 Hello, hope everyone can can hear me okay. Good morning, good afternoon, good evening depending on where you're on the world. And welcome to the second of three webinars that we're hosting here at digital surgery. My name is Dr Andre chow. I was the co founder of digital surgery before it was acquired by a metronic at the start of last year. I'm now I'm the general manager of the digital surgery business as part of the surgical robotics unit. The topic that we have on hand for today's webinar is especially close to my heart because it really lies at the center of everything that we do here at digital surgery. So really what we're trying to do is to use digital technologies to scale safe and effective surgery around the world. And we've long held the belief that you can't improve or scale surgery until you really have a deep understanding of the surgical process. And really that's what we mean by by codifying surgery. We're lucky to have two guest speakers with us today. But before we jump into things, I'm going to hand over to our producer mark just for a few housekeeping items. This session is being recorded and will be distributed. This system is not intended to direct surgery or aid in diagnosis or treatment of a disease or condition. The opinions expressed by our guest speakers today are theirs alone and do not necessarily reflect those of metronic. We invite you to ask questions throughout today's session and we'll cover them during the Q&A. To ask a question, look for the Q&A button at the bottom of your screen. Great. Thanks Mark. So let's kick off with some introductions. I'm first going to hand over to my co moderator today, Dr Karen Kerr. Hello everyone. I'm Karen Kerr. I head up Research Strategy and Operations here at Digital Surgery where I oversee a lot of our clinical research collaborations and work very closely with our R&D teams on testing and developing our new solutions. Thanks Karen. And I'd like to hand over to our first guest speaker today, Professor Tom Hugh. Yes, good afternoon. Good evening, everyone. I'm a hepatobiliary surgeon based in Sydney in Australia and I'm really delighted to be part of this webinar. It's really going to be fun. Thank you Tom and thank you for staying up so late to be part of this. And finally, our second guest speaker, Dr Hany Marcus. Thanks for the invitation, Andre and Karen. My name's Hany Marcus. I'm a consultant neurosurgeon here in London and I too am really excited about this webinar. Great. Okay, if we could move on to the agenda slide. We've got quite a lot to talk through the day. So we'll see, we'll see how far we get through. First of all, we're going to start by talking about what is a surgical workflow? What do we mean by codifying surgery and how can we apply that to really understand variation in surgical technique? The second part of the agenda will give us a little bit of insight into how you could actually start mapping your own surgical workflows in your own practice. Thirdly, we'll try and then apply the surgical workflow on top of surgical video. Surgical video obviously was a topic that we covered in our first webinar. And what we'd love to do is to combine the two and show how understanding your workflow and having access to your surgical video really does allow you to find more analysis of your surgical performance. And then we'll finish up with a look to the future and hopefully we'll have time to take some Q&A as well. Great. Thank you, Andre. So yes, as Andre said, the first session we're going to discuss today is understanding surgical workflows and variation and how we can understand these and use them to inform surgical practice. So if we can move on to the next slide, we're actually going to just bounce back to Andre quickly to ask him to describe about the Touch Surgery app and how we originally started to break down surgeries into steps for our simulation. Thanks, Cara. So like I was saying, understanding a surgical workflow really has been the base of everything that we do here at Digital Surgery since the beginning. Before actually we were co-founding the company, my co-founder and I, Jean, used to talk a lot about kind of how in our surgical rotation every consultant that we operated with would do the same operation in a slightly different way. And what we used to end up doing was kind of writing down in our textbooks and notebooks kind of like the different ways that Professor X did something versus Professor Y versus Professor Z. And we were quite astonished actually that this sort of stuff hadn't really been written down before. And this was just within our own institution. And then when we looked at our friends in other hospitals in London, across the UK, across the globe, you start to realize that, hey, you know what, there's a whole load of surgical information and technique out there that we will never see, understand or gain access to. And obviously, you start to realize that, you know, throughout your surgical rotation that the different ways in which people do surgery does have an effect on patient outcomes, right. But there was no real centralized database or collection of knowledge to actually demonstrate this. So, so that's really how we came up with the concept of the touch surgery platform, which was really around using a process called cognitive task analysis to break down the surgical procedure actually into all of its component parts, steps, decision points, etc. And that really provides a basis by which you can look at your own practice, compare and contrast how you do things differently than others. And as we'll see later on in the conversation, actually start to analyze what techniques work best for which patients. So we released this, this app, you know, five, six, seven years ago now, and have over 200 different simulations or workflows on the platform. It's reached millions of people around the world as academically validated as a, as a, as a essential part of training. And, and yeah, really, really delighted with with how it how it's turned out so far but obviously there's a, there's a long way to go back over to you Karen. Thank you, Andre for sharing that with us. Okay, so let's let's start off with understanding about how you first became interested in surgical workflow and Tom will start with you here please. I think Andre is right I became interested as a lot of certain do when you desperately trying to learn how to operate and it's a really scary thing being in the operating room. And if you think you know the anatomy, and you think you know what the operations about. There's a whole lot of emotions that go into doing an operation, particularly if you're left to do