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Um Our next speaker is Professor Dina Hardy who is a consultant colorectal surgeon in Manchester University Foundation Trust. Uh She's recently been awarded an NIH are advanced fellowship and she's been appointed as associate professor in surgical trials at the University of Leeds. Please. Can we give her a warm welcome? Thank you very much. It still feels really weird here in the name. Professor, I consider myself quite young and trendy and I'm a millennial. So, you know, my name is Dina. Um I'm going to give you a flavor of what surgery 4.0 is and it's really going to be um an insight um and just a little bit of uh sort of setting the stage for my colleagues who are going to come and follow me. So what do we mean by surgery? 4.0? So we mean digital surgery. We're talking about the era of bringing a new digital technologies to crystallize clinical practice and training to improve outcomes for patient's. We've gone through this revolution in surgery really. So we've gone from traditional open surgery to minimally invasive laparoscopic surgery. And currently, we're in this era of robotic surgery surgery. 3.0. And we're seeing this huge growth and adoption in robotic technology. But those early adopters of robotic surgery have realized that robotics is what spearheaded the next evolution or next phase of that, which is digital surgery or surgery. 4.0. And when we look at what that is defined as this was defined by a consensus statement of 52 experts. It's the use of technology for the enhancement of the whole patient pathway, whether that's preoperative planning, surgical performance or surgical training, therapeutic support and it's to improve outcomes and reduce harm. So what does that mean? So I think there are four key technologies that really encompasses digital surgery or surgery, four points areas. And that's data, analytics and data sciences. That's machine learning and AI that's advanced visualization, which is primarily holographic and that's surgical robotics and all of that should be crystallized with the cloud and connectivity to make sure that all of these technologies are interoperable. And we want these technologies to be delivered across that patient pathway from that preoperative patient consultation to diagnostics, to intervention to post operative care. And we're starting to see how digital technology is doing that. But we need to make sure as we've already heard really elegantly from Josh Burke that the surgical training pathways incorporated into that process and what surgery 4.0 does is it gives you technological digital technology um skills and it allows you to have um process optimization and objective optimization of what we are doing. It allows us to collect objective assessment metrics. It allows us to provide us with instant objective feedback. It monitors performance and eventually that leads to improved outcomes which can only improve outcomes for our patient's and for our trainees. But that's quite a difficult arena to contend with in the current NHS. And I think that one of the things I've learned as a consultant of, you know, consultant that who's only been imposed for about 14 months is you have to be pragmatic about the current system that we work in. We're currently a resource limited system, but I'm going to try and inspire you because there is a digital transformation going on within the NHS and it's going on within pockets of the NHS. And I think it's important that we understand that that's happening and harness it and learn from each other to try and see how we can expand that further. So I'm going to use my own example. I'm based at Manchester University NHS Foundation Trust. I currently work between the two key sites which is with ensure and MRI, but we're trust of 10 hospitals. And our biggest real world example of digital transformation is our electronic patient record. It went live last October across all 10 sites on the same day and it didn't crash. Now on my phone, one of my most utilized apps now is my epic at I can see what happens to my patient. I can see their results. But more interestingly, my patient can see their own results. My patient's get their letters straight away. They have the ability to contact any of the specialist nurses. Should they need to or any of the doctors, should they need to? And we're starting to collect different sorts of data. So not, are we getting real time objective clinical data that is coded properly? We're starting to get patient reported outcome data. So the data that's the most important to the patient and we're starting to bring those together. And that's giving us a much broader understanding of what we do and what impact that has. And so certainly, I think electronic patient record is a key aspect of digital surgery 4.0. And then obviously, you know, we've heard a lot and you, we will hear a lot about robotic surgeries that clearly, I'm a robotic surgeon. And I think in Manchester, it was our vision for having a multi platform robotic institute that really spearheaded our interest in what a digital surgery platform would look like. And I think most robotic surgeons understand that the robot is just a tool, but it's a very powerful tool for collecting data and for putting a computer into the middle of the operating room that gives you an understanding of objective assessment metrics, but it allows you to do other things. So it allows you to perform fluorescence guided surgery, which is a form of digital surgery. So this is a patient who had a diverticular disease and had a coal over cycle fistula. And what you're seeing here is I C G injected into the left ureter so that we don't damage it. So the green there is the urethra and that is a form of digital surgery. So that means that we're operating safely for patient's who have complex disease. But it's not just about what I can do as a surgeon. It's about what my trainees can do within that operating space. So these are all my trainees um across both sites. So for the Davinci trainees, they get access to simulation. And I think robotics has really changed simulation and transform simulation gone other days where you sit in a real but the back of the hospital that's cold and dark and damp when you sit on a lap box trainer that halfheartedly works know we're going into the realms of VR simulation. So the robotic trainees or the trainees that come through my department within sure, they get three sessions of um, two hours. Usually in the evenings of hands on with the robot, they learn how the robot works, they learn how to doc the robot, they learn how to emergency undock the robot. And I can tell you you might think, well, three hours isn't that two hours of 33 sessions? Isn't that much my trainee at the front there with Anna of Rover. She's