 I have the honor to actually introduce Clayton Lau, who's the Director of Urology at City of Hope in Duarte, California. Clayton, as many of you know, is a world expert in millenium invasive surgeries, performed over 3,500 robotic surgeries. Also very prolific with research, has had an R01 and has had several papers published, chapters as well. Probably the most important distinction about Clayton is he survived Tim Wilson, which is a real challenge. But I want to have Clayton come up and he's going to give us his perspective and experience with the digital surgery platform for metronic. Clayton? I want to thank Naras and Jim and John Davis for this kind invite and I'm going to talk a little bit about touch surgery and we've had the pleasure of using this for a few months now. So the title of the talk is Unlocking the Power of Surgical Video. And I'm broken up into the value of surgical video, talk about touch surgery itself and training experience that I have. I'd like to introduce Ed Chang, he's one of my fellows trained at University of Washington, wanted to give his perspective as someone new to learning with this platform. So we're all trying to hone our skills. That's why we go to these meetings and we've learned new techniques, want to get to perform better, more efficiently, less complications and similar to surgeons and similar athletes. We look at video. We look at things pre-operatively, post-operatively. We use it for education. We use it for coaching and skill improvement. I had the pleasure of being Dr. Wilson's fellow. He wouldn't say I was probably one of the worst fellows, but I think he was just poking at me. But when I started a fellowship in 2005, we only had to get videos via the CDRWs if you guys did to kind of date me. Then it transitioned to USB keys and also portable hard drives. And now we can have videos go up to the cloud. So this is great because not only can you automatically get to the cloud, but you can actually simplify the workflow, looking through videos. You can categorize them by type of procedures. You can collaborate with other people that are in the same network, the touch surgery network. And you can look at data, and it has built an AI looking at data in terms of timing and also efficiency. So we started the touch surgery system back in May of last year. We had three operating rooms or three robots that were outfitted. We had five robots. One was SP, but we put them on three XIs. We had about 16 surgeons. All services use it and had a little over 300 videos that were uploaded. And of note, you can see, and it was mostly the audiology fellows, they were shared many of times and there are a lot of views. You can actually track if a fellow or somebody actually views those videos. The system is pretty simple. It's a DS1 computer. You actually can see it here. It looks like an Apple TV or wireless router. That's connected to the CRT, essentially. Then you have this remote. It looks like a basically telephone that controls everything. This actually can be connected to not only the robot, but you can actually, if you wanted to watch one do a whole lap or laparoscopic surgery, you can actually record that also. With that, within that, you can actually, it goes to the app on your phone or your computer and it has data on there where you can scroll through. You can share it to anyone within the network with that or signed up with touch surgery that you authorize. This is kind of a real-time picture. This is my settings here, but you can actually see the little DS1 computer back there. It's tiny. Actually, this is actually a picture of the cell phone. There you can actually just, you type in the type of procedure and add any edits in there and just start the recording. You just press the button and you have to stop it. Why is this great? Because if many of us have tried to record videos and it takes about 10, 20 minutes to wait for that case to record, sometimes there's security issues where it doesn't work or the portable hard drive breaks or you lose it. This makes it really quick. It's secure and it makes it easy for fellows and faculty to get these videos. It's also secure. There's no data information on the patients. In addition, when the scope comes out, everything's blurred, so you don't see any staff information or pictures of them. At the end with AI, it actually has procedural steps that are benchmarked. You can benchmark it to historical cases over time. I just wanted to show, when this is a case that I did in January, I can show the video here. At this point, it looks like a YouTube video, but it essentially has all the things that you can go from starting it and stopping it, moving it forward. You can just drag the cursor in the bottom to the specific points. You can scribble on it and you can actually see this little squiggle here. You can actually draw on there when you're teaching. If you're with a fellow sitting down on a computer, you can actually draw certain points if you want. On to the right, you can actually see, you can click on the top part, you can see the workflow and the analytics. The AI does is actually breaks the cases down, the time it takes and where it's at. Here's a case that I did, it's a prostatectomy with an extended lift-no-deception. With that, you can look at the analytics by clicking the analytics button and it'll show you the time it takes, an actual time that actually did the surgery, then your historical controls that you've done on all the cases that were recorded. This is important, I think, for many of us that want to look at efficiency. We can look at to see how much compared to how long it takes a fellow versus somebody else to do or one attending to another. It's kind of data that we can see there. With that, actually, it'll break down the steps and the graphs for time. I've used this with my trainees. We have three to four fellows a year and they love this application. They have all come from various programs. I use this to have them prep by looking at videos beforehand, kind of post-surgical debriefs. Also, if there are certain areas where they actually have difficulty or need more extra help, what kind of can go to those areas that I can assign them a specific couple of cases and go over those specific steps. It's a great way, an efficient way of training. In addition, you can download these videos if you wanted to use it for any sort of presentation and also there's like an M&M you want to use. You can put it, you know, ticket the clip in the area where you actually wanted to use it for an M&M within our own division. I brought up Ed Cheng, who is one of our fellows and wanted to kind of have him speak a little about, Ed, can you, does it work there? Okay, great, you can see there. So, Ed, coming from University of Washington, they do a lot, quite a bit of robotic surgery there. Anything left over that Jim leaves on the table in Seattle. But I wanted to get his perspective and using it for his training platform. So, when I was interviewing for fellowship at City Hall, one of the things that they recruited during recruitment, they said was we use surgery