it on your own or if you're under pressure to do it with one of your senior mentors. I was really interested in, in exactly the same thing Andre said, working out why people do certain things in certain ways and I to wrote down many things and wrote down many steps. And after a while, with certain operations you realize that they're very very consistent. And yes there are variations in a consultant but you worked out your own way of doing it so for me, breaking down was a really important step in getting over that initial emotional trauma of, of starting as out as a surgeon. That's really why I started doing it and it obviously went further down the track from there with the ability to record. Thank you. And, Annie, what would you, is that similar experience for you? What would you like to expand on there? Yeah, it really was. I think I was obsessed with writing down steps, partly so I could kind of internalize it myself. But I was also involved with the study early on in my training which had a big influence on me and on sort of recognizing the importance of these surgical steps. So the simplest operation we do in my field of neurosurgery is making a hole in the head to drain blood. And it's been done for thousands of years, long before modern medicine, people making holes in heads. But even in this extremely simple procedure there are still differences I would write down on my piece of paper about how sessions would do it. Some people make one hole, some people make two, some people would irrigate, some people wouldn't. Leave a drain at the end of the case. And to me that was a really minor step. You know, you do this operation and the last thing you do before you leave the operating room is leave a drain or not leave a drain. And most people didn't because it was an extra step. But this study we did early on in my training randomized, and there aren't many good examples of randomized studies in surgery, but it randomized people to either having a drain or not having a drain. And I was convinced there'd be no difference because it's one small step in the absolute simplest operation you can do. But actually, the rate of occurrence was twice if you didn't leave this drain in, or having that hematoma recollect and having to have another operation. And your mentality was double if you didn't leave a drain in. And so this tiny step in the simplest operation in my field of neurosurgery has huge ramifications to patient outcomes. And it's likely that that study that I was involved with very early on my training has had more of an impact than my career as an individual surgeon more because now everyone leaves drains in. But it shows that if the simplest studies with the simplest steps have huge impacts on patient outcomes and these complex operations or relatively complex operations. The same kind of methodological analysis of these steps could really bear fruit in terms of improving patient outcomes further. It's super interesting and to kind of understand and have a real life example of an impact that that's had. And so I guess you've touched on this a little bit but it'd be good to understand what you know the different ways are that surgeons use workflows you've got yourself but what about potentially your colleagues or others. And if you could shed some light on that please. Again, Tom will go to you first here. Look, I think I was also influenced by a teaching environment that I was in at my hospital we set up a skill center and teaching was really important for junior staff obviously, and right through to the senior staff. And so we realized very early on that we had an incredible resource in teaching operations by videoing really and I'm old enough to have used VHS videos in the operating theater. Let me tell you that was really hard work. It's so easy now and you young guys don't know what it's like how easy it is to just press a button digitally when we had to do the VHS and collected and you weren't sure it was going to work but we did it and we were able to transpose the videos and take them into the skill center. And we really found that that was very very helpful for the junior trainees. I guess I just touch a little bit back on on really more basic element of operations, even the simplest operations and in my field that would be an appendicectomy open or laparoscopic appendicectomy. It's remarkable how many steps there are in a simple operation and I take any point that some steps are really more critical than others but it's remarkable how often I've watched a trainee miss the most basic step because I think they've got a lot going on in their head, trying to understand the whole picture of the operation is really hard and so they tend to miss a step which may be reasonably critical. So again it was important in our training in the skill center to take it right back and to put them into big chunks, how you get started, how you do the next step and how you move forward. So again that was really a big impetus to me to start collecting videos of different procedures for our skills training workshops. Thank you. And, honey, do you do you think that all surgeons should really think in surgical work those when they operate and do you think that everybody does it in the same way. Well, I'm the fact I'm here is is probably a reflection of the fact that I'm in the extreme end of the spectrum in being obsessive over kind of analyzing the operations I do and the steps and things. I suspect it wouldn't be possible to do surgery unless you have some sort of mental map of the steps of an operation but I don't know that many surgeons are very explicit about it and I actually would look back to what Andre said at the very beginning which is at the beginning of my training. I think like like Tom and Andre, I read the steps of the operations and I was surprised that no one has done this, you know, that operation I gave you. And as an example that the bear hole, making a hole in the head for sub-drawing hematoma, there are millions of ways of doing it, but you'd never know because no one's wrote them down. It's not in the literature or in a book. You just have to kind of write it down as you go along. And so I felt that with my colleagues but in a wider sense I felt that within the surgical community feels weird that this is very untapped. Now I think neurosurgery is particularly behind. I mean, I know that in general surgery and urology there's good work being done but there aren't many examples in neurosurgery. I don't think there are any in fact other than stuff that I'm doing that's been published. Yeah, it's well hopefully we'll hopefully we'll see a change in that direction and start to get