Justin Collins

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Worldwide Live Robotic Surgery 24-Hour Event 2015

October 15, 2015/4 Comments/by admin Z.9

For the first WRSE24 we had over 2500 unique viewers registered from 61 countries (58 on the day).

This time we want you the global audience to get involved and participate online

In the Worldwide Robotic Surgery Event

Register now for free

In February 2015, with EAU approval, ten robotic centers from 4 continents planned to stream live surgery continuously for 24hrs.

Viewing of live surgery was limited to medical professionals using password protection, following registration. LiveArena ™ provided the infrastructure and technological support. All surgeries were completed without incident and we have submitted our outcome data to the EAU live surgery committee, who are supporting our next planned event. Further details can be found at www.wrse24.org

Following previously published EAU Policy on Live Surgery Events (LSE’s), whilst ongoing live surgery at conferences is assured, there remains debate as to how best we can optimise this form of training. The EAU panel reached >80% consensus view that performing live surgery from home institutions may be safer, identifying several issues with a ‘‘travelling surgeon’’. A BJUI poll related to the first WRSE24 found that 76% of respondents would ‘attend’ a streamed virtual surgical conference rather than travel if accreditation were the same, further indicating the potential for uptake into training and education events.

The outcome from the first event surpassed many of our expectations. Registrants came from 61 countries. 1390 unique viewers visited the www.WRSE24.org website during the live 24 hours and this number increased to 2277 over the next 6 days.

The event was well received by industry and the project was a finalist in the category of “Innovative Technology for Good Citizenship” at the prestigious Microsoft Partnership awards held in July 2015, which received over 2,300 nominations from 108 different countries.

We are also delighted to announce that the forthcoming WRSE24 will involve surgeons from 2 more continents making it the first live urological conference to have contributors from 6 continents.

As well as all the surgeons previously involved we will be joined by 5 new surgeons including 2 additional robotic centres: Clinique St Augustin (Dr Richard Gaston and Professor Thierry Piechaud) and Sao Paulo University Hospital (Dr Rafael Coelho). Benjamin Challacombe will be operating from Guys Hospital, London and Ketan Badani will be operating from Mount Sinai, New York. Our aim is to stream live surgery from 12 leading robotic centres, a list of whom can be seen below. Finally we will have a live teleconference link via Skype between Professor Hassan Abol-Enien from the world famous Mansoura University Hospital and Professor Peter Wiklund at Karolinska.

The second event will also see the 24hour studio sessions split into six 4hour sessions. The contributing centres are Karolinska Stockholm, OLV Aalst, Guys London, Mt Sinai New York and Keck USC, Los Angeles.

The first event was primarily focused on providing access to live streamed HD video of world leading surgeons operating in their normal working day, with their expert teams. The second event plans to build on this format with more audience participation utilizing social media. We are working with LiveArena™ and Microsoft™ to optomise this aspect. There will be improved opportunities to ask questions to the surgeons utilizing a Microsoft Yammer ™ app that will be integrated into the WRSE24 site or via twitter using #wrse24. Although the concept of a Twitter backchannel at educational events has become familiar, future approaches may be able to improve on ways of communicating within a global audience. Our aim for the 2^nd WRSE24 is to enliven virtual participation, widening access to a fuller, interactive, experience for the online audience, with an emphasis on conversation, connection and crowd sourcing of opinions. To highlight the benefits of crowd sourcing of opinions we are planning an ambitious project to have an interactive live debate between Mansoura University Hospital and Karolinska University Hospital. This will include polling technologies available via Yammer™, so that the second part of this planned live discussion will potentially be guided by the opinions of the global audience. A research-group at Stockholm University, with a specialist interest in Social Media are also working closely with WRSE24 to help interpret this data, so that we can learn from this event.

For more details on this worldwide event and the complimentary activities that are planned please visit www.wrse24.org

24 hour live Worldwide Robotic Surgery Event February 16th – 17th 2015

December 19, 2014/12 Comments/by Justin Collins

On the 16-17^th February 2015 ten leading robotic centers of excellence from 4 continents will broadcast for 24 continuous hours. All the surgeons operating are experienced live surgeons, pioneers in their fields, who have contributed to the development and advancement of excellence in robotic surgery techniques.

WRSE24 incorporating 10 world leading robotic centres.

“Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand.

