 Good morning. Good afternoon. Good evening to everyone. Apologies, I'm accidentally advancing the slides instead of just unmuting myself. Richard, if you could help me, just skip back to my first slide. That'd be great. My name is Andre Chow. I'm the vice president and general manager of the digital surgery business here at Medtronic. With digital surgery, we really focus on using digital technologies, data, AI, to really expand access to high quality surgical care. And it gives me a really great pleasure today to introduce you to the first of three webinars, which we'll be doing over the next few months. And today we're going to be focusing on the issue of surgical video and really how to use it best to improve your surgical practice, help your surgical teams, and so on. You can see the agenda. They're there in front of you will be going over some some high level concepts before kind of diving a little bit deeper into the evolution of recording surgical video and, you know, some specific points around how video can be used to improve your practice. As Richard mentioned, please submit any questions using the Q&A function, which should be there in your Zoom window, and we'll make sure to save some time at the end to kind of go over those. It gives me great pleasure to introduce our guest speaker today, Dr. Sanjay Perky-Yasla, who I've known for many, many years. He is a consultant general surgeon with a specialist interest in bariatric and upper gastrointestinal surgery. And he works at Imperial College surgery and cancer division, as well as the one Wellbeck digestive surgery, and King Edward the seventh hospital in London. Welcome Sanjay, real pleasure to have you here. And thank you to Medtronic for inviting me and thanks for everyone who has joined us to listen to our chat today. Great. All right, well, let's let's jump straight into it. So I'm going to try and advance these slides here. So let's start off with a pretty broad question here. Obviously, we're here today to talk about surgical video. And really, Sanjay, I'd really love to kind of, I guess, get your broad opinions, first of all, on what are the sorts of ways in which we can use surgical video to help surgical practice and so on. So I think a lot of surgeons and practitioners have been interested in the video capture element of surgery for probably decades, but up until recently, it's been quite cumbersome. Now previously, I'm sure there are a lot of people listening in who have recorded their laparoscopic or arthroscopic or endoscopic procedures. So you had to then either historically kind of burn them and then put them onto a format where they could edit them to use them for conferences, education, presentations, but also for training. Now from a training perspective, probably about decade and a half ago, when I was training, I started recording the laparoscopic procedures that I was carrying out mainly to see objectively after the cases were done. What did it look like when I was operating retrospectively? And I tried to push some of these videos under the noses of my then trainers to say, hey, what do you think of how I'm doing? And at the time, a lot of surgeons were not really keen to do so. And at the time, because of research and training, all of our patients were consented for image capture anyway. So one of the things I thought that could be helpful would be not just for my own training, but for a peer-to-peer review or even sharing things with patients. And that is an attitude that I think we really need to move towards. And that's kind of how the journey started, really, to try and improve my own performance and see what other people who don't see me working in the OR and who aren't my direct trainers thought of my surgical techniques. So that's where it kind of started from. That's really interesting. And it's fascinating that you've been trying to kind of use this digital media for really for quite a while now. So obviously, you've used it quite a lot in regards to self-improvement and your own training. Where do you kind of see this technology going in the future? Where are the avenues that this could help kind of beyond training? So it really helps in preparedness. And that's probably a term we've heard much more during the pandemic. But it will help us with rehearsal. It certainly helps with onboarding. It helps with academic presentations and training presentations. It helps with explaining things to patients, not just pre-operatively but post-operatively. For example, anti-reflux surgery can explain exactly why you did what you did, the extent of hiatal dissection, the fact that some patients hiatus hernias are under-called or over-called from the diagnostics and why we picked a particular approach during that surgery. There are also contentious issues, but if there are interoperative complications, we found actually using video is a lot easier to explain these to patients and relatives as to why it was a challenging case, why something may have happened pre-operatively. And we found that it helps dialogue amongst other practitioners as well as patients. A lot of places have moved to electronic records. A lot of us feel particularly in our institutions that the operative video is really crucial to electronic records, along with the operative note. And for certain surgeries where there is revisional surgery in the future, it is very valuable to know exactly what was done. But in those