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I think it's sort of like.

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I'm delighted to introduce Richard when he loves hit Hitler has been.

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So how pronunciation is right? Richard is an upper GI surgeon.

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He qualified from Rotterdam in the Netherlands and then he he did a Ph.D., which was awarded with honour.

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And he was a resident in Rotterdam.

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There's a lot of his surgical training, and then he was a fellow in surgical oncology in Amsterdam, the academic medical centre.

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Then he was appointed surgeon at the University Medical Centre in.

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And has been a full professor of GI oncology and programme group leader in 2009 and in 2015, he became head of surgical oncology in Italy.

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He has a very exciting programme, mainly focussed on minimally invasive interventions and robotic surgery.

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As you know, we have an expanding programme here in Oxford, which we've had for 10 years,

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and it's infiltrating all specialities, which I'm delighted about.

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He's also got the just speaking to him very briefly now.

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He's got an exciting programme on surgical imaging and also doing genetic profiling.

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He's authored a small number of 308 articles and 10 chapters.

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He's got many esteem indicators.

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He's president of many associations, community members, etc. And I won't take more time, which is we are delighted to have you.

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Thank you very much for sharing your experience with us. Thank you very much.

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Thank you very much for this very kind introduction and the invitation of Nick Maynard's and his team has Box,

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who is a fellow with us, and I think the Oxford Dutch Connexion is is is getting stronger and is getting better as he looks here.

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And then also some other colleagues from the Netherlands,

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and we talked yesterday about getting a joint meeting maybe next year or the day after which the Jewish versions of the Netherlands and the UK.

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And I think it would be fantastic. So looking forward to that.

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What I like to show you is our experience in them with robotic is a project to me over the years,

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and I'll show you also some some historical pictures of our our first project to meet with the robot.

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And if you look at the meta analysis, the reviews on this topic of many movies visual object to me.

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Actually, these are the items that always pop up and that the beneficial parts of a minimum of Asia for objectively are less blood loss,

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less complications, less pain and a faster recovery, actually, as we know also from for a coral rectal surgery.

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And the same counts for many, many years of physiologic to me. And I think this is really a landmark paper by Jim.

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Look at Age, who is in Pittsburgh and already in 2003, reported on 222 patients.

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Really impressive. He is one of the pioneers of this technique.

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I visited him in 2003 and I saw his technique and I thought that we could convert this technique into a robotic technique at that time.

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And this is actually the major landmark paper showing a randomised controlled trial of open versus minimum age is of Jack.

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To me, it's from the group, from Amsterdam, from Hugo Questar,

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showing especially less bone marrow complications and also less pain after one year follow up,

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meaning that the thoracotomy syndrome, which is causing pain, is still up to one year,

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resulting in a better quality of life after minimally invasive these objects.

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But still, this technique and this is a positive publication 2012 look at its 2003.

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This technique is not widely adopted.

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In 2007 and 2014, we did a survey amongst surgeons of the international societies for his office use through the Ujo and I as the EA.

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And here you see the distribution amongst the continents. About 250 222 surgeons were questions about a preference of surgical approach.

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And you see, in 2007, the minimally invasive technique is about 10 percent of all cases, and that increased to 40 percent in 2014.

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But the open technique still still nowadays, I think, is the standard of care.

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And maybe this this percentage has now increased that we are planning to do another survey next year.

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And but I think it will not be much higher than 50 percent,

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so what is the reason that this technique or those shown beneficial in is still not very widely adopted?

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I think it is overdue. Your surgery is really one of the most complex type of surgery involving the chest involving

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the moving organs in the chest with a very narrow band of of the section that you have.

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At the same time, you have to do a radical resection and with the minimum invasive surgery, have the two dimensional view.

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You had disturbed our hand coordination loss of dexterity because of the rigid instruments,

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and you are dependent on the assistance for the camera of you.

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And that is where I think robotic surgery comes in,

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showing you a three dimensional view 10 times and large should really looking very closely to the tissues.