more understanding as we as we progress work in this area. And how long have you recorded your surgical procedures for? I started recording them in earnest at the beginning of my fellowship. So in my last year of training I specialized in the field I now do, which is brain tumor surgery, but brain tumor is at the base of the skull. And as a educational tool, I just recorded every operation I did. And the other thing that made it easier is that many of the operations we do in neurosurgery are both open under the microscope, operating microscope. And my operations tends to be endoscopic because they either through the nose or through small incisions in the eyebrow. And if you have an operation that's endoscopic, most of the operation is being recorded, whereas if you have an operation that's hybrid between open and microscopic, it's just technically and logistically a little bit more difficult to do that. So I had a real opportunity to record really everything I did during my fellowship and reflect in those videos as I did them. It was an enormously helpful thing to do. If anyone watching who's in that stage, I'd recommend doing it. Yeah, good point. And Tom, I know that you've said that you, you recorded your videos for a long time but a lot of your colleagues and perhaps didn't do this and you were, you were kind of surprised to learn that do you want to share some insights there. I was a bit surprised, but it was hard. As I said, VHS was not an easy thing. The tapes were bulky. The theaters that I worked in had spare VHS tapes, but it was always a hassle to get them and put them in. But I, we also had in our hospital, it was fortuitous in the theater I worked in, a camera within the operating light in one theater only in the theater that I worked in. Not only was I able to record very early on in the early 2000s, the laparoscopic cases, but also some of the open cases. And there's a lot of tricks to doing that so that you don't look into the back of someone's bald head, you know, an old surgeon. But it, we recorded a lot on VHS and then I moved into CDs and of course that wasn't big enough so we moved into DVDs but I had so many of them by the mid 2000s I had to throw them in Sydney Harvey you know that picture behind me there. Put throw them in the harbor and I'm now moving on to hard disks and I think, sort of, to me, there's no real excuse now why you shouldn't record your cases, because it's so easy now on a hard disk I mean all of the towers in endoscopic laparoscopic surgery we use all have capability big memory banks to record them and then you can just dump them on to a hard disk so we do that as a routine. Now and you know I keep three or four terabyte hard disks at home and copies of and it's relatively easy so again I am puzzled why people don't do it because even my colleagues with those capabilities around them are still not doing as a routine and maybe Karen will touch on on why people are so nervous about recording cases, because I think that's a really interesting topic. There's the positive side but there's also the potentially negative side. Absolutely. And I guess I'd be interested to see how much, you know, you have looked at these, come back to look at your videos and watch them and use them for your for your own reflexive practice. I'm open to either Tom or honey here to comment there. I could start if you don't mind. Yeah, please. So I, I found actually during my training. It was a very routine thing I look at every operation that I did and see if I can get better, but I look at them a little bit more at work now and where I really look at them is where most people find it very very anxiety inducing to record a video in the first place which is where the operation is not gone as well as I'd hoped. And it's very easy as a surgeon to play tricks in your mind, you know you're convinced that you've, you've made some major error. And in those cases it's only happened a handful of times, thankfully, but in those cases when I've looked back at the recorded video usually it's been very good. And, and not only instructive but usually quite reassuring that there wasn't a major error it's just, you know, it's the nature of doing very difficult surgery. So I think there's huge value in the first possible learning curve in reviewing videos regularly but even once you kind of started to plateau a little bit, there's still great value in looking at cases without challenging. You know, deciding to routinely record your cases is a really big step in your life and if you're not an organised person, then it's going to be chaos. It's, you know, it's like an individual organises their files in their computer very differently to another person. If you don't do them in an organised way in your videos, it does become chaos and touch surgery was a fantastic opportunity for me to look back at a lot of videos that I hadn't really looked at. But where I found particularly helpful was the occasional case where you do have a complication. I think it's really supporting what you say, honey, and you know, a relatively straightforward case where things went terribly wrong. And you're able to, I was able to look back on the case and realise why it went wrong and or even sometimes not be able to identify where it went wrong, which is a message in itself. But at least it made me feel better and I slept a little bit better after looking at the case. And it was the it was a particular example of a laparoscopic colostectomy and it was probably an out of screen injury by my assistant. Now that was still bad for the patient. We got them out of the problem, but at least I felt a little bit better that it wasn't anything I had done operatively during the various steps. So, you know, we do look at them. They're a little hard to look at if you don't organise them though because you've got to work out who they were and what the pathology was and which makes it difficult to be organised. Thank you. Okay, so I think we've learned how you mapped out in terms of writing this down and and doing all of these steps and really getting into that that detail yourselves but you know by learning from your, your mentors and colleagues. So I think we're going to stop here and just do a quick poll and to the audience and so it's SAS if you can get that open that poll up. Yep. So this is just to see how many of you think or have mapped mapped your surgical workflows. It will of course depend on how many surgeons and are on this call. And so we'll just keep that that open for a second or more. And then I think the results should pop up. Wow. Okay, so interesting that a lot of people have not done this so it's obviously you