― Albert Einstein

We live in exciting and progressive times in healthcare, when technological advancements are rapidly changing the way we work and the way we learn as surgeons. Many of these technological advancements come from discoveries and innovations made outside healthcare, making the pace of change less predictable. For example, it is well known that the advancement of robotic surgery technology came from initial innovative developments made within NASA and further funded and developed by the US military [ref 1].

With the advent of minimally invasive surgery utilizing video technologies, opportunities for surgical learning greatly improved. No longer was surgical training a master-apprentice role, performed behind ‘closed doors’ with the associated limited opportunities to disseminate expertise. Video recording of surgery enabled wider dissemination of knowledge and live surgical video transmissions have revolutionized the way that national and international surgical conference meetings are now run.

Following the recently published ‘‘EAU Policy on Live Surgery Events’’, it is now assured that live surgery will be ongoing at conferences in the immediate future. However, the panel reached >80% consensus on the view that performing at a home institution may be safer. The committee also identified issues with a ‘‘travelling surgeon’’ performing complex surgery in an unfamiliar environment with a surgical team that is not experienced with the intricacies of the surgeon’s technique. LSE’s from a home institution remove or minimize these negative aspects [Declan Murphy]. Furthermore, there are other important reasons why LSE’s are enhanced when performed at a high- volume home institution. The potential to optimise surgical performance comes from working with an experienced team. Consistency is a key measure of quality, and robotic surgery in particular epitomises teamwork. An established theatre team will move purposefully through the standardised steps with well-rehearsed, orchestrated movements. It is therefore likely that the natural evolution of LSE’s, is that a greater proportion are broadcast from home institutions [Collins et al].

We aim to highlight the benefits of this approach to surgical training with a worldwide team who will represent the best of current standardized surgical technique. All the surgeons operating are experienced live surgeons, pioneers in their fields, who have contributed to the development and advancement of excellence in robotic techniques.

We will be coordinating the broadcasts using LiveArena hardware and infrastructure. LiveArena are currently, primarily a sports broadcaster and in partnership with Microsoft have developed, cutting edge video streaming technology that enables streaming of HD video onto the internet, whilst requiring minimal capacity (3Mb/sec). The videos can be watched in real-time and also paused or rewound via their link and the video can be viewed on laptops, PC’s, smart phones and tablets even on standard hospital wifi, making this approach very accessible and scalable.

Communication with surgeons in real-time:

There will be a blog set up on the WRSE24 website, that any doctor registered can ask questions or highlight a topic for discussion. Questions can also be posted via this BJUI blog or via Twitter #WRSE24. During the 24 hour transmission Karolinska will monitor these aspects, combining the discussions and providing regular feedback via a 24 hour ‘overview’ broadcast on a separate channel.

To see more details and to register now for this historic event go to www.wrse24.org

Registration is currently free and urologists who register before the 12^th January will be entered into a prize draw for 5 donated robotic courses (3 ERUS 2015 courses in Barcelona, one at USC Keck Medical Center in Los Angeles and one at Peter MacCallum Cancer Centre, Melbourne)

World Live Robotic Surgery 2015 SBS News

Justin Collins is a Urologist at Karolinska University Hospital. @4urology

Consultant on call: incorporating lean thinking or Chaos theory?

July 7, 2014/2 Comments/by Justin Collins

The RCS report on ‘the implementation of the working time (EWTD) directive’ has recently been submitted. Recommendations include the need to rethink teams and services working patterns.

In urology a combination of the EWTD, depleted middle grade numbers and political will, have necessitated that consultants increasingly deliver out of hours service. There are theoretical advantages to a consultant being first point of call: the most experienced clinician physically present on the ‘shop floor’, delivering expertise at the point of contact with the patient, identifying and treating conditions more quickly than a more junior doctor. These views were supported by a major impact paper published in the BMJ that highlighted increased death rates for elective cases operated on Fridays and at the weekend. The conclusion from this paper and popularised in the press was that patients are more susceptible when senior doctors are not on the ‘shop-floor’. However there are recognised confounding variables to the papers findings. Friday operating lists have often been allocated to the most junior surgeons and post-operative complications are primarily related to co-morbidities and what occurs on the operating table, rather than the variability and quality of decisions made in post-operative care. Incomplete data was excluded and there may be a weekend effect for routine coding. The study itself highlighted the weaknesses of using administrative data and selection biases that exist for elective procedures scheduled on weekends.