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Looking through the plains very nicely, the natural eye and access is restored so you don't stand in an awkward position for your back,

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for example, high degrees of freedom because of the risks of the instruments.

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Actually, all the all the, uh, everything you can do was a pulse and more can be done with this instrument instrument.

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And I think this is the reason that for complex procedures such as is object to me, this is an excellent tool.

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We were very lucky to have one of the first robotic systems worldwide in 2002.

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We had the first standard system of DA Vinci in our hospital, which is a university hospital in Utrecht.

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And this is the device we had on the lab. So we had actually two systems.

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One was in the clinic. One was in the lab so we could develop new procedures.

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And we really at that time had no idea what procedures could be done robotically.

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So we started with easy procedures such as cholecystectomy and just looking for

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the optimal port position at that time because this is the standard system we had.

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You see, it is very bulky if you know the robots at this stage, the development after 20 years is much, much, much more elegant.

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But the basic principles of this system were already there.

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But you had to be very cautious in your positioning to be able not to get collision.

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The consul was here where the surgeon is operating, and that has changed as well.

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But the principles are still there and we developed this poor positioning for the thorax,

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meaning that you have the camera in the sixth intercostal space and to the robotic arms

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in the fourth and in the the cost of space and two to assisting ports at that time.

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The patient is in prone position,

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semi prone position to keep the lung out of the operative field so that you can approach the oesophagus from this side of the rights to direction,

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and the robot was typically put in the dorsal cranial position.

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And this is actually still the position we use with the sort essi robots.

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And this way you have an optimal vision and you have an approach from the diaphragm

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upper to the thoracic in that this really works very well with X iRobot's.

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This position is also automatically put into place by the the robotic arms,

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but this took us some time to get a four lap tube to find out which was the best position.

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And then I will show you some papers we produced over the years,

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starting with our early experience in 2003 to 2005 and looking to the description of the technique.

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And it was published in 2006, and actually that was the proof of concept of this technique.

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Then the the follow up paper was in British Journal of Surgery 47 patient describes showing

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also the quality of this procedure with a short term safety and some early modifications.

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And then between 2007 and 2011, we showed that also in a record of 100 patients, hundred and eight patients,

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the oncological outcome was at least comparable to what we know from open surgery.

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This is the survival curve in those patients, and we operated on there was a 300 patients in surgical oncology.

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And you see that the majority of our cases is advanced.

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Cancer is T three T for tumours of about 77 percent, and the majority also has a node positive disease at presentation.

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Nowadays, we usually give neoadjuvant therapy, but in this series, because it was included with our early experience, it was about 70 percent that.

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You achieve in therapy from 2006 on as your standard treatment before we did surgery only and with the median follow up of fifty seven months,

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the survival is five year survival is about 50 percent. So that is at least as good as we found in an open surgery.

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Then one of the very important things in the programme that we developed from 2003 on was the introduction of API.

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EPA is a physician assistant. We have that system in the Netherlands introduced it.

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So around that time, which is actually a nurse who is very educated in the certain area and we were very lucky to have Sylvia from the horses.

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She was a biologist at that time and also trained as a script nurse, and we trained her, especially for robotic surgery.

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And the reason for that was that we we had a resident at a stable situation before,

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and every time the resident went for his next steps, he went away and the programme went down and we had to train the rest.

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It was the chief resident and he was there was most of the time, a good surgeon.

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But the programme was not flying because you had you had this dip all the time when a new resident come in and this this changed

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really this this point with continuity of troubleshooting of a specialised nurse that knows everything about the instruments,

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the board positioning and the assistance. So from that on, we really could, could improve and could build up.

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And I think another important step for us was the standard system,

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which you had until 2009 was changed by the by the next generation to see system, and there was an important step as well.

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And another important step for our programme was the and the staff member also dedicated to robotic is obviously what surgery was usually Huda,

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who is now with us since 2011.

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And I think when you have a PR physician assistant and you build up your team with another staff member fully dedicated to this procedure,

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that is really possible to to make the next steps. And we looked into our learning curve at that time.

