In the first of our ‘Colorectal Cutting Edge’ series, Miguel Cunha interviews Peter Coyne and Jim Khan, both members of ACPGBI’s Robotic Sub-committee.

Miguel Cunha, Peter Coyne and Jim Khan 

Peter Coyne is colorectal and anal cancer lead at Newcastle upon Tyne Hospitals NHS Trust and cancer lead in his UK region. He is a member of the ACPGBI Robotic Sub-committee and is actively involved in teaching at all levels of undergraduate to postgraduate education.

Jim Khan is a key opinion leader in robotic colorectal surgery. He has published over 100 academic papers and presented internationally extensively on the topics of robotic surgery, rectal cancer, CME surgery and training/learning in robotics. He is core member of ESCP’s Colorectal Robotic Surgery Working Group and chairs the ACPGBI Robotic Sub-committee.

Miguel Cunha: Firstly, let me say it is a pleasure to interview both of you about two combined and interesting subjects: robotic surgery and tele-mentoring.

We all know that robotic surgery is being increasingly used among several specialties, and colorectal surgery is not an exception. With its emergence we face the learning curve concern and tele-mentoring may be a possibility to assist progress along that curve. To introduce the topic for our readers, in a short sentence, according to current knowledge, can you define tele-mentoring for us?

Jim Khan: Tele-mentoring is a technique of providing support, guidance and help to a healthcare professional remotely, when the professional has limited experience of such a technique. This is a branch of telemedicine and is finding a lot of interest in surgical disciplines.

MC: I’ve read with great interest about your recent achievements in robotic tele-mentoring. Can you give us a short explanation on how the system works?

Peter Coyne: Essentially, robotic tele-mentoring allows access to the theatre, patient and robotic views that the operating surgeon has at the operating site. This can be accessed anywhere in the world on a secure network connection with the correct software by another surgeon on their desktop or laptop computer. A small webcam and portable tablet allow theatre overview and patient views. This is important to help the surgeon spot and solve difficulties with arm clashes or difficulty in access. The console view of the surgeon is also shared. The mentor is able to freeze frame and interact via a software package allowing tele-fenestration (the ability to interpose on the screen), for example: pointing out anatomy, demonstrating where to grasp tissue, how to position and set up dissection. At present, the remote surgeon cannot physically operate or take over, and all movements are made by the primary surgeon in the operating theatre.

Tele-mentoring examples: Audio communication with the mentor (left) and Portable tablet allowing theatre overview (right)

MC: Have you experienced any legal or regulatory barriers within the implementation of this technology?

PC: No, not directly. At present, the remote surgeon can only offer advice or guidance and cannot physically operate. Thus the trials we have undertaken need a robot competent surgeon to perform the cases and to trial this as proof of concept. This can be used for training and mentoring once the surgeon has passed basic competencies or perhaps more excitingly, come together for difficult cases such as extra-anatomical dissection (e.g. pelvic exenteration).
It is important that the access and transmission of data is done securely to fulfil the Caldicott and legal aspects of anonymity and data safety for the patient. We were fortunate to work with a great team in theatres and IT to help facilitate this, and this is important prior to set-up of the system.

MC: What other challenges do you envisage for the broad dissemination of tele-mentoring in robotic surgery?

JK: First of all, telemedicine is not a replacement for surgical training and hence one should not think that it can reduce the need for hands-on training with trainers. It covers the initial phase of learning curve very well when the surgeon is trying to ‘fly solo’ and may need guidance and support for successful completion of a procedure.

The technology is evolving and we are going to see better interface and software to utilise and provide support for the operating surgeon. The reliance is heavily on a good quality high speed internet internationally. Although the 5G networks are going to make life a lot easier, there is a room for some significant improvements with the existing networks.

Lastly the whole programme works on good understanding and team work between the two sites, and hence communication, common language and appreciation of the limitations of the technology have to be accepted by anyone involved in such an exercise.

MC: Is private information from the patients secure within these kinds of platforms?

JK: The short answer to this is yes, it’s a very secure platform. Nothing is recorded during the event and the images captured in training are destroyed at the end. Also principles of good clinical governance should apply and no patient identifiable data should be transmitted anyway. Patient and the staff in the operating should be appropriately consented.

MC: Do you think that, in the future, robotic tele-mentoring will supersede on-site mentoring in an advanced learning stage?

PC: At present, this technology is useful for those surgeons who can perform independently but may act as a refresher, or help with a particular case, or for further training after an initial case series. Over time, this is likely to change and, as the technology and ability to interact increases, future cases could be performed remotely or jointly. This would have legal, ethical and technological considerations but could mean that we can improve access to minimally-invasive, high quality surgery for many more patients. Experts could be on hand for intra-operative difficulties. It has huge possibility for safety and care, but it will need to be managed properly.

MC: We cannot ignore the COVID-19 pandemic, and the potential benefit of tele-mentoring is potentially enormous at this point. For both of you, what are the main advantages of robotics tele-mentoring?

PC: Potentially this allows future training without travel, access to experts on hand for difficult cases and to continue some of the bonds of friendship and sharing of expertise we currently have within the limitations we are currently under with COVID-19 and beyond. Innovation can lead to improved care for all. Sharing of these skills between us all will make a potentially huge difference to the patient.

JK: I agree with Peter. The limitations on travelling, lack of direct interactions with peers and limited training opportunities have stalled surgical training everywhere. This technology can offer a great resource to re-establish such links, provide an excellent learning experience from the comfort of our own work place and above all extends the expertise for surgeons across the globe to the patients who benefit from them the most.

Robotic tele-mentoring team

MC: That brings us to the end of the interview! I would like to thank you both so much for sharing with us your insight and expertise in this area.

Thank you so much for sharing your knowledge with us.

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