The downside of frontline consultants is underutilization. The need to maximize utilization of staff-skills is not unique to healthcare and whole support industries have developed to optimise this most precious of resources. One of the most successful approaches has been lean thinking, which originated in the Japanese car industry. Lean methodology has been successfully replicated in multiple industries including healthcare improving costs and quality in parallel. A commonly quoted example, which highlights advantages over the ‘old way’ of thinking, was the understanding in how to optimise the factory conveyor belt, resulting in numerous correlations with other industry workflows, many of which use Mitrefinch US to optimize such processes. The conveyor belt was introduced by Ford in 1913, revolutionizing the car industry. It dictated the productivity of ‘the line’ with any interruption having significant implications to workflow. With this in mind Ford had a policy that only the most experienced person in the factory, the foreman, could stop the line, believing this to be safest and most cost-efficient. However this assumption was proved incorrect by Toyota in the 1960’s. Coming from a culture of respect and valuing the contribution of co-workers, they ruled anyone could stop the conveyor belt and that sections of the line work in teams. When the line was stopped all the team rallied to solve the problem and later performed root-cause analysis. In the Toyota model problems were identified and quickly fixed, but more importantly all the team were demonstrating continuous improvement, reflected in minimal rework required for completed cars. In the Ford model the primary aim was to keep the line moving, as a result many cars were completed with problems built in, several panels often needing removal to access mistakes and rework contributing 20–25% of total workload. Effects compounded by lack of feedback so that the same problems/issues were repeatedly not identified nor understood how to correct or prevent. In the Toyota model the line that could be stopped by anyone was on average stopped four times a month approaching 100% efficiencies, compared to 90% efficiency at Ford with the line being stopped four times a day on average. Disempowering the workforce resulted in reduced quality. Toyota thinking highlighted the key element for improvement was access to expertise when needed and that root-cause analysis resulted in continuous incremental improvement (kaizen in Japanese).

Lean Methodology was popularized by Toyota

If accessibility is the key it seems illogical in a time when technology gives us increasing options for audiovisual communication, we as a profession are choosing to regress to an approach outdated in the car industry half a century ago. An alternative approach could be a smart-phone or tablet linked to 3G and hospital wifi with an allocated Skype and mobile number. As a ‘baton’ tablet it would also necessitate face-to-face handover between consultants, whilst delivering a mobile consultant on-call service. Guidelines could be on websites and forwarded direct from the tablet to GPs and other doctors.

Downloaded apps would aid patient communication and local treatment guidelines/pathways that are evolved with contributions from all members of the team would enable ‘kaizen’.

Another key element of lean thinking is the necessity to reflect on decisions made. Make decisions slowly by consensus, thoroughly considering all options and then implementing decisions rapidly.

Reflection (Hansei): what would I do differently next time?

The Chaos theory states that complex dynamical systems have outcomes sensitive to minor changes, so that small alterations can give rise to strikingly greater unpredictable consequences. However, some affects are predictable, others probable. Changing a consultants’ working patterns to on-call services reduces the proportion of elective work and is likely to result in more ‘shared-care’ and reduced ‘ownership’ of patients. These effects are especially likely in smaller hospitals where the consultants’ on-call responsibilities will be more frequent. Sub-specialist clinics and surgery will be reduced and in some cases become non-viable. Shift patterns are by definition a less professional working environment. The true resultant effects are likely to be a down regulation in services with decreased consultant responsibility for long-term personalised patient care. The effects on individual trainees and the profession as a whole are harder to predict.

The changes to consultant working patterns supports the current political needs; however, they have been instigated without level 1 evidence. Only time will tell whether a consultant delivered service corrects the identified short-comings in out of hours service. Let us hope it doesn’t result in Chaos!

Justin Collins is a Urologist at Karolinska University Hospital. @4urology

Social media as a conduit for resolving surgical challenges

June 3, 2013/5 Comments/by Justin Collins

Wikipedia defines social media as a means of interactions among people in which they create, share, and exchange information and ideas in virtual communities and networks.