a C T T trainee. I trust her implicitly with the robot. She can run my robot for me, with me at the console with no problems. And that's just with dedicated simulation training. This is Karina Stylinski. She's my ST six training at the moment. She's transitioning from the simulator onto the console. So robotic simulation training, you have to build into your robotic, your robotic program for your hospital. And you can see here this is one of our F ones. She is hanging out on the CMR VR headset learning how to doc the CMR robot. So I think, you know, robotics and digital surgery combined together in a beautiful way. We talk about smart glasses technology. So we want to capture interesting operations, we want to capture complex operations. So one of the things we've heard throughout this is that actually trainees haven't had the same access to surgery and the same access to operating theaters as they once did have. But we can take our theater and we can broadcast it to the rest of the world if we say wish. And that's particularly important in cases that you wouldn't normally see day to day, particularly complex setting or the multi visceral setting or you have multi specialties. So this is the pelvic exenteration team at Manchester. Two of us, a colorectal surgeons, one of us is a gynecologist and this whole case was captured for a patient who had a very, very rare procedure. So she had a total perfect accentuation with the left private sidewall dissection and a delayed killer anal anastomosis. And here you go, this is me operating during the left part of it. So, dissection and you can see that you get my view. And so everybody who wasn't in my theater could see exactly what we were doing during that operation and we were training them and we were telling them what the important landmarks were and how to do things in a rare case that they are probably not going to see that often, but some of them might be interested. But it's not just about the weird and wonderful when it comes to smart glasses technology, it's about the common and the um about the common as well. So this is Dan Dougherty. He was my S T six last year and this is him doing a sister and Leno. So proctology is really common in colorectal surgery. But it's one of those things that surgical trainees don't get that much access to and particularly in a pandemic where things like hernias, proctology, hemorrhoid weren't given, um weren't prioritized because cancer was prioritized. You didn't get the same access to those training opportunities. So here I'm sat in the coffee room and this is down operating using rods and cones and I can see exactly what he's doing and I can tell him what to do what not to do or just encourage him and one of the great things about smart glasses technology is it's not just great for the trainee. It's great for theater staff because they all know that you're on the other end of that headset, that it empowers them to be able to allow the trainee to train beyond just the case, but be the leader within the operating room. Because remember being a surgeon isn't just about doing the operation, it's about leading a team and then there's wearables. You know, we have to think about postoperative recovery and how do we want to manage our patient's effectively and efficiently. This is one of my colleagues, Anthony Chinese, a consultant, general surgeon at the MRI and he's running the Embraced study. So we're looking at smartwatches or the or a ring to see if we can send our patient's home early, but capture there postoperative data and capture their postoperative observations to highlight if there are any post operative complications that need them to come back to see us or to reassure them that they're doing well. So there's a lot of room for digital technology, digital surgery and digital training adjuncts in the current N H S. And this is one of my phd students, Aidan Bannon's work, he's going to start in August. So Aiden's going to look at digital technology solutions to look at how we can create sustainable solutions within colorectal surgery and how we can use um A I to identify what waist is and what good looks like. So there's a lot of applications of digital technology beyond what we think our current traditional outcomes. But I always think it's important when you're thinking about technology technique, new process, new procedure to look at the horizon and look at the landscape and look at what everybody else is doing on a global platform. Because peer to peer learning, a peer to peer knowledge transfer transfer is really important. So when we look globally where the healthcare systems are different, they're doing some really interesting things. So this was in China Hawari um did the first remote operation using five G surgery, February 2019. So it was a category cooperation. It was a uh hepatic operation, it was hepatic lobectomy, 60 minutes with no latency and no data lag. That's really exciting. That means that in the future using five G technology, we might be able to harness surgical expertise across countries, across cities, across patient's. And the UAE has just launched their first metaverse hospital. Now, it's a private hospital facility. But can you imagine if suddenly we take the whole of surgery and the whole of surgical care into the metaverse and how patient's that surgeons and trainees might interact with that? The opportunities are limitless. And then there's autonomous robots. Now, if you told me five years ago, when I started on my robotic training journey, that we might have an autonomous soft tissue robot, I probably would have never believed you. But this is some work that has been done in a lab in uh the USA looking at developing autonomous robots for intestinal and Estima Asus. And in a lab setting, when you compare an autonomous robot to a davinci robot to a normal laproscopic um uh procedure for a small violent optimus iss, you know, autonomous robot has much lower anastomotic leak rate, which is obviously of great benefit to our patient's. I think we're a little bit of weigh off that, but certainly this is something that is going to be coming. So why is all of this important and why is this all of this relevant? So I'm a millennial. You guys are all much younger than me, but you're all digitally connected. My life is digitally connected the way I access news, the way I access fashion, the way I access media, it's all digital. It doesn't make sense to me that I then work in an analog healthcare system that is completely different to what my normal life is like. And it certainly doesn't make sense for you as a group of trainees to train within an analog healthcare system. And I think you've already heard that with the technology enhanced surgical training report, you know, there is this shifting balance. Now