. They have something like a thorn. Thorny stitches. So once you take stitches into the tissue, they don't come out. So it's a it's a uni directional stitch. Unlike other stitches like proline, which kind of tend to become loose in these teachers, you don't even have to tie a knot if you take a stitch through the tissue. The barbs all these, uh, threats within the tissue doesn't get loose. All right, so that's the anastomosis, which is complete now. And, uh, usually, we test this anastomosis by infusing a lot of selling into the bladder. Uh, check for any leak in the anastomosis. So you're feeling this blood of it's Elaine. Look for any league. Usually there won't be any leak. Uh, there are stenosis. Good. There's no leak there. So we keep this category for 10 to 14 days and remove it later on some centers place a drain. We don't place a drain in our patient's interval. Sorry if you do lymph nodes, we generally place a train at the races. Not okay. And post property care. We don't give any antibiotics. We give dalteparin during the stay in the hospital. Nowadays, we have started, even even started to a day case possible to be where the patient goes home on the same day. Or, uh, usually, uh, they go home the next day, the catheter gets removed in 7 to 10 days. We also do a self talk program where we teach the patient's how to remove the catheter and, uh, they removed themselves at home. The histology report will tell us the grading, staging and if the margins are positive or not. And also, any extra prosthetic extension is present or not. These things are important factors to decide about subsequent follow open management. We checked the first P s a value in three months. Same after the operation. Subsequently, it will be a three monthly psh check in the first one first year and six monthly for the 1st 22 subsequent 2 to 3 years. And after all, it will be hearing so some of the topics for future robotic surgery so This is a single port system where so, as we discussed in the previous pictures, instead of putting in several ports, you have only one port through which you pass all these instruments and do the operation. So this is the single port Trocar, which has a set up to part the camera for the scissors for the midland forceps and fenestrate for everything goes through one cannula and all these in students are flexible. They have multiple joints and they are flexible. So finally it will be This is a single port robot inaction using a single portal abdomen, you can't remove the prostate. So other future prospects in surgery one is, uh, augmented reality. In surgery, there are a lot of companies coming up with, uh, super imposition of augmented reality images in the surgical field. So look into the last picture. This is a kidney. Uh, this is the ABC, but the augmented reality software kind of predicts all these things accurately. And in Fox, a surgeon tells you that this is IBC. It even predicts this is a gonadal vein here. A Novi surgeon may miss this gonadal vein here, but you got the gonadal vein there, and three D printing is another, um, upcoming thing. We even doing a lot of centers in the UK especially useful in kidney operations. So if at all, the patient has a tumor in the upper pole on the lower pole, we feed these CT scans into the software, and the software prints the kidney with renal artery, renal rain, Toyota and the tumor. So you get a very accurate depiction of what's there in the kidney. And several robotic systems have come into using artificial indigenes in robotics. Uh, they're not dead it. But there are few robots, including the Smart Tissue Autonomous Robot or the Star Robot, which has autonomous functions for repeated tasks, which need high precision. So this cannot perform an operation skin to skin, but it can do some very precise steps in an operation like bowel anastomosis, vascular anastomosis alone. All these things can be done by this robot. This has Flores in a three d meeting with the camera system, and it can sense the force are played by the instruments, and it can position very accurately, and it makes precise cards, even in irregular soft tissue. It's camera visually tracks the cutting pot and cutting tool while adjusting to the moment it can do independent anastomosis better than experiences in. It's in a lot of studies. It's not. They're available. The market hit. It's not not it licensed for human use. So in a natural, robotic surgery is here to stay. And New York platforms will reduce the cost of the surgery. Uh, it is, of course, being expanded to other branches in surgery, like general surgery, hepatobiliary and, uh, gynaecology, you know. So training future surgeons in robotics is vital, but it is challenging because of the non availability of dual consoles in several centers. But this can be overcome by to some extent by tell if surgery and tele mentoring. Uh, so I hope you enjoyed our session today. Uh, if you have any, uh, any inquiries, you can conduct me in the abo, uh, email ID and that's metrical handle. Uh, I hope you had a good time. It was a pleasure to discuss robotics with you. Every one of you wish you all the best. Thank you. And thank you. Scalpel. And for cause for giving me this opportunity. Thank you. Thank you so much. Thank you. so much. This is very interesting. I personally have enjoyed that. Uh, I think, uh, robotic surgery nowadays is very challenging, as you mentioned in terms of training, especially for especially for the junior doctors as well. Um, it sounds scary to me in terms of will robots replace surgeons in the future because we know that robots can do things very precisely better better than experienced sections. So that that I think it scares me personally. Star robot. Yeah. So what What has happened is there are some robot which there are some robot companies which have infused artificial intelligence into the robotic system. And it's very easy to do that integrate into these systems. Uh, they have tried a lot of things, but each and every individual is different, and there are a lot of considerable anomalies, So the robot cannot most likely do a complete operation, but it can maybe made two, or let to do a particular step in an operation like supposed retinal operations, which needs very precise hand movements, can be done by the robot. So you open the clearer and everything give the retina to the robot. The robot will operate, and then you'll start closing. Something like that are of astral estamos issue. You can open, dissect the iota everything and then let the robot to the anastomotic part alone, which is fixed in every patient, the fixed part. The constant steps can be done with the robot. Will you say that the outcome of robotic prostatectomy is better than previous methods of prostatectomy such as Opener? Yes. So, uh, in open surgery, the base will be having a very huge, uh, lower incision scar, and they will be staying in for several days. The catheter will be for more than two weeks because in open surgery, many seconds to do interpret anastomosis, not the continuous anastomosis. So there's always a margin of error and leak, so we cannot keep the category for long duration. And, of course, the only difference which is not there is an oncological. Of course, if you're a good surgeon, uh, you can give cancer control with robot or open, no matter what the tool is. So, uh, what is it? A fool with the tool is still the full. Just like that. So you have to obviously be a good surgeon. Finally. Thank you. That's that was very interesting. Thank you so much for your time. Uh, thank you guys, for joining us. I will shortly send you the feedback link so you can also generate your certificate. Your feedback, as you know, is very important to us so we can improve in the future. Uh, thanks again, Danny. Uh, thank you. Uh, yeah. And thank you. Scalpel and tacos for organizing this, uh, good job. Keep up the good work. I look forward to working further with you. Thank you. Have a good night. Thank you. Good night. Thank you. Bye bye.