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The learning curve of myself and we compare that to the learning curve of the new colleague Yellow.

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And so we looked into the area of 2003 to 2016, and the initial case was of three hundred and twelve patients and the proctor,

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the two hundred and thirty two cases and the north is 80 cases.

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And we looked into that. Um, the data with the Q some methods, which means that you calculate for each item,

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you calculate the mean of the whole group and you can have that as a as a reference.

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And for each sample that you measure, you will measure the difference of the sound of the of that sample with the mean that you

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just calculated and then you have three options even and the sample is above average,

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which means that you are not not improving.

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Actually, it's at the level then the same as the average.

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Then you are a horizontal or you go below the average and then you are actually improving with your with your learning curve.

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And we looked into two items the operative time and we are looking to blood loss.

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And this is my curve starting in 2003. And you see that in 2008,

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the learning curve is is actually completed because you have a flattening of this line and you see that even after 130 cases,

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the line goes down, meaning that I'm improving actually all the time compared to the average, which was set at zero.

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Then you see, in 2013, we were expanding our experience with more difficult cases.

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So we're adding in, for example, T for B cases that we're down staged.

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And then you see the the line comes up again for operative time.

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But this is a very good measure. Looking at your, uh, you are experiencing a learning curve.

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And then the the novice surgeon, he was introduced by a structured training programme,

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meaning that he was first doing the table surgery, looking at about 20 cases.

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Learning actually all the steps of the procedure. Then he was introduced into the console, with the console surgeon beside him for about 15 cases,

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and after that, he was on his own, independently doing the procedures.

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After about 15 cases, you see, that was happening within one year in 2012.

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And then you see that only after about twenty two cases, including the proctoring phase,

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he has completed his learning curve and the line was flattening off and even going under the mean.

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And we also looked at all the oncological parameters during his training and all the

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oncological like lymph node dissection number and also like radical was just crazy.

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They were all at the level of the of the Proctor's surgeons.

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So without compromising the the quality of surgery, you can introduce this technique.

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And if you and then sum up what we did for this trainee, you see that the doctor completed his learning curve in seventy procedures.

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It was five years was the pioneering series and with a structured programme, you can reduce this time by twenty four procedures within one year.

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So that is a way we would like to continue for this, for training this and this technique.

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So the conclusion from our experience in this stage 2003 to 2012 was that as feasible as technically safe and logically

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safe and that you that we completed in this time the learning curve and also for the for the training programme.

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So at that time, it was 2012. We and we decided that we could do this technique.

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We could analyse the technique in a randomised controlled trial. There were no other centres worldwide that passed the learning curve at that point.

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So we decided actually it would be nice to do multi-center trial where we couldn't do that and decided to do a single centre,

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randomised controlled trial. Looking to this technique versus the open standard of transfer risk is over joke to me.

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But was the protocol was published in trials in 2012 and these were the items we are looking at.

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The study was running between 2012 and 2016.

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I think the nice thing of a randomised controlled trial that you really can prospectively analyse all the data very, very precisely.

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So to all the postoperative complications every week were discussed in a panel and

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this court's been scorched prospectively quality of life oncological outcomes.

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And we also looked even at cost because we know cost is with robotic surgery.

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Always an item. This is the this trial was this year published in the Annals of Surgery,

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and I will show you the results of the trial that we in total randomised one hundred and twelve patients looking into these two groups,

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and we ended up with fifty five versus fifty four. And this is the baseline characteristics just to show you type of surgery.

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It's the type of patients is typically male patients.

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The majority of 65 64 of age, there were no significant differences in all the baseline characteristics.

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The majority is out of the question normal about seventy eight seventy six percent.

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And a majority is also in the lower part of the oesophagus, the lower third of the oesophagus.

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As you can see here, about 80 percent received new HIV treatment.

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Are the baseline characteristics concerning comorbidity and medical history,

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you see that the majority had a comorbidity 75 to 80 percent has comorbidity and

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the majority of that is cardiac and vascular and also pulmonary comorbidity.