cases, sometimes you don't have to watch the whole video, and if you have access to the right segment of the video, then preparing for revisional surgery is very helpful. So all of these different tools have come about and during our journey in the last eight to 10 years with different ways of video capture, as we'll talk about in a second, it's also opened our eyes to other potential patient safety positives. There are swab counts issues with kits during the procedure, ensuring that certain steps of surgery are followed, and it has certainly led to increased standardization in our unit across the board when it comes to deciding which kit we're going to use, and which operative steps we're going to use and it has also meant that, particularly in our specialties, we've all sat down, all surgeons together to kind of decide, can we standardize our approach to different procedures as a unit, and not just from a surgeon to surgeon perspective. So it's really aided collaboration as well. So kind of you can see how you've started to think about using this all the way through from training, through to actually standardization of practice, and collaboration of colleagues as well, it's absolutely fascinating. Before we move on to the next section, I think we've got a little poll that we wanted to do just to get a bit of a benchmark as to how our audience feel about video currently. So hopefully a question will have popped up on your screen at the moment that's going to ask you how often do you record your surgical video with a number of options there so either you record for every elective and emergency case or just for elective cases, or just sometimes really or never. So if you could just take a second just to answer that and then the poll should disappear from your screen. You can get a quick snapshot really of what our audience thinks. And here we go. So it looks like the majority of you only sometimes record your video. And yeah, so that's a nice little snapshot really of where we are. Great. So let's move on to the next slide please Richard. And really Sanjay what I wanted to dive into here was about I guess the experience that most surgeons have today with trying to record surgical video right so you mentioned previously, you know the need to potentially burn DVDs and so on and so forth. Before a lot of surgeons have experienced now with you know integrated operating rooms and you know advanced laparoscopic towers and so on. But do do those devices make accessing your surgical video easy today or are there still problems. I mean things have moved on a lot in the last decade and a half. I'm sure everyone will remember the days where we had to burn everything onto CD. That took a long time that then had to be uploaded onto your hard drive and you know to edit a video. You know even a straightforward laparoscopic callus astectomy or laparoscopic hernia repair is you know minimum of 30 to 45 minutes of footage you'd have to edit that down. It all I mean the data transfer itself took a lot of time. The advent of USBs made it easier. You know encrypted hard drives are very useful but still even with USB threes. It does take a significant amount of time because it is so much data and with the advent of high definition and ultra high definition images that the amount of data on that bundle is even more. And so at the end of each case you know previously you or the end of the day you're downloading this huge amount of data and then you have this issue of where do you put it where do you keep it where is it safe. And so those issues with data safety and encryption were some of the things that we had to discuss. You know at our internal review board equivalent and get through our NHS trusts and other hospital governance boards to make sure that they corresponded with in the UK or the GDPR data. Regulatory issues got them all ticked off but it just means that now that we have a way of uploading this video almost automatically at the end of each case and for standardized procedures where we have worked as part of our research collaboration and research with my PhD students to be able to segment these videos into the major steps that at the end of a procedure you just hit one button and basically it's uploaded into a cloud and several eight minutes later you have a video that you can edit the different steps on know how long each step took and then actually put footnotes if there were problems and then market to see if it's something you want to discuss with your colleagues it's useful for training it's something you want the people who have access to your portfolio to look at and all of these things just takes a matter of minutes at the end of each case and then if something were to happen to that case it's very easy to pick it up and then actually discuss it with the images in your routine monthly by monthly or whatever you know each unit does for their morbidity and mortality meeting so it's really kind of made that whole pathway much less cumbersome it also means that if there's a particular step that is of is the bit that you know you want to take to a conference or you know use for training you can just use that particular step and it means you don't have to go through reams of video trying to find exactly the bit that you need so loads of positives don't have a negative at that moment to share with you I'm afraid. No worries I mean you brought us on nicely to the next next section actually which is around the solution that we've developed. Richard if you wouldn't mind advancing the slide just one. So really the product there that Sanjay was talking about which he's been using now for for over a year is our touch surgery enterprise system, which essentially was developed to to solve the issues of data management and surgical video management. As Sanjay mentioned you know we've all come across colleagues who do take a lot of time burning DVDs or saving files to USB drives, which are often unencrypted and really what we've developed is a very simple almost plug and play system that plugs into any laparoscopic stack. Using our DS one computer that you can see there on the right hand side of the screen, which then essentially connects your operating room with our secure cloud based video management system available on your computer or on your mobile device. So essentially you have all of your videos that at your fingertips minutes after finishing your operation. And also should mention around data security which was one of the one of the concerns that Sanjay brought up the whole system is compliant with a number of different regulations including HIPAA high tech SOC to etc. So it's been designed really from the ground up with privacy in mind. Sanjay now that you've had the chance to kind of use the system now for, for, you know, well over a year and I've seen you've actually uploaded hundreds of videos now onto the system. You know, what, what change in practice has this made for your team or what has this allowed your team to do you think that that can't be done in other places. So it's been useful in areas where we were expecting it to be useful such as for, you know, perioperative training, presenting useful cases m&ms etc. But it was also highlighted the need for a proper onboarding system with surgical trainees so for example I'll be getting a new trainee in April. I've already been sent a link to be able to access my portfolio that portfolio doesn't just have the cases that we've done but the standardization of how those cases are carried out the positioning the kit little links to how to use the kit. In a lot of places, particularly in the UK induction or onboarding revolves around coming to the hospital and understanding the geography of the hospital. And what things you need in your training portfolio and a whole bunch of other things including fire safety and, you know, lifting regulations. But until recently, you know, we weren't actually providing induction of what we do in the operating room so that they can prepare for it. So onboarding is one. The second thing is rehearsal and preparation. There's great evidence out there that cognitive task assessment and analysis, just like athletes thinking through what they will be doing on the big day of their big race is very relevant to surgical brains and surgical decision making this alongside the touch surgery platform allows that both with video and animation now. It also allows our scrub text to prepare if they're new and I'm sure everyone's experience during the pandemic that you work with very different teams and the continuity of teams has broken down. And so that allows others other than the trainees to actually prepare for the case and the kit. It also allows comparison, which some people like some people don't, but we can tell you from standardizing our procedures that actually five or six surgeons. There is very little difference whether the between the different consultants operating or when the registrars or trainees are operating. The system has allowed us to demonstrate that during the pandemic, even with lockdown in the in the times that we were allowed to carry out benign bariatric surgery. You know, out of the 180 cases that we carried out between July and end of November. Last year, 70% were carried out by trainees. So it's a whole host of benefits that some of which we were hoping for and some of which that we have stumbled across. But most importantly, it's been very simple to record cases. You just need to plug the stack in and hit record. And then at the end you just need to hit stop and it can't get any easier than that really, even for someone who, you know, I'm not a social media kind of guy. But using this technology is has been very, very straightforward for me and the whole team. It also led to behavioral change across the unit with my surgical colleagues who all of who in the unit have now agreed, not just in bariatrics but across specialties. Anyone that carries out laparoscopy in our trust across three sites has now, you know, agreed to using this and recording every case when and where possible including emergencies. That's fantastic. So let's jump on to the next slide Richard. And let's dive a little bit deeper into surgical training, which we've touched on a few times so far in this discussion. So could you could you tell us kind of how do you encourage your trainees to use video. And how has it kind of changed the way that they approach learning how to operate. So, as I kind of alluded to there's the onboarding process, which is also part of rehearsal. There is obviously the, not just learning the steps but watching the movements of someone who has carried out these procedures hundreds of times compared to themselves. There is the ability to debrief that picture on the slide is actually myself and Jasmine, who's one of my fellows, looking at the procedure at the end of a case to understand, you know what could have been done better. There is also the ability for peer to peer comparison so trainees can look at their videos with their colleagues and say, you know, this is what you think similarly with other trainers and not just the one in the OR. So there's a whole host of comparators that it allows. And it also allows a portfolio to be built. And we have any portfolio in the UK that's taken into consideration at the end of your training. But I think a system like this will almost allow for almost like a real to be produced, a bit like a real that, you know, actors and other performers may have, when they go for a new job or a new role or an audition, you know, we should have a real for our trainees at the end of their training of all of the lap colis they've done all the herniers they've done. And it also shows you how their movements have changed at the beginning of their placement with us, and their end of their placement with us. And that gives you some objective feedback that you are able to give your trainees, which they really have appreciated. That's great. I mean, so you mentioned almost like creating a greatest hits real for trainees to add to their portfolio. How about the other way around how do you use video to, I guess, look at, you know, mistakes or things that could have been done better. Is that something that's incorporated into your practice? Yeah, so that's part of the debriefing as I call it, but also if there are technically challenging cases, all the trainees and, you know, our colleagues across the unit we know, you know, to specifically kind of highlight these and use these for education. The best example is probably laparoscopic colis mastectomy. It's either a very straightforward operation that, you know, can, you know, half an hour, you know, in or out. But, you know, the more and more acute lap colis you do, you know, there are challenges that junior surgeons can, you know, fall into easy pitfalls with obscured anatomy, distorted anatomy. You know, it is an area where you will, you can have a major complication. And those are the kind of tips and tricks and visual images that we can share with each other, not just in a unit, but actually, you know, across the surgical community to make surgery safer by sharing those slightly unusual situations that you may find yourself in. You know, perhaps, you know, and a bit of instrumentation may help, you know, we've had some challenging lap colis through COVID. Everyone will tell you that acute lap colis have got much worse. You know, there are some anatomical variants with the acute pathology that has led to a slightly higher use of one instrument in our unit, the endomini retract that allows you to get round tubular structures with a blunt dissection, for example. So these little tips and tricks are really helpful. And actually, I think there's a huge bias in not publishing and talking about problems and complications. And I agree with you, we need to get away with that. We need to share the complications so that they're avoided and we learn from mistakes, not just of our own, but everyone's. Let's pick up on that point a little bit further. So, you know, I know that when I was training, I didn't see my consultants, my bosses, kind of getting together and discussing surgical techniques very often. But you've mentioned that, you know, now that your colleagues record all of their surgical video, there is more collaboration. Can we touch a little bit on that as to how that's done and how that's, you know, affected practice? Well, from a collaborative perspective, to be able to do this, you have to think about standardizing your procedures. If you've got, as we have five or six surgeons carrying out bariatric procedures. And if everyone uses different techniques, different kit, it just gives heterogeneity within the operating room. And that is what can cause potential problems. It also has cost efficiencies. If you all use the same kit, it tends to be cheaper. You can package it in a different way. But also from a training perspective, if you have the same steps, it's a lot easier for a fellow to come to the department. And if they're working with five surgeons, they actually have five times the volume of the same operation if it's done in the same way. And so it's collaborative because it forces standardization. And I think for elective surgery, that's, you know, particularly something like benign upper GI surgery. I think that is the way forward. If you do something well and you do it over and over again, it's easier to train, not just for the trainee. It's easier to train for the scrub tech. It's easier to train for the runner. And actually our anesthetists prefer it as well, because we all operate in the same way. Richard, let's move on to the next slide, please. Sanjay, you mentioned patients. A couple of times as we were talking. Personally, I don't know many surgeons apart from yourself who who actively uses video when when talking to their patients, but I'd love to hear kind of how how this has changed the way you interact and communicate with your patient group. So patients get lots of information through the provider's website through the internet. But when it comes to counseling patients, it's quite useful to have your own surgeries to be able to tell them what you're talking about. It's all well and good explaining an operation and showing some diagrams to patients, but patients quite rightly have become more educated and want to know a bit more about your particular technique. For example, some patients even want to know what kit we use and why. And it's very helpful to have the access to the videos, you know, quickly. And so although we talk through things and now we're virtually consenting patients. So they get there on a platform where we send them the consent form virtually while before we do the consultation both in the NHS and in private practice here. So it is very useful to be able to also talk them through video. And after the surgery as well psychologically, it's very helpful I found to show them either images or bits of the video and if it's their operation even better to say this is what your liver looked like at the time of the sleeve. This is how big the stomach was this is what we've removed this is what was left. You know we had no complications this is what the operative field looked like at the end of the procedure. And we think that you're going to do really well and now we've done our bit over to you to do the hard work. So that's an amazing amount of transparency, I guess that you're having with your patients. And then you also mentioned that you're using video to potentially explain when things haven't gone to plan to patients as well so I'd love to hear a little more about about that experience. Sure. So, you know, everyone any surgeon who has no complications, as my old boss used to say, is either not doing any surgery, or is telling porcupine. So it's really important to share complications and I know that surgeons that will be listening and providers that might be listening in are worried about litigation etc. Why I would say to all of those is actually being transparent and talking about things would probably reduce complaints and we've certainly found that. And I think if you have a complication if you share it with the patient and you explain it to them, along with, you know, the continued input from senior clinicians, even if you have complications. Actually, you there's less risk of failure to failure to rescue, the patient gets sorted out actually, even though they've had a complication, there doesn't have to be a complaint or litigation to follow. Now that might be different in different countries, but I feel that the UK is definitely going towards the direction of North America with regards to litigation. But I think it's very important to consider to be proactive, rather than reactive to complications. So if you do have a problem, share it with your patients share it with the relatives, talk it through with them explain to them why it happened and what the challenges were. And then make sure that you're present and more present than normal during their recovery, and you will work with the patient and their family to get them better. And they will actually become some of your star patients, one of my patients. In fact, the only Jejano Jejano perforation that I've had which occurred three or three and a half weeks after surgery. And the patient needed re-operation is actually one of our biggest advocates of bariatric surgery in my patient cohort. And I know him and his family better than some of my other patients you've done amazingly well with no complication. So, I would just say that, you know, transparency, sharing data with patients. I think it's a positive thing, and we should celebrate what goes on in the or not hiding it, even if they are errors. That's great. That's great to hear. Up on the screen here we've got on the left hand side, one of our, I guess privacy measures that we built into the system, which is our redacted technology and as you can see essentially what it does is automatically blur the screen when the laparoscopes taken out of the body, just to stop accidental pickup of faces and so on and so forth. So, Jamie, thanks for your question. He's asked how is procedural video managed and distributed securely and how is access controlled. That's absolutely vital Jamie and these are steps that are different with regards to regulatory issues, depending on I guess geographically where everyone is we have GDPR guidelines in the UK in based around European law and British law and so I would say to you that it's very important that you get all of your information government governance ethical approval for this and IT infrastructure discussed with anyone who's interested in doing this and the digital surgery team are very open and transparent to provide all the necessary documentation so that all procedural videos are managed in a way that conforms with the regulations wherever you are. The distribution so it is all secured on an encrypted cloud based server of the highest in encryption for healthcare and can only get access to that if the surgeon or the provider wants you to have access. So for example, I will have access to it on my account and I'm allowed to give access to my account to other trainees and other surgeons. If I want to show anonymous and all the videos are anonymized because of the redacted system. So if I want to show a bit of a video to somebody to explain what things are about that has already been cleared from a regulatory perspective by the provider. And we've consented all of the surgeons and trainees that operate so any new trainee that comes to the system comes to the unit gets consent is allowed to consent so far no one has refused to consent for surgeries that they're carrying out to be shared with colleagues to be used in m&ms to be used if in case of complications and also if the patients request images, then we are happy to share those images with the patients. And initially that did cause some pushback from some of my colleagues, but subsequent to, you know, some of the benefits and the fact that so many people in fact all of us are now happy to record things has meant a huge change in kind of institutional behavior and allowed real behavioral change within the system that you are to occur so that, you know, you can go ahead and and use the videos and the ways that I'm describing but it is absolutely imperative that you go through all of the necessary regulatory information governance and encryption procedures. If you are looking to set up a system like this or similar to this in your hospital. Thank you so much. I'm going to step in for for Andre my name is Kristen D'Angelo I lead our marketing for digital surgery. And so I love if we can now move to the next topic I think we have spent a, you know, got a really good understanding of patient experience and addressing some of the concerns that that were brought up in in the q amp a Richard if you could please advance the slide. So, we're really interested now and hearing more about your experience and how this technology can also improve or efficiency. So, can you talk a little bit about the features that you've used and some of the standardization that they you've described Dr put the asset on on really the ways in which you've been able to achieve standardization and improved workflow in your operating room and also explain some of the different snapshots that we have here on the page and how those have assisted in that. Thanks Kristen and thanks for stepping in. So, a lot of the efficiency I think comes from standardization so that's a decision of the unit, you know whether we were going to use video data capture or not, but having standardization does allow a better use of this technology in my opinion, particularly with the integration of the machine learning so, you know, there are all the bariatric procedures I carry out with collaboration with digital surgery now is recognizable to a machine learning system. So it knows all the steps. And it knows when I, you know, when we're not going to when we're not carrying out the next step so if there is a difficult case and we're not carrying that out. There is an option to have that. But from an efficiency perspective it collects all the time stamps in in real time. You can see there on that third image on that on that smartphone. There are little lines above the bar charts those are the average times of each step. Compared to the times that you're carrying out of that step and you'll be able to see that literally at the end of the procedure. That allows you to be able to feed back to your trainee or to yourself. You know this was a pretty straightforward case. This was an average case or was there a problem. Those timestamps are collectible not just for an individual but for the whole team. So technically they are comparable. And that is something that we have looked at and as I alluded to earlier, they haven't been, you know, because of the way that we work we all work pretty similarly and our outcomes and our times are the same. It's also allowed us to understand which by looking at the video and actually analyzing it, you know, are we using which kids are we using, you know, what should be within our car decks and what shouldn't. It's helped, you know, take things in and take things out of our kits and sets. So it's not just helped the surgeon but it's helped the the administrative and the scrub team as well for efficient. That's great to hear. And thank you for those examples. You know, before we head into the Q&A where we'd really like to hear more from from all of you would like to do one more one more poll so you'll see that now flash up on your on your screen here. And we'd like to ask the question of, you know, as we've gone through these three different areas for opportunities of how surgical video can improve practice and and achieve excellence in the operating room. What's your take where do you see the best opportunity for for that improvement. Wonderful. Well, it's great to see just, you know, where there's such strong use and an opportunity to improve surgical training. And certainly in the other areas that we've talked about as well. And certainly, as you've shared, Dr. Koyasa on on just the ways in which you've seen this with your trainees and in your practice. We've certainly been able to supply some some great examples of how that can be made possible with technology like this. So at this point, now we'll move to the question and answer so Richard if you could please advance the slide. And so with that, we're going to put back up the instructions just to remind everyone about how to submit those questions which I believe are on the subsequent slide here. Okay, great. So we will, we'll get started. We've had some great activities so thank you so much for for the questions that have have come in. Can you describe Dr. Perghiasa how long did it take this technology to get approved at your facility can you describe a little bit more about what that process was like for you, who was involved what kind of questions were asked and and what kind of conversations did you did you have along I think that's whoever asked that fantastic question because that is that was the most painful part of this process for us. But one of the reasons it was the most painful is when we started doing this, you know, this product really wasn't out there and we were. We wanted to carry out research to see whether, you know, this sort of technology and process would be useful so there wasn't really any prior system or example to go with. And the second thing that was painful for us is, you know, this is part of the NHS, as well as an academic institution so that meant we had two different governance systems to go through and one is the largest healthcare provider in the world, with lots of issues with information governance and had an issue with being hacked in 2019. So, I would say that those conversations were challenging, we had to plan and although we've been using this system for over a year. All of this actually started in 2017, which is four years ago now. It took about six to eight months to get all the discussions carried out with information governance with the information technology team, the internal review boards, and with the institution executives on one side which was the NHS Trust, and then we had to go through ethics and all of the paperwork for the university because this was an academic enterprise at the time. That did take a very long time to get the parties together, but it did eventually happen. It had to get signed off by the academic leads and the divisional leads at the trust and the university and once we were able to convene that meeting, we were kind of good to go. These things would be very different now that we have gone ahead with this. I know that there are other trusts in the UK that do use this technology that have had a much easier route to doing that because they've spoken to us. And when they're relevant colleagues in their IT and information governance departments contact hours and kind of have a chatter on a kind of professional level, it makes things a lot easier. Wherever you are in the world, I'm not sure if your administrative issues will be as painful as ours. I hope they're not. But to avoid those, you should plan well in advance, and I would say a minimum of four to six months of conversations will need to take place unless you work somewhere very forward thinking. No, thank you. I think that it can be a really difficult process to get started and requires championing like you described. And so does everything that's worth doing and it's disruptive. So thanks for adding that. Yeah, so we've had one question come in that we've talked a lot about training. If we could give an example about how this technology has helped in an example for patient safety. And I know I know Dr. Brigasi you've you've had some great experiences here so maybe we can hear from you on on an example of how you've encountered that and how you use the technology. There's a couple of cases, but one case in particular, which we've we've actually uploaded and is available on the touch surgery platform as a learning tool. It's called the needle in a haystack case. We had a gas an uneventful gastric bypass in a BMI of about 60 something where right towards the end of the procedure where one of the final sutures was being put in the needle broke off the suture and disappeared into the background somewhere. And despite looking it was very it was impossible to find with x-ray laparoscopy. And at the time this happened probably about two, two, two years ago, there were no protocols for what we should do so ringing our head of patient safety. We got three different answers. One was keep the patient asleep, send them to CT scan and then retrieve the needle. Do a laparotomy and have a good look and take it out. And the other one was just leave it in because it's not harming the patient and we'll find it later. None of these three felt comfortable to me as the attending surgeon. And actually at the time of these discussions which had added already 45 minutes to the case. My trainee actually suggested why don't we just rewind the video and watch it in super slow motion which we did. We actually found that the needle had popped off by catching the laparoscopic port which was in the right upper quadrant bouncing off the diaphragm and falling down between the spleen and the kidney. And was actually in retrospect we took it out laparoscopically but we had to mobilize the splenic flexure and take this needle out. There was no harm to the patient. There was an addition of an hour and a half to this procedure which normally takes less than an hour and a half in our unit. So it's double the procedure time. We have a duty of candor criteria in the NHS which is to explain all complications in lay terms to the patient so this was explained to them. We actually showed them the video and said this is what happened. They were nothing but grateful and thankful that they did not have to go and have a CT scan or have a laparotomy. And actually as with 80% of our gastric bypasses in our unit, the patient went home the day later. So even the extra 90 minutes of anesthetic time didn't make a difference to their outcome. And we've obviously followed them up and they've done really well. But this was discussed in our morbidity and mortality meeting and it has now led to a policy of how to deal with these things. And because we record everything, we're able to play these things back. So if you do have an interactive complication, you can play things back and see what the problem is, not just with a broken needle, but with where did the bleeding come from? What was the structure that was damaged? Or if you can't find a swab, you can actually play things back to see when that swab was put in, the laparoscopic tonsil swabs that we use to see when to take it out. So it's really helpful to be able to in real time retrospectively have a look back at the case that you're in if you come across a problem intraoperatively. That's great. And very, very powerful example. So thank you. This next question, Andre, perhaps we could direct this to you. We've had a question come in around how do you handle these huge data files? What is kind of the processing experience like? And what's kind of the workflow is someone kind of turning this on and off and so forth? And then I'll combine that with another question because we've had a lot of great activity on the Q&A. But in the processing of that video, can you talk a little bit more about how patient information is protected as well? Absolutely. So I mean, yes, the question is absolutely right. Surgical video files can be massive. They can be gigabytes at a time. And we are lucky that we live in the era of fast internet broadband speeds and cloud computing. So we're able to manage all of this up on our cloud servers. You know, openly we use Amazon web services to run that. And that gives us the ability to securely store these and process these really as quickly as possible. And as we mentioned previously, literally minutes after the case is finished, you can have access to that video right there on your mobile device. So the use case or the user experience we feel is significantly changed through the use of our system. In regards to, you know, I saw some questions about kind of rights to the video and so on, once it's on our servers, you know, again, just to be clear, you know, we act as a data processor. We are not a data owner. So the data, the original video remains the property of the hospital or surgeon or whoever uploaded it in case that's of a concern. Come on to another question I can see here about the sort of different specialties that the system has been used for. You know, obviously we're, we're focusing this right now on the general surgery space or more specifically the laparoscopic general surgery space. But the question here is about other specialties like orthopedics neurosurgery and cardiac surgery. The answer really is, you know, wherever you are using video or a video camera specifically as part of your operative workflow. And then then you can use this system. Right so, you know, for also I guess that would be arthroscopy. You know neurosurgery with with my microscopes, you know, cardiac surgery potentially with robots. You know anything that uses a camera for minimally invasive type operations and can can use our system today. And they require really is a video video output to connect with our system and up to the cloud. So, hopefully, hopefully that answers that one. So, like we mentioned, our system is designed with kind of data security and privacy from the ground up. Once we have the right agreement in place with a hospital. We are our systems are certified to hold that sort of data as long as we have permission from the hospital. If there is concern about spread of that. We can actually enable the system to completely remove all PII and completely divorce the the video from the actual patient case as well. So, you know, we're able to adapt our installation, depending upon really the the appetite of the hospital on exactly kind of what they what they require. Let's pick a question here. Yeah, here's, here's one that came in. As we excitedly await the metronic robot. Can you explain how the touch surgery platform will work with the robot. Absolutely, you know, working working with the robotic team here at metronic was one of the big reasons why we decided to join last year. The touch surgery enterprise system will be available with every Hugo robot system as it goes on sale around the world. And, you know, I think I can openly say that we are an integral part of the roadmap when it comes to the digital tools that will be enabled as part of the robotic platform. I would say that starts with, you know, video management smart video management cloud based systems and so on and so forth. And then as we get into the future. You know, really we're we're talking about using AI in the future to actually help introduce further safety features of the robot and so on and so forth so so it's going to be pretty closely integrated with it. Well, thank you. And so, I wish we had more time to address more of these, these questions but thank you everyone really for your engagement during during our webinar. I'll hand it over to Andre to wrap things up and Richard if you could please advance the slide. Great well as Kristen said, we're at the top of the hour. Thank you so much for your time and engagement and some some great questions. My apologies I dropped for a few minutes. But thank you Kristen for for picking up the slack for me. Like I mentioned, this is the first of three webinars that we will be doing. So keep your eyes peeled for for the next ones which should come out in the next few weeks or so. And yeah, see you next time. Take care everyone. So, I should also say thank you to Sanjay. I appreciate the time. Thank you Andre. Thanks Kristen and thanks everyone for joining.