and we do surgical coaching for video. And I think just thinking about my experience during residency, I felt like that was going to be a very valuable tool because in residency we recorded video, but we had an old platform and to be honest, I didn't watch that much video and my tenure was going to review video with me. So, a lot of the improvement kind of came on the fly. But so far, during fellowship, I sit with Dr. Lau or Dr. Yu, our program director or our different faculty and after cases or even up to a week after a case, we'll talk about the case while we're watching the video and talk about specific things we can improve. And I think that's really changed my perspective on how to approach different cases, where my hand should be during the case. And we get to pause the video and talk about the theoretical concepts while having that in front of me. I think that relationship and being able to watch video in that way has really changed the way I think about how I operate. And then in addition, I have two co-fellows and we can watch the video together. So, actually, we use Touch Surgery to coach each other, watch each other's videos in a very non-judgmental way and that's actually helped a lot because we're learning and teaching one another and we're trying to teach each other how Dr. Lau does this, this step to me or step to me. And then I would say one of the biggest game changers is what Dr. Lau mentioned in terms of downloading video because it actually makes creating a surgical video so much easier. When I was making my video for this conference, I had to use some of the old platform because most of it was on the SP and we don't, our SP is not connected to the system yet and so I had to go to four different ORs and plug in my USB and get all that. But when I make videos off of Touch Surgery, you just log in, download, you have a complete clip. It's not a bunch of segmented clips in different folders and I think that really makes it so much more accessible and it makes it easier to share video and submit videos to presentations and conferences. And Ed, so one thing, what do you usually use Touch Surgery on to use your phone or your computer or what's usually where your workflow preparing? Yeah, I use it on both. It's nice to have it on your phone because sometimes in between cases or before a case, I'll just review something real quick. It takes like five to ten minutes. I'll just go to the portion that I want to take a look at and I could watch it easily on my phone. If I want to watch a case for a more extended period of time, more than like 20 minutes or so, I'll usually watch it on my laptop. But I think both platforms end up working out pretty well. I had a question, Clayton. Sure. So, how is City of Hope handling the discoverability of these videos as far as, you know, you mentioned M&M. So, what's, has there been a policy established or how do you guys handle that? Yeah, so we, you know, I would say our thorough contract was, you know, with Metronik but all the information that's from the patient, there's no identifiable part that's to the specific individual patient. So, it's been fine for my work. You know, for us, we actually just go back to the data surgery. That's the only way we figure out which case it was. But it hasn't been an issue for our institution. I mean, I think a lot of places are looking at data capture as quality measure. And if it's quality measure, then that kind of protects it from sources that might see, you know, uses of this that may, you know, legal use. Correct. Correct. Yeah. And it's only, you can only, it's really, the video only goes back to the, to the owner, quote unquote, and only can be shared with people that they decide to share with, within the touch surgery network. So, for me right now, there is all the faculty that have within my work at City of Hope and also my fellows that I share it with. Can you speak a little bit to the editing function on the application? Yeah, sure. So, that's in its infancy. So, right now you can download the whole video right now, but down the road, it's going to be able to be a situation where, you know, I've been talks with Metronik, they're going to have you able to edit clips and take out clips like iMovie within. So, they're working on that. So, right now you're taking the whole video and then putting in another software? Yeah. Correct. Yeah. Any other questions for Clayton? Well, Clayton, really thank you. Oh, please. It does not. Yeah, it doesn't do that now. Yeah, it's a good question. So, it's basically subscription based. So, there's a fee that you pay for the year and it's for one unit. That unit can be moved, but we typically keep it at the robot. So, for instance, like Envy Anderson, let's say you have eight robots. So, you would probably purchase eight of them, or if they're, you know, most of the time you only use four, I would purchase four and put them on the robots. We have five robots, so we're buying, we're subscribing to five machines. We did trial with three because that's what they gave us. So, we just took it, you know, but it was actually a detriment because the fact is it's so busy sometimes that some of those other robots are being used and there's many other cases going. So, for anyone that's, you know, has a busy practice, you want to make sure that you have one on your robot or all the robots if you can do it, but you can actually use it for laparoscopy or cystocases too. It does and it's really small and it's easy to use. It's honestly the hardest part is actually, and I think they're working on it is knowing when to stop it. So, sometimes like they'll have the, they won't stop it until like this, you know, they're closed with the skin. So, you have to tell them to turn it off to a specific point, similar to like if you're hard recording it. I'm sorry, is it, yes. Yeah, the question Dr. Linhens says is there AI. So, it is, there's AI built into certain procedure types where they will break down the steps to these operations, namely right now for urology, what they have is for prostatectomy and also for partial effectiveness. So, when you bring this in in order for it to connect to the cloud, do you have to get your IT people involved in the hospital to try to make that happen? Yeah, it's not, it's not too difficult honestly. There's, right now actually it has to be hardwired to the wall, but it wasn't, it hasn't been an issue. And the time it takes to upload, it's been shortened. It used to be the time of the length of the surgery, but it's now about an hour or so for each surgery to be uploaded into the cloud. Dr. Lau, could I actually give an update to that? Sure. So, we actually have now a function where it's real time. So, you're actually, it's going to hit the cloud as soon as you walk out of the OR that that whole video will be accessible to you in your library. And yeah, so thank you. If everyone has any questions, I'd be happy to kind of share my, even to show you guys at my table anytime. Well, if there's no other questions, thank you very much. Clayton, I really appreciate you guys coming and we'll be starting next.