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Then to the to the results of this study, you see, the operative term is longer in the Romney procedure,

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which is a field of 49 for just two hundred ninety six.

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And you see that in actually all the robotic literature probably has to do also was a changing of

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the instruments and the the more precise of the surgery that you are performing with the robot.

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Blood loss was significantly less in the robotic group of 400 versus 500, the 68, and we had hardly any conversions.

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The main outcome the primary outcome of the study was overall complications.

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And you see this is significantly less in the robotic group of 59, which is 80 percent.

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This includes all the complications. If you look more closely into the most common.

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This is the pneumonia and pulmonary complications were significantly less in a robotic group 32 versus 58 percent.

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If you look to cardiac complications and this is also, I think, very interesting,

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it's mainly and for fibrillation, there is 22 percent versus 47 percent.

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So there's also significant reduction in cardiac complications by M. Invasive surgery.

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You're, of course, operating over the heart of the pericardium, which cause maybe the atrial fibrillation in.

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So you can the 50 percent reduce this complication by many more invasive surgery?

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Than to wound infections. There was a trend also to less wound infections in the water group.

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This was not significant.

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And especially in the terrific part, you see there is no one defection after the invasive surgery versus nine percent in the open group.

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Then to the functional recovery, I think this is also very interestingly defined not only the day of discharge but also the functional recovery,

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meaning that the patient is able to walk and to eat independently without any drains.

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And this was also within two weeks in 70 percent of the cases, with robotic fresh 50 percent in the group,

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significantly different functional recovery and the course of the procedure were calculated and they were not significantly different.

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This includes not only the machine, but also the instruments, but also the cost for the hospital stay and the management of complications.

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And because you have a higher complication, rates cost equal out, then quality of life.

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We looked into two time periods at discharge and after six weeks following surgery and as an older man's physical functioning.

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Also, health related quality of life was significantly better in the M.E of age group at all time points than postoperative pain.

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We had exactly the same pain regimen in both groups with epidural catheter and the PCI and PCI in in all cases.

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But but still you see that that old time points.

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The minimum invasive surgery group has less pain than the open surgery group that continues until two weeks after the surgery.

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Then the oncological outcome, we looked at all the parameters and we didn't see any difference between the oncological outcome.

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So that's actually what you would like to see no difference in.

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Well, look, go back, no difference in our zero rejection rate, which was about ninety three ninety 96 percent.

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And also the number of lymph nodes, which was twenty seven and twenty five percent in both groups.

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So no compromise in oncological outcome. This also translates into survival, with a median follow up of thirty eight months.

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You see that the survival curves are parallel and about 50 percent five year survival in both groups.

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So conclusion of this trial is that the minimum wage of robotics was open is improving postoperative outcome, a lower percentage of complications,

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lower cardiopulmonary complications and less pain, better quality of life,

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better short term functional recovery cost equal and oncological comparable.

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And what our future developments are will hopefully have time to show you a short movie of our technique of T for B,

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that means the tumour is invading the adjacent organs in most of the time in the talks after chemo radiotherapy you can downstage,

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you can with this technique, even in upper mediastinal tumours, you can dissect it because you see it so well and you have all the dexterity.

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We do a hand-sewn introduction on this. The most is and we have introduced with the new robots the four arm technique because

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you have your are dependent on the intercostal space with your troca positioning.

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It's not so easy to have four arms, but with the new robotic systems with the very elegant and small arms, you can do that.

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And also the abdominal phase was now introduced robotically because of the multi quadrant capacity of the new robotic systems.

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And finally, we are training our other centres and also training fellows and residents in this technique.

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This was a major next step. I think this is the robotic DaVinci Ixion with a completely new concept of the arms of the robotic arms.

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Very elegant and with a lot of dexterity and really designed for multi quadrant surgery.

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That means that we can now use four arms techniques,

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and this makes the surgeon really independent of the assistance, the table assistant is not so important anymore.