we are looking at trying to make your training more objective through the medium of digital technology. But the future of the technology enhanced surgical report identified something else that was really important, identified the importance of innovation in surgery and innovation in med tech and innovation in the digital space. Now, innovation has always been part of the surgeons fabric. We think of ourselves of innovative dynamic beings because it takes a certain amount of self belief and self courage to become a surgeon. But this is innovation in a different sense. This is innovation in the sense of ideation, taking it all the way to delivery of a technology or a product that is going to make a difference to surgical patient's and surgical trainees. And there's a real shift now in the thought process. So when I was younger and probably at your stage, there was this thought about how surgical academia was not at the quality that it should be. And we've seen a real shift in that through the surgical research collaborative. We're now thinking about innovation. And I think some of that has been spearheaded by the pandemic and the introduction of digital technologies within and outside the NHS. And there's this shifting feeling that maybe we should think about adopting innovation earlier, maybe we should think about creating our own innovative products and processes and maybe we should look at robustly evaluating those innovative products and that has been supported by the Royal College of Surgeons. So the Royal College of Surgeons and currently piloting an innovation hub to help support trainees and to help support consultants who are interested in that very early phase of innovation. So we're all full of bright ideas. But how do we develop that bright idea? Well, that's where the hub will come into play. And the hub is a series of team members. I'm one of them. You've got Angela Lamb who's representing asset. You've got Josh Burke, you've got medical students, you've got foundation doctors and you've got a young body of consultant colleagues. And we're all here to say innovation should be part of a surgeons fabric. And as you've already heard, you know, we're about transferring skills and knowledge and education for the youth of today, for the trainees of today so that you get the skills that you need to integrate digital technologies into your Armamentarium, but also to perhaps develop those within and without the NHS. And you've heard that there's a shifting mindset. So perhaps integrating innovation will spearhead the integration of digital technology within healthcare. So I think the time for digital surgery 4.0 is now, I think it's already happening in pockets. I think sometimes you perhaps don't realize what is going on in your own doorstep. And I think that there's lots of opportunities to get involved. And I think that you are the generation that is going to take this forward. So I think it's a really exciting time and I would encourage you all to embrace surgery 4.0 in any way, shape or form that you can thank you very much Thank you, Dina for inspiring talk. It's clearly a really exciting time to be a surgical trainee at the moment. So we do, we have three minutes for some questions from the audience or from online. Um So if you do have a question from the audience, please raise your hand and we can uh find a microphone for you. You've got one of themselves you can see. So um that was a really good talk. Um I've got some questions regarding um the outcomes conferred from robotic surgery and also from an economic standpoint. Um Do you believe that robotic surgeries in the position to maybe be more commonplace and clinical practices? Um Even if the expense, sort of 1 may argue the expense doesn't really um justify um it's, it's widespread clinical innovation. And do you believe that the partnerships with um more technical technological sort of industries may cause um like a Silicon Valley esque environment in the NHS and potential economic um conflicts of interest because at, in the day, like products are being sold. Um Yeah, I think my, that's my question. Sorry if it wasn't clear. No, thank you. I think they're both very valid points. So everybody um talks about the economics of robotics. And I think that, you know, when you um and that happens from the sort of top CEO level down all the way down to grassroots. And I think that we felt as a robotic community that as new platforms come to the market that perhaps that would reduce the price, the capital costs of robots across the across the landscape. And so that would make it more cost effective. I think that's not happened. But I do think that there are lots of new robots that coming to market. I think one of the difficulties around robotics is when we think about cost effectiveness, we think about the capital costs and the consumables of the robots. And then we say that is more expensive than current traditional methods such as laproscopic surgery. And for many specialties, particularly mine, we haven't really proven the benefits of robotics over laproscopic surgery using traditional outcomes using traditional clinical metrics. My um counterpoints that is is that the value of robotics is much bigger than how we currently measure that. And we're going to, I hope see some of that through the reinforce study which is funded through the NIH are to look at the health economic aspect of robotics across the full patient pathway. So it's not just about your inter operative costs, but it's about does that patient need? Um do they have a lower length of stay? Do they have a lower complication rate? Do they go home quicker? Do they have a better quality of recovery? And all of those things add to the economics of society as a, as a as a whole. And I hope that it's that understanding that robotics is not just about, it's cheap. It's more expensive than laproscopic surgery intraoperatively will lead to its widespread adoption. I think one of the difficulties about robotics and digital technology as you've already alluded to is it does, it does create silos and it will create silos within the NHS. And I think we need to think about how we reduce those silos because I think we need to make sure that there's equity of access. So there should be equity of access for our patient's and equity of access for our trainees and equity of access for our surgeons. And I think some of that is about reconfiguring how we work and how we train um to make sure that the best technology is used by the best person for the right patient. So I think it's much broader than, you know, coming to Manchester to have a digital operation or robotic operation. I think we have to think much more broadly. I'm afraid that's all the time we have for questions. And thank you again. Thank you. Thank you, Dina.