know is is a new and emerging area so let's let's move forward to the next poll may may then not have quite so much relevance because it's looking at how many of you have shared your workflows with your with your trainees but let's see what the kind of proportion is there. That's interesting so those of you that probably map also then also then share and brilliant. Thank you. If we can move on to the next slide please. So now we're going to kind of go into a bit more detail about some considerations and actually the details of mapping these surgical and workflows and get some more insights into Tom and honey's experience with it and start to look into some of the different use cases that that we have. And so if we can go to the next slide please. So this this slide you can see an example of how some surgical workflows have been segmented using using surgical video and the colored boxes show an individual surgeon's face timings and the gray boxes show the department the average department times. So this is an example of how we can compare and case and face timings within a department to look at and significant deviations or inefficiencies. And we can use this data to understand surgical variation and standardization across surgeons and their teams and for example some work that we've done in cataracts which really is quite a short and relatively or so we thought relatively standardized. And procedure we actually do see quite a lot of variation we see differences in surgical workflows and surgeons preferences and also we've looked at some of the differences that you can see there between experience levels so kind of the novice advanced and and experts there. And so we'll we'll keep this in mind as we move forward into the discussion of the next part so if we can move to the next slide please. Okay, so you've touched on this a little bit but I think we're going to kind of go into some of the work that we've actually you've done with touch surgery so honey will start with with you there on the recent work that we've been doing. Thanks Karen. So, for my index operation the operation I do most regularly, which is a removal of a pituitary tumor. And the first step really was to decide what the steps were of this operation and as we've talked about already that's not entirely clear. I mean I've been taught by my mentors and have a map in my mind, but we had to do some work some preliminary work through societies and other professional bodies to try and get a consensus and determine what those steps are. But the work that we've been doing in touch surgery in particular is to try and automate that process of identifying in real time in operative videos, what steps of the operation are and that is huge value. But both I think in real time during the operation but also as as Tom alluded to earlier, you know, being able to look at this huge volume of cases as a trainee or as a as a surgeon I want to review their cases. So that's where we're at at the moment we've just published the initial part of that work, you know automated workflow analysis using the touch surgery platform. So you can look at that soon in the Journal of Neurosurgery. So congratulations on that. And it might be useful if you could also talk a little bit some about how you've done some of the annotations and actually have to go through through this process with your team as well. Yeah, so after we had gone through the I might say extremely painful process of consensus on the steps of the operation. I might just spend a moment to talk about that so we have a group of expert protruding surgeons and there are a few things they agree on, then they disagree on I mean there's it's in that Venn diagram there's a tiny bit of overlap and quite a lot of variation. And it was actually extremely informative. I think as a very initial step to get that consensus process done because what it's meant is that we have a list of core steps and optional steps for each part of the operation. And then for each of those steps, we've come up with a consensus on what could go wrong. And the value there I think is that where we align we know that those steps are core and that can be used for education and training. And where there's variability that's interesting from an academic point of view because you know if lots of surgeons doing things different ways. That's where you could see that that perhaps one way might be best and that could you know by standardizing and making everyone do it the best way you might improve outcomes as, as with that example of drainage of a subdual hematoma that I gave earlier. So, I think the process of just developing a consensus was, was really, really valuable. Then annotating based on that kind of steps and phases is is also extremely useful. I have to admit painstaking boring. There's a paper in your surgery, which does tell the one we've published, which was talking about the process of annotating and they described it as the most mind numbingly boring thing that they had, that these these academics had done. And to go through 100 videos and hundreds of hours of operations and then to painstakingly annotate, you know, in seconds which phase and which step of each phase you're on is really hard work. To admit that I think it was an extremely useful thing for me to do as a trainee, this overlap with me being a fellow you know doing my fellowship, doing this work with touch surgery and so I did a lot of those annotations myself, early on, and it was extremely useful to force me to pay very close attention to the operations in order to annotate and edit a video you need to really kind of interrogate in great detail. And I think it's the same with my junior trainees, but they wouldn't disagree anyway. You'd have to ask them privately. I will, I'll do that. And Tom, could you share a little bit about some of the work that you've done both in the simulation side and also the lapcoly phases. Yeah, so we've done two projects with touch surgery and both of them been really good fun and really interesting so laparoscopic colostectomy and laparoscopic appendicectomy and the colostectomy is a very common procedure in general surgery. And it's commonly taught to trainees early in their general surgical training. But one of the problems of laparoscopic colostectomy a number of problems are that there's very different pathologies that you encounter during a colostectomy, particularly if the patients are admitted as an urgent case through the emergency department so sometimes the case can be very straightforward. And sometimes they can be really difficult because of gross pathology and a lot of edema and inflammation. And so what I've been doing for a long time is being grading these gallbladders and. And I've always believed that it was very important to understand the grading and to document that during the operative notes, because no one case is exactly the same in terms of its likely outcome and particularly for trainees. So junior trainee is it's very straightforward for them to do an easy case, but much more difficult for them to do an acute case and more likely that should be for a, either a fellow or a consultant or a consultant. So the work we did with touch surgery was to look at a large number of these videos that I'd pre recorded a number of years ago, a couple hundred I think we did and really exciting to look at the various workflows and the various steps. There are five or six very important and relatively consistent recognizable steps which obviously change if the pathology becomes more chronic or inflamed, but still the steps are pretty critical and one of the really important issues of laparoscopic colostectomy is the ongoing injury to the main product that is occurring. Now this is said to occur in somewhere between 0.2 to 0.3% of cases only but worldwide the number of colostectomies that have been done means that product injury is still happening and it's a very serious and potentially life threatening injury. So Colostectomy is an operation is ideal to look at the various steps and then to look at the really critical steps that might lead to a potential injury to either the bar duct or vascular structures underneath the liver. So that work was really exciting to look at that and to go through. I didn't have to do as much annotating and did a little bit with touch surgery but again I could see how important that was for training and that's why I pursued it was really, really great fun. And we then took those same steps into the laparoscopic appendectomy, which is a little simpler a little easier but still the same principles apply. So really good fun. Great, thank you. And I guess you're kind of speaking to the converted here and but I guess surgical video we, you both agree that is a really useful tool for being able to segment and review and actually analyze, analyze these operations and as well. If you want to comment on it please do. I'm not sure if there's any way else you could do it so I wholeheartedly agree I was just going to follow up on Tom's point. I'm Karen and say his work and kind of grading the complexity the operative complexity of operations is is really valuable and and just as with the other steps stuff that we've been talking about not really done. I mean there's nothing like that in my fields and no two particular operations are the same and so capturing that is very impressive stuff. We need to be doing more of that. And I guess what's been most surprising in your work when you've kind of you've you've mapped your work so I think Tom we kind of you know we looked at the gradings and I guess the timings correlated with with those but is there any other insights that you you gained there from doing that. I think I'm getting better. I think I'm getting better at I've done three and a half thousand of these I think I'm actually getting better although other people can judge that. But that was one of the interesting things I mean clearly we didn't map the timing right from the exact beginning of the operation to the end, because we didn't include the boring parts of preparing the patient and then sewing the wounds up. The timing of the different phases in the grading was really interesting and we put that work into a manuscript and it hasn't been published yet but we've submitted that and again that was exciting not so much to try and validate my particular grading system or the one from our hospital because there are a number of different grading systems. But it was just interesting that that we could then have some objective evidence of why it's important to focus on what you find at the operation and to focus your the training to the appropriate level of trainee for that for that degree of difficulty. That that's really not out there that evidence is not available. And it's just objective evidence so that was also very exciting to see that. Super that actually takes us on really nicely to to the next topic so if we can go to the next slide please. And so this is kind of we're going to move on to discuss some of the insights which you definitely you know shed light on there. And but let's look at how this can the benefits this will offer to surgeons and their team and I think let's start off with kind of the training and education angle and how you think these just you know thinking about the fees analytics in the first instance how these could actually be used to help trainees. And I mean, I'll start off by saying I mean that's pretty pretty simple again in my field of laparoscopic colostectomy, but it's applicable to all operations that certainly our college of surgeons in Australia and New Zealand is moving towards competency competency based training where really they're going to for each particular year and each term that they do which are six month terms, they're going to have to sign off on certain operations and certain steps in operations, and putting it into a video analysis and be able to do it offline out of the stress of the operating theater, you know in terms of just taking them through that and testing it, and then doing it in the operating theater and recording that. I think it's going to be critical to assessment of competency based training and again, as honey said I don't know how else we could do it, because it was probably fudged in the past, or someone would sign you off and say it's okay. It's very hard to fudge video analysis when you record it in real time and then go back over and assess it. And I think that will become really important but I guess the other area beyond training is clinical audit. Now I know that clinical audit for surgeons all around the world is is is important but it has varying degrees of importance and it's more compulsory in some parts of the world than it is in others. Again in our country, we have some mandatory components of our continuing professional education, which means that we have to conduct clinical audits, and I think again, conducting a clinical order to say of a small aspect of your practice is ideally suited to the assessment through video and to have a I assessment of it rather than manual would be an ideal way of reviewing it and deciding whether whether this is a suitable completion of that clinical audit process. Thank you. May, would you like to to comment. I think I'd agree with everything that Tom said and