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You don't need any clipping anymore. You don't need any cutting.

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The only thing the table situation now does, and I think a script nurse can do that is the suction.

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So you're not dependent on the second surgeon. You can really operate and you can expose your own field without without an assistance.

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This is the poor positioning.

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Be designed for the four arm technique and again, little bit different, but also the same principle as we had with the three arm technique.

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But you look into a curve the positioning of your toe course in order not to have any collision.

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And this is the the setup we have in Utrecht.

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We have a dual control system.

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The advantage is that you have the surgeon and you can have an experienced surgeon if you have a difficult case to help each other,

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for example, but it's especially used for training purposes.

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So you have the ability to take the arms for a short period of time or two to point with.

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You have a pointer 3D printer where you can guide the trainee through the 3D operation.

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It's really an excellent way of of training surgeons.

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This is the abdominal positioning we use actually a straight line for the abdominal ports.

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And we use liver retractor, so you don't need to have.

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You can also start using the fourth arm as a liver objective. It's much better to have the fourth arm if as an active surgical arm.

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And this is the the abdominal poor positioning and the phenomenal setup of the of the patient.

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Then I'd like to show you a few films, short movies.

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This is the abdominal part and you can see we all have the gas, the conduct and you see this is very nice.

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You have a wristed stapler. So this is a robotic wrist.

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It's very, very exactly control the the angle of your stapling.

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And this was the guest economy that just shows you this is the Linfen activity we're running over the station age.

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This is the common hepatic artery towards the portal vein.

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So a very short clip just to show you how you can can do this abdominal abdominal phase.

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And this is the the setup we have in our old car or in Utrecht.

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We start here, you look towards the vertebral column of the patient.

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So you really have to adapt to this anatomy.

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Also, you see older structures very much enlarged and you really have to to get used to that and take the advantage of that.

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This is the wristed instrument showing the Humalog clips of the crossing, the zygier's vein.

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We're looking down to the upper mediastinum and the dressing in that you can see you can see because you see the plane so well,

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you can now remove over the trachea sparing.

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This is the recurrent nerve at the left side pointing upwards.

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So you can do a very extensive para tracheal lymph connectome at both sides.

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Shapiro cable vein running over disappear. OK, vein at the right side at the left side is a joke.

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Here you see the vagus nerve, the trachea at the upper Torres Inlet, and you see that there is a lot of dexterity.

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This is a vessel seated bipolar device that can congratulate the structures.

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This is the vagus nerve and the right side where we're running over.

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We cut the vagus nerve just below the right main bronchus.

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And here at the level of the diaphragm is the thoracic duct,

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which is encircled and is taken with the specimen and is with again the restored clipping device is.

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Is there to take off the clipping you, you see the thoracic duct. Now we have lifted at the level of the diaphragm, you have lifted the oesophagus.

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As you can see, you can take the vessel sealer as a as a retraction device and we move over to pericardium,

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which is down below to the coronial sip coronial notes.

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This is the right main bone because you see the cartilage of the Rypien bronchus and you

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can see how you can move over the right and left main bronchus taking all the tissue out.

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This is the gash. The comedy was created in the abdomen and we take it up into.

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The oesophagus is dissected and we measure the level of the anastomosis we use.

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ICG and the ICG is used as a measure of the vasculature of the conduit in case we have a vascular top.

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We will. We will staple it off.

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This is the similar technique we use nowadays, which is a handsome technique with a running suture, posterior and anteriorly.

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And this is a bracketed suture. So you have like a v lock.

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This is a strata fixed suture and we use V and the anaesthetic technique with amount of plastic surrounding the anastomosis.

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I hope you can see the rest of the instruments really help you. This is we were in the upper and upper mediastinum.

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Now we are down below the diaphragm doing a cruel plastic.

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And this is the end of the thoracic procedure where you have everything done.

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Then I'd like to show you an experiment we do with ICG.

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This is a fluorescent substance that was injected preoperatively the day before surrounding a tumour, and we are looking now at the Seelig trunk.

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And you with a light images,

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it's very difficult to distinguish the lymph nodes and to to distinguish that from the pancreatic tissue in a fatty tissue.

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But with the as you can see here with the ICG, you see a lymph node appearing there that was actually, uh, just at the border of the pancreas.

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Not so easy to distinguish, actually impossible to distinguish without ICG.

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And you can take it this way. You can really identify lymph nodes that you couldn't see before, and we use it now in early tumours.

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We have a group of patients that were treated with ESD, and they had bad histological logical characteristics, and they need a lymph node next to me.

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And we use this now as an experiment. Then to conclude, I would like to show you our programme of proctoring and training this technique.

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This is the group of Bruno also is as part of this issue, very nice group of European, um, minimally invasive oesophageal surgeons.

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We had several meetings and we have a meeting this year again in Munich next month.

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We come together and discuss various topics on this technique and really aiming for the dissemination of this technique.

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And one of the things we did was the finding in Adelphi consensus meeting the

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the way you could build up a structured training programme for this technique.

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And we came up with several items and a summary of that is the what is it?

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What is the what is mandatory for a team to start up this technique? You should have these have two surgeries dedicated to this technique.

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I think otherwise it's you should really have support of your your team,

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preferably also dedicated anaesthetist and scrub nurses because you don't want to wait all the time for the setting up of the system.

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You want to have a smooth programme running and and then you have the dedication is very key for this.

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Then the sufficient caseload, I think in the UK, there's no discussion about it, but there are countries where there are hospitals doing less than 20,

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and if you have less than 20, you take too much time to get through your learning curve.

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So we decided at least 20 cases a year. You need to to start this programme,

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and this is very important for your board of directors that you have a guaranteed access to the system because if you do some cases and then months,

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you don't do anything, then you really have to start up again. There is a simulation programme that you can do in between, but it's, I think,

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very important to have access weekly access to this, to this reporting machine.

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Then what about the programme we have run running that been running now for the past years?

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It started with the case observation team comes to the expert centre and to observe, preferably with the whole team,

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the the procedure and the one or two times is, I think, an excellent way to start a programme.

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Then we advise to do go for a basic course, basic robotic course.

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Also, the basic training course, as we are running in Utrecht, was endorsed by Esso and just analysing the technique was lectures,

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was hands on experience and then after that to do a specialised cadaver training where you have

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the access and the hands on with the proctor during the day to go through the whole procedure.

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After that, the boxing programme is started on site and the proctor is coming to the through

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the unit of the trainee and is getting through to the cases step by step,

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preferably during the period of of some weeks.

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This is the training programme we are running since 2009 in the Netherlands.

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It's in the Utrecht.

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It's it's a it's a yearly programme of two days and we trained all the surgery in the Netherlands and now training with the endorsed,

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of course, also surgeons worldwide in this technique.

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The next course is March five to six, 2020.

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This is how it looks like we have a skills lab where we have also a cadaver facility,

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where you have small groups with each of them, a proctor will guide you through the system and through the technique.

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And we have now several we have now several of those robotic systems as well available.

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And this is an artificial model where you can train the suturing robotically,

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and here you can see also some some other models that you can use for your training.

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And I think especially also the now the simulation programme that is available

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on the da Vinci robot is excellent for you for training your your skills.

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What are we doing now? We have had more than 40 teams coming over and we have three teams in the Netherlands trained.

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There are also some teams that we trained that are now put Proctor for intuitive and are training on a teams in the Netherlands.

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I think now in total, there are about five teams, two teams on the way and three three four teams in the Netherlands and the UK.

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And we have very recently and a second team that now finished and two are on the way.

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And in Germany to finish and one is underway and this is the group of of countries and surgeries that fish this over the past two years.

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Then this is also a very exciting and crisis here.

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And he is the first. He is the fellow.

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We designed the fellowship programme because trainee surgeons, I think, is very important.

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But training fellows even may be more important to train them and have a year of experience and really

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hopefully have them ready to set up and to help setting up a programme at their home institute.