In 1965 Moore’s law stated that the volume required for a memory chip or processor would decrease by 50% every 18 months. This predicted exponential development rate has continued for the last 50 years and can be most visibly seen in everyday items such as smart phones or digital cameras. Whilst there is no clear explanation for this phenomenon it is most often attributed to the way in which ideas and technological breakthroughs are replicated throughout the industry and also transferable to different applications. It is the access to others’ knowledge that results in the rapid improvements.

We have recently had a paper accepted looking at Karolinska’s first 113 totally intracorporeal robotic cystectomies. Part of the published data is their complications and this includes a table of common complications with suggested solutions to avoid them. For example, when the results were analysed we found that 1 in 5 intracorporeal ileal conduits showed evidence of urinary leakage from the anastomoses. On reflection it was felt that this was probably due to the stoma spout being created after the undocking of the robot and that the anastomoses was put under too much tension. This part of the procedure had effectively been done blind. Their solution was to put the camera through one of the lateral ports when they pulled out the conduit through the stoma site, so that they could avoid rotation of the mesentery and tension on the anastomoses.

This was their experience and their insight and will not be the same as other series. But what if we created a table that surgeons shared and exchanged different insights into their more common or more severe complications, could we avoid making the same mistakes in our learning curves and improve our outcomes?

Consider the last time you were faced with a likely technical challenge during an upcoming case. Would it not be good to counsel the advice of a wider audience as you planned a robotic radical prostatectomy for a 200cc prostate and you worried about how to get the bladder down for a tension-free, watertight anastomosis? Sometimes small nuances of surgical technique do not get print space in the established surgical atlases or peer-review publications of surgical technique. Anecdote-based advice is sometimes essential to get through difficult cases, which is why it’s good to have a senior mentor available for advice as your own surgical experience develops.

But perhaps this is where the rapidity of communication and online archive in social media may have a role to play. Have we as a profession missed a trick in the directive to publish our results and our complications rates when we should be publishing and sharing our solutions to the complications? Could a blog of surgical tips and tricks for certain procedures provide a repository of surgical knowledge that others could both use and add to in a Wikipedia-style?

I hope we can utilise this blog to document our experiences of difficulties in robotic surgery with accompanying tips and tricks on how to avoid them. If we get enough then we could do something rather old fashioned, such as publishing them together in a table in a journal! Do leave a comment and let the world know what you think.

Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology

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Learning curve vs discovery curve: Training urological surgeons, what can we learn from sport?

March 4, 2013/2 Comments/by Justin Collins

Improving training in the United Kingdom may benefit from a more analytical assessment of natural abilities, individual learning curves and understanding and providing the necessary training methods to let trainees reach their potential. It used to be said that surgeons learnt from their mistakes, but surely this philosophy and approach is unacceptable in the 21st Century. To learn from a mistake when it could have been avoided in the first place, with the correct guidance, could be considered negligence. Of course to err is human and none of us are superhuman. However, what we must try to avoid is the “self-discovery” curve in surgery.

Vickers paper assessing fellowships to learn radical prostatectomy showed that a fellowship could shorten your learning curve. I have been on several fellowships abroad and what they had in common was of course numbers. Centres do not get a reputation or expertise by doing one case a year. However they also had in common a structured approach to training fellows that started with observation in theatre, then bedside assisting and finally doing defined steps of the procedure.

The combination of structured training and suitable experience is key to good surgical development. The individual who takes up golf and teaches himself or herself is unlikely to become a scratch golfer and may develop ugly habits that hold them back from reaching their potential. This can be seen in surgery. To complete the golfing analogy (and apologies to non-golfers): once a golfer has a reasonable swing and knows what he/she is doing, the single thing that will define how good he/she gets is how often they play.

Modern professional sportsmen are assessed for their technique using technology and we are starting to see this level of scrutiny in robotic training. Anyone who has used the Mimic technology in the Da Vinci robotic training, will recognise that it looks at several aspects of surgical technique, including economies of movement. In my own experience as an early trainee in open or endoscopic surgery I was rarely told how to hold an instrument properly or indeed about ergonomics and economies of movement. The focus was usually on the operative field, where to cut etc.

In professional sports much thought and investment has gone into creating the optimum environment to initially assess individuals for natural ability, then supporting and nurturing their talent, strengthening them both mentally and physically so that their “investment” is enabled to perform in the toughest situations as well as having longevity. Should we not aspire to do the same for our surgical trainees?

Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology