 Hello everyone, and welcome to the very first digital surgery webinar. My name is Andre Chow, I'm one of the co-founders here at Digital Surgery and the Chief Product Officer. I'm really excited about today because, firstly, we've got loads of people joining online from around the world. I think we had hundreds of sign-ups. So thank you very much for your time. We're here today to talk about the subject that's very close to our hearts here at Digital Surgery, and really that's about the use of surgical video. As I'm hoping everyone knows, our big mission here at this company is around creating products and technologies that essentially help the delivery of safe surgical care around the world. And today we're going to be talking about surgical video, which we believe is really highly available in the majority of operating rooms around the world. But we believe is currently underused and actually has the potential to deliver a lot more value than it currently does. Today I'm really excited to bring on Dr. Sanjay Perkyasthar as our guest today to talk about this topic. Dr. Perkyasthar, well, we've known each other now for many, many years. Dr. Perkyasthar actually trained me in my very short career as a surgeon and has been a really big influence on my life in terms of how I approached patient care and technology as a whole. He's a consultant bariatric and general surgeon at Imperial College London, and I'm not going to take up any more time, but I'm going to hand over to Sanjay to tell us about his experiences using video and digital technologies in his operating room. Thank you very much. Thank you, Andre. First of all, thanks for inviting me. Second of all, thanks for making me feel really old 30 seconds into a talk. First of all, good afternoon to the in-house audience and the team. Good morning to those of you west of us, and good evening to those of you east of us. As Andre said, I'm a general surgeon. My sub-specialty interest is bariatric surgery, so surgery for the morbidly obese, and I'm an upper GI surgeon. I work at Imperial College, where we look after general surgical elective emergency and trauma patients, and we also carry out robotic surgery and use a lot of digital technologies within the operating room, and I think that's one of the reasons why Andre and I have worked so closely together. Today, I'm going to talk to you about how I feel video in particular, but that's just one part of the digital transformation of forming an intelligent operating room for the future looks like. So there's a few disclosures that I have to make. So first of all, I was one of the original co-founders of digital surgery. I'm the director of my own private practice. I'm a surgical lead for a non-surgical central London private practice, as well as a brand new private hospital in central London. I collaborate in research with digital surgery, and we actually have the first joint fellow, Jasmine, who's sitting in the audience here. I'm the clinical lead for Imperial private health care at the Lindo Wing in Paddington. So boring stuff out of the way. What are we going to talk about today? Well, there are some challenges, and the challenges are international and worldwide, but particular challenges to the public health care system. And I work within the NHS as well as private practice and those things overlap. There's no such thing as perfect in surgery because we don't believe it because we're very hard on ourselves, but the particular potential for a perfect future. The benefits of digitizing surgical record keeping, which I feel is apparent because of the work that we have done in the operating room together with industry and clinicians over the last two years. And then at the end to talk about touch surgery professional, which is digital platform that I use and I find very helpful for training, patient safety and various other things. So what are the current surgical challenges that we face? Well, I work in the NHS. It is the third largest employer in the world after the Chinese Army and the Indian National Railway, and it has similar problems. So too many people, difficult to keep track of records, secure records at your fingertips records, and being able to use those data sets in the best way. Through the journey over the last few years, and currently with some of the work that we're doing, we've realized that there is no standardization for the policies for GDPR, ethics, acquisition, encryption, how long we should hold on to the data where and when. There really isn't adequate storage for the amount of data that we can generate, let alone from video but for healthcare in general, and we need to understand how to do that better. Our data systems transfer is relatively archaic, particularly within healthcare systems. We still have to transfer things with hard drives, USBs, email, etc. There are better ways of doing things. We all know about it. We need to actually do them. Some of the things are behavioral traits. So a lot of my colleagues in healthcare, particularly in surgery, who we've discussed pathways for, don't want to have their operations recorded because they feel that Big Brother will be watching them, or if they make a mistake that that will lead to litigation. And that leads to a lack of transparency internationally, and we want to get away from that. We want surgery in healthcare to be completely transparent. We want surgeons and clinicians to be able to learn from their mistakes, not hide them, and the best way to avoid mistakes in the future is to analyze mistakes that have already happened. We are all humans, we are not robots, and we will make mistakes. We have to be open and learn from them. We want a completely secure system that is accessible anytime, any place. And the system that I'm going to talk about later actually allows that. It also takes the manual labor away from recording and uploading. It allows us to be completely transparent because that should be part of the medical records data system, not just the operation note, because that is an interpretation. And in my opinion, a lot of the operation notes that I've seen from my medical legal practice are highly subjective, not objective. It will allow us to link data for outcomes, nationally, locally, internationally, so we can learn from people who have better practice than ours. And I'll be the first to admit that I'm very proud of our outcomes, but there must be people out there doing things better than me and my team, and I want to learn from them. It will allow us to have less waste, be more lean, and have a better cost-effective service. And it will allow trainees to have a different attitude towards learning surgery. I'm going to talk about that in a second. I think it will help us to recruit senior surgeons in a different way. I'm going to talk about that too. We have appraisal and revalidation, and I think surgical videos should be used for that. And we've discussed cases, and there's one in particular. I'll show you later within our morbidity and mortality framework. I'm just going to show you a little video here, which explains better than I can in words what our vision was a few years ago about having surgical digital recordings in the operating room. And what this video shows is how sometimes it's very difficult to explain something in words, but if it's captured on video, it's a lot easier to explain, no matter how bizarre or fantastic it may sound. And ultimately, our aim for products around this stream is that this should be very similar to the Aviva driving app for surgeons. I had to react because a horse ran into the road wearing a dress. And who comes chasing after it? A tin man. I would recognise the tin man if I saw him again. Who also had a red dress on. It was more like a kaftan. A tabard poncho. It's not what you see every day. On the way to Ellesbury, is it? Some things aren't tricky to explain. So at Aviva, we added a dashcam to our drive app. So that says in 34 seconds, basically exactly what happened. And that's what we want for surgery. That's what we want to understand for near misses, for problems and for the best cases to actually demonstrate. Change the slide. So some of the benefits. Patient safety. We're going to show you a very short video of a needle getting lost in the abdomen soon. Changing the ethos of training. Early standardisation. Learning and development. Different forms of medical legal documentation and assessment. How to disseminate information. And also to track errors and cost saving. So video recordings I found in the last decade since I've been recording laparoscopic surgeries. Actually reassure patients, they don't make them nervous. I actually say to my patients that if they want a copy of the video, even before the operation, they are always welcome to have it. That is reassuring for the patient that you are not hiding anything. It does discourage inappropriate practices. It acts as an aid memoir because when you are looking back at your mortality and morbidity and you want to understand what happened in this case. Was the senior surgeon the primary operator or was it the training case? Was there difficult anatomy? Was there an anaesthetic problem? Could actually potentially link the timestamps from the digital recording of surgery to the timestamps of the digital recordings from anaesthesia and we're in the process of thinking about doing that as well. It helps pre-operative planning. It allows us to review performance intra-operatively and not just peri-operatively and review post-operative complications. This video shows... If you can play the video... This video shows life feed of a needle getting lost and that was originally in slow motion. This was during a very challenging gastric bypass in a patient with a BMI of 60 and the needle bounced off the diaphragm and fell down between the spleen, the splenic flexure and the kidney and we would never have found this needle live in the OR if we weren't recording this procedure. It just would never have been found because when we used X-ray to try and find it it was not showing us exactly where it would be. So that patient probably would have had to have an open operation to remove that needle. So just recording every single case has led to this patient benefiting and just that on its own is enough in my opinion. Next slide please. So training. So we have an induction process in the UK. It's called onboarding in other places and that usually means when trainees turn up at their new placement, hospital or residency they are told a myriad of different things about the hospital, the grounds, the facilities, a bit about their training, their pathway, who to call, their rosters, their rotors, etc. Onboarding and induction shouldn't start the day you start your residency and digitizing the surgical pathway allows us to contact my trainees who are coming here in October to work with me six months previously and not just telling them where the hospital is and where you go and have your lunch and what your on-call rotor is, but these are the operations that Mr. Perkaster and his team does. These are the instruments that he uses. This is the setup and these most importantly are the standardized steps which he would expect you to have read up on before you come to the operating room. This helps with cognitive task analysis. This helps improve pattern recognition. This introduces the concept of surgical standardization really early on in training and it also allows surgical groups, for example, our bariatric group has standardized the way we do operations. Although we have five different surgeons we all basically use the same steps, the same position and the same kit to do that. It allows to share results whether good or bad. It helps us to analyze our learning curve better. It's part of CPD and I think it should be part of self-assessment, appraisal and five-year revalidation. So in my opinion, the gains are safety, efficiency, we get automatic operative time data and it actually allows us to get, if we want, a standardized operation note with timestamps on them. It allows us to assess the team's performance and when we have different members of the team participating on a weekly basis that are not regular staff members, for example, because of sickness, lack of staff and changes in staff, any temporary staff or agency staff that come can be guided through the procedures in a very different way and it's much safer and quicker. We don't waste time because we can actually analyze the camera is in and out of the abdomen. We don't waste instruments because we can analyze which instruments have been used and which ones don't. For example, of our normal general surgical, minimally invasive surgical set, we can actually take 10% out because none of the surgeons use them. That saves on sterilization costs. It means that you can do more operating in the operating room because things are more efficient and ultimately it's more profitable and our managers have had a look at the system. It allows almost a telemetry of the operating room and comparison of surgeons, teams and eventually hospitals. We've used it in clinical governance and audit. It allows training, a digital layout for audit. We've discussed it in morbidity and mortality and we can link it to national outcomes and these four things, in my opinion, will allow best practice to be disseminated internationally so we can share the good things. Next slide, please. Medical legal practices have changed internationally and this is the same in the UK. At the moment, the gold standard for documentation is the medical records, but the operation, though, A is often not there, B difficult to find, C usually illegible and D is often an interpretation of what's happened. Having the actual operation, annotated and kept in the medical records now that we are all leading towards papilla systems is a natural evolution, in my opinion. It helps us to retrospectively see was there an iatrogenic or technical complication we missed the first time round. I remember a case from about 18 months ago when a patient had peritonitis after a sleeve gastrectomy. We looked at the video of a certain thermal injury to two centimetres proximal to the pylorus using that particular energy device and that allowed us to understand how to avoid these problems in the future. We have a duty of candor process in the NHS and I'm sure there are similar systems internationally and nationally in other places, but this means that we can explain exactly what happened to the patients. If there's a mistake we can actually show them. We can show them what happened, we can explain why it happened, why it was a difficult case or whether it was just a technical error and it allows us to be completely transparent with the patient and the families. Next slide please. So medical legal issues have significant costs. So in the one year between 2017 and 2018 the NHS paid out £2.2 billion sterling because of medical and legal negligence within the service. All of you here are HMRC taxpayers, that's what we're paying for £2.2 billion we did a local audit in six months at our centre we admitted 34 NHS eligible bariatric patients who had gone abroad for their surgery and had complications and we have spent £2.4 million of UK taxpayers' money looking after those patients. These things can be learned from and potentially avoided it's a huge cost-saving. Next slide please. So it's useful for conferences and meetings, it's useful for case reports I'm going to show you one in a second and video and images help overcome language barriers. With regards to rare unusual cases, this is a good example never seen this before this is a revision bariatric case what you're seeing is not for the squeamish but this is essentially I hope you had your lunch me pulling out lots of blended vegetable matter for a patient who decided to eat day one after a revision bariatric surgery and got a food bowler obstruction which we had to laparoscopically evacuate. So these are really rare things that we can actually share with our colleagues. Cost savings a lot of cost savings are in training and appointing people and assessment. This is Quentin Tarantino's showreel and I think that if you're going to be appointed as a surgeon you should have a showreel equivalent I think you should also be test-driven we're happy to test-drive cars and they cost us tens of thousands of pounds and if you're lucky maybe get a Tesla which is a few more than tens of thousands but even those get test-driven surgeons never get test-driven we are so expensive and if we make a mistake recurrently we are really expensive. So I think all surgeons should learn to be test-driven and part of that process is you need to have live capture of your procedures so that they can be analysed saved and if necessary assessed automatically and certainly observed by people that want to appoint you. I think this will have a profound effect on training costs I think it will definitely increase our efficiency the cost goes down I've talked about less waste and less medical legal expenditure and I think the patient outcomes will be much better if we all buy into a transparent system next slide please it doesn't change much to actually deliver this in your OR it involves collaboration some technology some hardware and software and I hate to put up a paper form but we still need to consent people in writing so we have standardised consent forms for the surgery, for the risks but also for video capture and what we do with that data because it is potentially potential identifiable data which we make anonymised anonymity is further enabled by the digital surgery product the hardware and the software because every time the camera comes out of the abdomen it is blacked out next slide please so this is the view from the head operating table if you were a patient and the reason I put this here at the end of this part of the talk is this is what it's really all about it's about the patient perspective and at the end of the day if you're lying here looking at your foot plates just before you're going to get put to sleep you should be reassured to know that your surgical team will be doing everything they can to look after you in that team you should also be reassured that you're all completely recorded and that if necessary you can have a copy the hospital can have a copy the provider can have a copy your GP can have a copy and anyone related to your care can have a copy because that is part of your medical health record and I think patients that we have had experience with find that very very reassuring so I've been using this product next slide please and it works I'm not here to sell it to you it is something that I use it has helped my trainees it has reduced the amount of time that it takes for them to become part of the team we've had excellent feedback from the trainees that have already used the system because they've said they've got much more operating in the 6 to 12 months or 18 months that they're with us because they were up to date with what I do before they get into the operating room the world's first AI powered video storage analytics platform we were the first collaborative team to use it live in the OR two years ago and we've never looked back it allows me to look at my data compare my cases see how my fellow is progressing is he getting better than me maybe I need to do some more cases what are the time stamps where are the complications and most importantly if there is a readmission we can actually go anytime anyplace online have a look at that particular case and see was there something that we missed does this patient need an early re-operation next slide please so case analysis and surgical training really is crucial it allows trainees to securely organize their videos it allows surgeons to securely organize our videos and we can share that encrypted data with the people that we want to look at it it allows safeguarding of the this sensitive information it also allows us to annotate things so anatomy and steps are annotated for you you can share it with the scrub team you can share it with the specialist nurses and we can actually assess our performance in a very different and objective way next slide please it's approved by all the right data share holders and in North America it has all its standardized certification for being covered for data protection it is GDPR approved and it is a safe system that basically you can have on any mobile device so you all know this man he's the fastest man on the planet we've seen so far he prepares you have to prepare too hard because he decides to just chill out at the end of this race and still break the world record but not all of us have that natural raw talent but it allows us to optimize our performance before, during and after surgery it helps reinforcement of best practice it helps to improve that performance reduce the onboarding time and keep everything transparent it's a really easy reference now particularly for my team and my residents that present videos at conferences and case presentation thank you