in the UK we have a similar shift towards having competency based assessments and I'm convinced they've been fudged in the past and probably been a recipient of some fudged assessments, where people make quite a global assessment and just say well he's probably fine and just pass. I think we should just analyze videos properly. And, and look at the particular phases of an operation and which bits you struggle and which parts you do well is I think the way things are going to move and should move. I would go a little bit further with the order and say that actually what we found in our analysis of opportunity operations is that it was quite a lot of insight that we could gain from looking at the lengths of the various phases and I think it surprised actually what they were, you know, parts of the operation took much longer than I expected, but also the variability of those phases. So, the phases where there was huge variability where the places on the operation where perhaps you could say that you were still on your learning curve but also in a wider setting. When we did that consensus work when no one really knows what the right thing to do is the closure of our cases is the area where there's huge variability. I won't bore you with the details it's quite niche but it's tricky to repair once you've made a defect in the base of the skull because you can't stitch up there with your instruments it's too narrow the canal. And so you end up just stuffing things in in blue and and hoping that it all works out okay but no one really knows what the right thing to do is so that variability prompted us to review that properly and do an order within the UK of how all the two surgeons close their cases and it confirmed in fact that no two surgeons do it the same way. I mean it's 100% heterogeneity in repair of this part of the operation. Do you think it'll ever become any mandatory legal document the the video record. Do you think it's good it's getting to that stage in the UK because I think it is getting close in our country in the media medical legal environment where where if you don't record. What's wrong, you won't have a leg to stand on. Do you have any comment on that. I'm not really sure I think the reluctance is going to come from the surgeons I mean, I think I'm the appropriate surgeon in my unit that records regularly. And I think a lot of that reluctance is is for medical legal reasons people are really scared of of something they've done being used against them in court and I that's not be my experience and I'm quite proud of the operations I do for the most part. But but that is the reason that lots of surgeons are reluctant to do it and that pushback might be one of the things that would slow that process down but I can't see how you wouldn't have that. If you think about some of our sister specialties when people have endoscopies, you know surveillance endoscopies, that's all recorded and expectation is that if something's been missed they review it. I mean the analogy is in obviously in the party for pilots. I mean could you could any of us imagine that that the pilots were flying without a flight recorder that was accessible and used for records we couldn't imagine that. And so, you know, I've always argued locally here that it's better to own this and to run it because it'll become compulsory and you won't like what you say it's much better to own it and control the video editing and the collection, but that's just my perspective that's all I think it's exciting and I think it's not going to go away is the point and it's only going to get better so why not embrace it. Yeah, wholeheartedly agree and I think also doing it from the positive side of actually sharing best practice and sharing parts of operations that you've done it well because if it's not documented or broken down or there then how you know how do you learn from those as peers as well. And so I think we're going to, I'm going to hand to our on Jay to talk, talk through some of the reports and the data that we, we get from our touch search enterprise solution and some of our automated analytics that that we have. And so if we can go to the next slide please. Thanks Karen. Yeah, so I just wanted to be able to show people an example of some of the sort of data reports that we do get out to to our surgeons are using our platform. We'll start here with a very common operation that Tom's already described the laparoscopic colostectomy. I won't make the mistake of calling it simple because it has a huge amount of variability and as Tom's mentioned, actually some very critical outcomes like mortality or even mortality is for the patient, even though it's one of the index cases that we start learning as a trainee general surgeon. So what we've done here is to actually look at laparoscopic colostectomy at actually quite a high level. So not looking at individual steps, but looking at actual global phases of the operation. What you can see is that each kind of row here with a date on it represents an individual operation that has been videoed and stored in our cloud. We obviously give the timing on that. And then we break down the operation into five or six kind of global phases there. On the right hand side, what you'll see is that the surgeon has actually added some additional tags, which they believe are important when it comes back to kind of reviewing the entire data set together. And the sort of insights that you know our surgeons have been getting out of this are really to look at firstly, you know you'll look at the case timing, for example, and you're very easily able to pick out variation from your own average. So this is not from the department average, this is from your own average. And what we're trying to say here is not that time is a corollary of quality, like that's not what we're saying but if your time is significantly greater than your average, there's probably something in that operation that's a learning point there. Right, that's kind of what we're trying to get across. And then, once we understand that the whole, you know, operation time is longer than normal, breaking it down into its phases and understanding which phase in particular took longer than normal. Then allows you to dive down into a particular part of that video, much more easily. Right, so what we're trying to do essentially is to make the process of learning from your video, much, much easier. And then obviously, you know, as you start to build that data set, you can start to, you know, apply some some data science to this sort of data and understand what sort of patient variables end up leading to a longer operation time a longer go bladdered section time etc etc. And, and you know being able to analyze your videos in a in a more directed fashion has has actually given a lot of benefit to our clinicians. So we move on to the next slide. This is an example actually of a more complex operation in terms of steps. It's a laparoscopic gastric bypass. And here what we're doing instead of looking at one individual surgeons cases we're looking actually looking at a whole range of surgeons across an entire department. And don't worry, all the, all the names are pseudonymized, even though the actual data itself is real. So here you can see that actually the the global phases of the operation are much is much longer there are many more phases of this operation. And interestingly, from a department level. They all thought they were doing the same operation laparoscopic gastric bypass. Let's see I don't know if I can. But if you actually start to look at the way that we've broken this down. What you can see for example is hopefully you can you can see my my annotations on the screen there. That there's a part of the operation for example called the week test where you test the integrity of your anastomosis, and you know and we can see that you know I've circled a load of surgeons here who kind of do that. And there are some surgeons who, you know, choose, choose not to do that on a regular basis. And this brings me to kind of thinking about what Hani was saying about his initial paper with burhals, that there could be one particular step in an operation that some surgeons do and some surgeons don't, that actually ends up having a significant impact on patient outcomes. And this is not a study that's really easy to do in terms of creating a randomized control trial or anything like that. But if you're able to look retrospectively at the data and use AI to automate that painful process of annotation to pull out this data set. It actually speeds up the learning that you can gain from from from this sort of data set. I'll point out another example here that's quite interesting for for us anyway, this part of the operation where you actually have to measure the small intestine that you can see is done here that I've circled here. But then another part of the operation where you actually create the gastric pouch. Yeah. And so even though all the surgeons are doing both of those steps they're doing them in different orders. Some surgeons essentially are measuring before cutting and some surgeons are cutting before measuring. And that's also raised a huge manner of discussion with our with our bariatric colleagues as to actually which is the least risky way of doing the operation, because the last thing you actually want to do is create the gastric pouch and then figure out the small bowel doesn't reach. So, and I don't think that sort of insight would have been available from just an ad hoc conversation, even in an M&M meeting you really do need to be able to gather this sort of data all in one place to be able to have a conversation. So, so yeah that's the brief overview of some of the sort of data insights that that we are providing. Thanks Karen. And so if we kind of move forward to kind of close the last the final session and thinking back about the topic of today's webinar which is about code, codification and digitization of surgery and how it supports can support surgical performance improvement and for surgery and surgical teams in the future. So it'd be great to hear both of your thoughts Tom and honey kind of on the you know the short and the long term impact that you, you see here. So, let's go to talk first. Look, I think the fact that we can now record so much of our operations whether they're minimally invasive, or open means that really we have no choice the future is here now and we need to be doing it. And it's, we should, as we said before, embrace it. And, and the sooner we do it as a routine part of training and break it down to the steps and use such things as I just talked about to really analyze what we're doing and and get better at training, but also try and avoid mistakes for for established surgeons that's really key and I think it's exciting. And I'm really looking forward to it and I think it's crazy that certain stone embrace this when this technology is available. Honey, and maybe you can comment on that and then tell us about what's next for your work with with with touch surgery. Please. Yeah, well, as always, I think I am on the same page as Tom and this I think it's an absolutely essential part of our work and practice in the future. I have to say just reflecting conceptually the big insight has been that what you do during an operation is not magic, and people who are experts, then have some unique talent that no one else can get you know an operation is is a series of technical maneuvers and that can be codified the same way that other parts of medicine are. And that feels so simple hardly worth filming, you know, being mentioned but actually, when you started a trainee it's very. When we do use this I'm operating theater rather than operating room UK and it's very theatrical you know you go inside it's been there's a lot of rigmarole it's quite overwhelming as a trainee you, you, you take things very dogmatically by your your hands and it takes a little bit of insight to realize that the operations are just built up steps, and that can be coded and analyzed and taught the same way that anything else can and medicine. And so beyond just training and teaching, I think it going forward in the future the real change is going to be using this stuff to improve the nature of the operation itself, both a single surgeon level but even more for a wider level. A single surgeon will learn throughout their practice and it will will improve their performance hopefully by by getting feedback from the outcome of their patients. But there's no reason it should be limited to a single surgeon learning from their own practice and picking up the objects and pieces from reading literature what would be ideal would be if every surgeon is logging their data and if all the data is being coded to data is being looked at with respect to their outcomes and then we'll know, you know which surgeons are doing it well which steps of which operations are being really, really valuable in terms of permission outcomes and if there's further research for those steps to kind of pre bit then great but if that's enough to change practice as a community we should do that too. But I think collecting and sharing data beyond individual surgeons is going to be the key to really moving forward. Hopefully that will happen. Hopefully and we're very