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And this was the reason for this European myI Fellowship and this is fresh use on the website.

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And he has already done his basic course so you can see on the left side and here you see, he is really part of the group.

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He's really, really happy to have him. Yeah, I'm really grateful that we were able to have to have such an intelligent young surgeon with us.

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You see, don't love visiting us a few weeks ago and you see the whole group you're dressed.

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So another thing is the air,

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which is the Upper GI International Robotics Association found it's very recently also dedicated to the dissemination of this technique.

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And this is another fellow.

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This is Peter from the sloughs, and he's the first author of our robot trial. And this is Peter Grimier.

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We trained him now three years ago in and Brahmi, and he was already done within two years, more than 100 cases.

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I think that's really a very successful programme.

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He's now official, Proctor also for four robotic origami procedures and you have he has Peter from the stage as his fellow.

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So we're very proud of that. I think we can I can finally show you this my last video.

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This is an advanced case of T four B cancer.

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And oh, and this this shows you actually in the ultimate form of how you can use robotic techniques.

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You see a lot of that positive knowledge in the upper mediastinum. This patient was treated with chemo radiotherapy and had a ibas.

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So, um, showing that there was a growth in the trachea restage after the adjuvant chemo radiotherapy and then was downsized,

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but still had positive pet positive notes on this on this pet scan.

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So we we did a rejection. And this is something I would, I think, really showing you the benefits of this technique.

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This is our old or I always draw the poor positioning.

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I think every patient has a different than enemy and it's always important to really draw exactly the ports.

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On the basis of some landmarks. This is the S-i system that was we used before.

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And you see the way you can manipulate the instruments in a console.

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Now we're looking again at the level of the pericardium.

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This is at the level of the diaphragm again, you see. We do the cutting of the crossing, a zygier's arch.

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This is done with the hemlock. You can see how very nicely you can restore the instruments.

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And here again, you can see how we can. We can move over to, as, I guess, fame.

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And then you get to the after getting all the lymphatic or the lymphatic tissue that that can contain lymphatic metastases.

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Here we are in the sub Coronil area. And there was a lot of reaction because of the chemo radiotherapy.

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This patient did a lot of oedema, but.

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Because you see, it's 10 times in large, you can very precisely move along all the area, all the in the vital organs you see here,

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the left main bunkers, you see the whitish coring of the tissue, which is typically after chemo radiotherapy.

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It's a very strong reaction you have of the tissue, but because you see it so well, you can very precisely move over the member in this part.

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And this is the structures we identified as the Mesereau's all figures.

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You see you open up to the fascia and then you come into a plane with the lymphatic and also the and the are the direct auto itself to your branches.

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This is the upper mediastinum and this is the tumour.

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You can still see at the very much connected to the memories part of the trachea because you see it so well,

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you can exactly with your hook up very, very localised energy transfer of the DETERMINA.

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You can dissect it of the member in this part of the trachea without damaging the.

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And you see that in the upper mediastinum, there were still some positive notes, very strikingly positive notes.

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That were dissected, this is the the left side of the turkey and the turkey is pushed downwards with the suction.

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And here you see the superior cable vein along the superior cable vein and the turkey

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also and large positive notes that can be dissected along the right recurrent nerve.

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And I think what is really striking that you hardly see any blood and that's the reason you because you're following all the planes,

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um, there's virtually very little blood loss in this is difficult procedure.

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There is this is the area of the subclavian vein and artery where the recurrence right recurrent nerve is running.

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So over the right trigger and nerve and enlarged lymph nodes are dissected as well.

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And this is the image of the waterways, the intercoastal arteries.

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This is the the image you get when you have a radical than a radical limb for the next to me with unblock,

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this section of the oesophagus and the lymphatic over the period kadhim over the aorta.

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The left pleura there. And the is the ship Gravano, the ship Chrono, our notes are on block dissected.

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You see the the pointed right and this is the pulmonary vein and the right and the left main bronchus.

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OK. There was a thank you very much for your attention.