excited about the research that we're undertaking with both of you as well, conscious that we've not got left very much time for Q&A so we'll just move if we can just go to the next slide and we'll let Andre close with a couple of a short insights into kind of what's next for the future of our analytics and AI with touch surgery. And I think, you know, essentially where we're going with this is, you know, we, we have a belief and I think it's been, you know, corroborated here by by Hannie and Tom that where possible every single operation should really be recorded. Right. There's so much potential value in it. And to be honest in our experience we are yet to see a negative outcome for a surgeon who started to record all of their videos. In fact, we've seen the opposite that's actually have very positive impacts on not only their own practice but probably the practice of their entire department as well. And really what we are trying to do is to make the recording of that search video as easy and as painless as possible for surgeons because surgeons are busy people. And if we can make this sort of tech available to them this sort of data available to them literally touch the button. That's what we're going to do and that's going to be our contribution to improving the standards of surgery around the world. In terms of the analytics like the reports that we've been showing. I think it's a case really again of making the useful. Easy, right so taking away that that pain that Hannie described that annotating his own videos and making it automated at a touch of a button so that you know literally five minutes after you finish an operation you've got your analytics there. And really what we're hoping is that reviewing your cases will eventually become as natural as let's say a pro athlete reviews their game take. And if you look at like you know all of the pro athletes out there and the amount of value that they get out of there watching their game tapes and analyzing their stats using that to improve their performance. You know, we should be doing that as a surgical community. You know, I'm a big believer in the fact that you can't improve what can't measure. So we're on a mission to help surgeons to be able to measure themselves to improve the service that they deliver to patients worldwide. Thank you, Andre. So I think it's over to you now to open Q&A for the final five minutes that we have. All right, so we've gone through quite a lot of stuff and as predicted we're probably a bit short on time for Q&A. And we have Kristen on hand who's been shuffling through through the questions. Any any good ones that we've got for the last four minutes. I wonder, could the panelists talk a little bit about future publications on this subject. Maybe I'll throw that one. Yeah, go ahead. So, Hany, Hany, you go first. You've got a couple ahead. Oh yeah, so the two ones that we've just published or just have accepted. We're describing the workflow for pituitary surgery, and then the work with surgery looking at automating that on on existing videos rather than real time. So the next steps for us are showing that works in real time. So we can add to videos in real time as we do operations and then showing that that real time insight can be used to improve outcomes and help patients. As I mentioned, we've just submitted our paper on looking at the grading system in laparoscopic colostectomy and using the touch surgery platform to analyze the various stages and we're really excited about that work. I can't say much more about that because it hasn't been accepted yet. One of the things I'm really interested in looking at is to see whether there's any difference between being analyzed by AI really in using 3D optics. So we now routinely use 3D optics compared with our 2D. And it's very hard to measure that and some people are very anti 3D whereas others are very pro like myself, and I'd like to be able to measure that so that's something I'm really looking forward to doing and in conjunction with touch surgery in the near future. Really fascinating. Thank you. As the next question. Wonder if the panel could talk a little bit more about perhaps opportunities to be thinking about procedural costs as part of variation to any any thoughts about how how we can use this this work also just to think about about that. Well, if I may I mean initially it's always going to be more expensive because theoretically it slows things down a bit if you're having to record as a routine but when it does become a routine and now that we don't have to use VHS tapes to do it it's it's much cheaper just to get a hard disk so there's really no argument when it becomes routine you just press a button and it's recorded on the hard disk so it's not expensive to do it anymore and I think it's going to take a little while but we will be able to show where the savings can be made by understanding where each of the steps are where things are slower than they should be because of the trainee or because of the pathology or the equipment or whatever it is so it's going to take some time but I think there was great opportunities for cost saving. If we can really understand in detail much more detail than we have in the past, how each of the various steps in the operation work. That's my take on it. Yeah, I would maybe go even a bit further and just say that I guess in the long term if you have insights as to particular steps that will either improve outcomes or reduce complications. There is both a benefit to the patient but also it's huge cost saving I mean the cost in my own field of a neurosurgery of a single complication is huge. And to give that specific example like a value of draining a hole in the head, you know and draining blood clot, taking those patients back to to have surgeries terrible for the patient and, you know, affects their mortality, but it's also enormously costly. So I think there's huge benefits became but as Tom was saying, it takes a bit of time to see that. Great. Thank you. I think we only have time for those two so I'll hand it back to you, Andrea to wrap up. Thanks, Kristen. Yeah, just want to want to finish up by thanking everyone who tuned in today. I really appreciate the time I hope you found it interesting. A massive thank you to Tom and honey for joining us today. Really appreciated the conversation and your insights and I'm hoping that the audience enjoyed it just as much as I did. And then just a quick reminder for the next webinar which will be our final part of our three part series, which we will be hopefully sending more information about in the next few weeks. So stay tuned and hope to see you next time.