Let's go to move on to the next session. For me,
it's a great honour to introduce the speaker of this Ashley Cooper Knoll lecture,
Professor GP Hong from Seoul.
Uh, probably many of you, you know him, he's uh He's an amazing microsurgeon.
He's one of the probably the biggest educator around the world.
He's travelling and he's inspiring and he's teaching.
Unfortunately, it's not perfect because he doesn't work with breast,
you know. He's more basic, his specialty is mainly,
mainly lower limb and lymphatic and some other things but not breast,
but I know. That even he's not perfect, he likes breath a
lot. And um he's coming here to talk about this,
you know, uh, new um artificial intelligent robotics, how can be in the future
if it's going to be something worth, you know. Thank you very much,
JB.
So when uh I came to this meeting, uh, I, I don't know if you know,
follow my work, but uh I'm not really a breast surgeon, so everybody was asking,
oh JP, are you finally getting into breast?
I mean, are you doing skips on the breast because, you know,
that's what I do skip flap, and I, I realised and I look back on my medical records and
actually there were a few cases that I did skip.
It's not because they don't have small breast because they had very big chronic osteomyelitis.
And that being said, Gion asked me, JP, you wanna come to the London breast meeting?
I said, yeah, I mean, uh, you know that I don't do breast.
He said, yeah, it's OK. You just come for the party and the food,
and so far the party and the food has been amazing, so thank you.
But when he said there's always a but when he said but you have to talk about AI and robotics,
and I said, G, you know that's worse than asking me to give a presentation on skip flap
skiff flaps on breast, but anyway, here we go.
So, uh, great honour to be here as to be in London and to,
uh, be with, uh, so many, um, friends and to make new ones and to really learn something
other than my field of lower extremity and lymphedema and today I'd like to talk to you
about evolution.
An evolution that has been continuing in the field of reconstructive microsurgery,
and if you look back, the field of microsurgery really goes way,
way back, maybe almost 3000 years um before to the days of India,
Doctor Shu Shustra, uh, who really did the first nasal reconstruction.
And and the thing is in the last 2500 years not much has really been changed except that
we knew a little bit better about the um the vascular supply um and the works of um uh
Lambert and uh.
Uh, what, what's that guy's name? I forgot again.
Cormac and Lambardy. Uh, we know a little bit more about axial
pattern. We know a little bit more about vascularity,
but the real knowledge in terms of flap anatomy really came from during the World Wars with
Doctor Gilli. But in my mind, the real first evolution in
microsurgical or in reconstruction is at, at, at all looking at all is with uh Doctor.
Mathis when he introduced the concept of.
Um, microsurgery.
And I think that was the first true revolution and taking a flap or a tissue from other parts
of the body and putting it in to do reconstruction and then henceforward a lot of
um innovation has been made uh through Doctor Askol talking about the original idea of a
freestyle flap or Doctor Kohima talking about the pufferator flap and of course Doctor Fu
Chang Wei has really made who has really made the concept of the freestyle flap much more
popular and with more detail.
And I think the um the next semi-evolution in reconstructive microsurgery came with a concept,
a relatively new concept called super microsurgery, and what is super microsurgery is
that it's manipulating small vessels under 1 millimetre, and I'd like to share this case.
I think it really demonstrates very well what this concept is all about,
and you can see that this patient had a very bad injury when he was young and 8 years old
and he amputated the left leg.
And he had a growth problem after um he was able to maintain his his right leg.
He came back with a chronic osteomyelitis, and of course the common sense thing to do is to
amputate the right leg and use a prosthesis because he's already using a prosthesis,
but the patient was very adamant and refusing amputation.
So we decided to do the evaluation and this is the vascularity of the leg and you could see
that there's no major vessel flowing to the site of fracture,
the site of uh osteomyelitis, and distally on onwards.
So how does this tissue, um, getting the blood supply if there's no major vessels and of
course the.
Proliferation of these um collateral vessels, that's probably what made the limb to survive
and of course it has limits. So nevertheless we plan to do a flat
reconstruction, try to find what we can do and during the dissection we're able to find these
small perforating vessels are probably collaterals in the subcutaneous area.
And we're very intrigued at this that we actually start to take a video and on the right
is the head and on the left is the foot, so the flow is coming from the right to the left.
And of course I like to do the vein first and after we do the vein again from the proximal to
distal, uh, taking the skip flap, we start to do the anastomosis of the artery.
And after the vein anastomosis, which went pretty well,
uh, we, we started to do the artery and you could see that the orientation of the artery,
look at that, when we cut, where is the major flow coming from?
The major flow is actually coming distally.
How do you explain this?
But nevertheless, when you have a reasonable flow, we use it,
we use it as a as a recipient source and we're able to hook up the small skip flap,
and at the end after the anastomosis, uh, the flap had a relatively good vascular supply.
So here we're taking off the clamp after the anastomosis.
You could see the, the, the, the, the recipient site flipping over,
so actually getting flow from the distal.
And nevertheless we're able to salvage this limb.
So the idea of using the small vessel, which is an end vessel,
um, going near the skin, as long as it has a relatively good supply,
we're able to use it.
And I think that's the fascinating thing about super microsurgery and the concept of free
flaps, uh, of freestyle flaps, and of course the concept of pufferator flaps,
but nevertheless microsurgery is an art. It's not only addressing the microsurgical
aspect it's about knowing how to do preoperative planning as well as make good
intraoperative decision and with a good postoperative care.
And this is relatively the same principle of using small vessel is applied in lymphedema
surgery as well and using the modern technology of using ultra high frequency
ultrasound, what we're now able to do is completely map out where a functioning
lymphatic vessel is. After the skin incision,
we go through the subdermal.
Fat into the superficial fascia because in the superficial fascia is where these deeper
lymphatics are usually located and when you go through stage 3 or late stage 2,
there's a lot of dense fibrosis along with a lot of fluid.
It is important to find that superficial fascia and then cut through that superficial fascia
until you reach the deeper lymphatic structures.
Now as lymphedema aggravates, it is usually these deeper structures and the distal
structures, the lymphatic structures distal on the leg that are usually spared from
fibrosis.
So now we're going through the subdermal tissue, going through the superficial fascia.
And now reaching toward the lymphatic vessel.
Here's a typical example of how a superficially located lymphatics versus the deeper located
lymphatics look like.
So I'm not gonna bore you with uh further um uh videos, but nevertheless,
now we have the technology to find where the functioning lymphatics are using ultra high
frequency ultrasound technique.
And we know exactly where to look at and this kind of surgery could end in 40 minutes solving
a problem that has been unsolvable for centuries and now this is the reasonable result
with a multidisciplinary approach after creating a lymphovenous bypass and you can see
that's the beauty of going smaller it's giving you new possibilities and of course the
question is. And can anybody do it?
But the problem is small vessel surgeries are difficult because it's just small.
A lot of the times when you're doing perforated perforated nastomosis,
you have the risk of losing the whole flap. It's all or none.
And, and of course to do this, it requires a very long learning curve.
And it takes a long experience uh which really demands good stability,
dexterity and motion precision and this is why not a lot of micro surgeons are able to do this.
And furthermore, they are building evidence before the age of super microsurgery that if
you do surgery less than 1 millimetre, there is a statistically higher chance of failure.
But as we all know, with the evolution of technology with better microscopes with better
sutures from crowngen and better instruments, we're now able to do this and for me,
when you start with classical microsurgery of 2 to 3 millimetres,
you eventually make a natural evolution into going smaller,
smaller, smaller, smaller, smaller dimension vessels, and you could actually see the
pinpoint comparing a 90 to a uh a 12-0 nylon sutures.
And in my mind, if you're doing microsurgery, this is the natural evolution.
So nowadays we're now able to use this kind of small dimension surgery in doing small boutique
flaps in doing minimal invasive reconstructive microsurgery in providing solutions for
problems that were not able to be solved such as lymphedema or nerve flaps or
ischemic diabetic foot or zone t zone one finger um uh replantation.
So this has really changed the way we're able to provide a better alternative solution for
difficult problems, but.
How can we make it better?
How can we do it easier?
How can we do it faster? How can we have more success?
How can we intervene with complications early enough?
And how can we make this sustainable as you know, as you're getting old,
it's very difficult to see these small things and most of all,
how can we have young surgeons to not go through the long learning curve that we did.
That is the question
I just love Star Wars. I have to do this.
I'm sorry if it was a little bit corny, but you know I'm a guy.
I mean I think it really resonates well to AI and robotic,
um, contents that we'll be talking about today.
So these are the challenges, the questions that we have.
And if you think about it, we are already living in the age of artificial intelligence in
in our hospital, at least we have clinical decision support system which is a very basic
form of AI. If I by mistake uh put an order for an
increased amount of insulin we automatically get a text message saying is this right?
In breast surgery we already have a mock models to to prefabricate our flaps before going in
to the uh to the uh underneath the breast skin in wound healing we have AI cameras which
actually takes a look at it and know what kind of bacteria there is and if there was enough
debridement. In hand surgery, we have um diagnostic tools to
see where the tendon rupture is and how much tendon lengthening or the tendon strengthening
we have to make. And most incredible in our field we're already
using this kind of technique which has 98.4% accuracy to actually tell you if the flap is
doing well or not.
In aesthetic surgery simulations are used in the hands of the surgeons as well as the
patients to actually know what's going on.
So it's incredible how AI in the last few years has already been part of the
medical uh society.
And what's really incredible is this um piece of work which was being done in one of our um
hospitals in Seoul and through this um liposuction it creates an XYZ pattern of
how what is the angle, what is the position of the handle,
and this is actually put into a cloud and it's evaluated by a computer.
So whenever the angle's too acute or the angle's too shallow.
Uh, uh, maybe be resulting in an irregular, um, irregular, um,
contour of the skin or if it is in risk of penetrating the def fascia,
they automatically get a message.
So it's incredible how this kind of AI is allowing relatively new unexperienced surgeons
to at least walk in a safer way.
So right now there's many types of AIs. The one that we do a supervised learning,
so we're giving the data for them to evaluate, semi-supervised, we give some data and they
also think on their own and of course the future is deep learning or unsupervised
learning as well. And the reality is we are already in the 2nd
phase of the model in the in the world of medicine today and it's creating a lot of buzz
and in the future it's not only going to be used and it is already being used in
diagnostics in surgical decision making, postoperative monitoring.
And of course in research and education, so it's an exciting period to be in to have these
kind of big data allows us to guide in the right direction whether it be clinical or in
research but as surgeons, our main focus is hands on and,
and what about hands on and there's a lot of robot platforms out there and I think the
previous speaker also talked about Da Vinci.
And there are two very exciting uh platforms just for a microsurgery like Simani and
Microshore. So what has this to do with the surgeons?
And what the great thing is about Marco Innocenti, who is one of the pioneers in
robotic microsurgery platforms, says.
It executes micro sutures beyond the natural dexterity, and this really is a game changer
for microsurgeons, especially if you're doing small dimension microsurgery.
It is a 7 times a degree of freedom for the wrist, 20 times motion scaling,
and it's already been performed more than 800 cases around the world,
so it's still in the preliminary phase looking to uh give more insights.
And there has been a lot of clinical data showing that it is almost or even slightly
better in looking at the results compared to the classical uh microsurgery.
And as you can see here in this previous report, the learning curve is also very responsible,
uh, uh, is, is very reasonable for the surgeons, but is there clinic
is there statistical evidence to show these initial insights are true or not?
And this is what we did a pre-clinical study using the Simani microsurgery robotic platform
to look into these exact questions.
So we used the rat and, and, and allowed uh microsurgeons with less than 5 years'
experience, uh, do 128 anastomosis with the robot and 128 anastomosis
just by using the hand.
And as you can see here, the results in the beginning, there's a lot of gap between hand
and the robot because it takes a while to really learn how to use the robot.
Time to pick up the needle eventually becomes the same.
Time to start the suture, single suture eventually becomes very similar.
The suture time also becomes very similar towards the end and of course.
The time to cut is not similar because the robot has a very small um working space and it
takes a lot of motions to pull the the suture and ultimately cut but other than that,
um, to pick up the needle to actually make the suture uh remains pretty much the same as doing
a hand saw and artery, a hand sewing uh microsurgery.
So but looking at the overall time of approach, we see that there's a big gap.
There's a statistically a big gap between imani and the hand,
and hopefully this will this will become better with the addition of the AI which the AI will
guide into creating a faster movement for the robot.
And what is really interesting is that as you accumulate more experience,
the overall suture time also becomes similar with the hand,
not in the beginning, but ultimately as you do 7th and 8th trial,
the time to actually do a suture becomes very similar with the hand.
So this is also an exciting result.
Looking at the patency, it becomes similar on the 4th trial,
the patency and the outcome, the skills become similar in the in the 4th trial.
But this is where it really gets interesting.
If you look at the intergroup analysis, so on the top left corner you could see that this is
for microsurgeons who had more than 10 years of experience.
You could see that the hand suture is relatively stable because they have a lot of
experience. But look at the robot.
The robot needs additional learning, but it's quick learning maybe on the 3rd trial you're
already plateaued in times of skill.
But for the unexperienced group on the right upper upper corner you could see that for the
hand, it also takes some learning curve, same with the robot.
But what is really interesting is that the gap between the hand in comparing the experienced
versus the inexperienced surgeon has still a long gap and has a big gap.
So this gap takes a very long time.
To ultimately become similar, which is proving that hands-on takes a lot of learning curve to
actually reach the expertise of a surgeon who's done more than 10 years of of microsurgery,
but using the robot.
The learning curve is exactly the same between who has less than 5 years and who has more than
10 years. So I think to answer the question that Jian
asked me to uh to solve or to give insight.
Thus, are we playing with a toy that really allows a junior surgeon to
overcome the gap of time to have the same result as an experienced surgeon?
I think the answer is yes, looking at this patency which becomes similar in both groups.
But what's quite amazing is that looking at the electron microscope in the experience group you
could see that comparing the hand versus the electron uh versus the robot look how
irregular the sutures are and look how much micro um a tearing there are there are actually
small gaps. So in reality, we always say we have around 98%
success rate. However, there are one or two cases out of 100
that we know that we did a very good anastomosis, but end up getting some kind of
thrombosis and we actually have problems.
And maybe it is this kind of micro injury.
While we're using our hands compared to the robot, you see it's very clean,
well distanced, no micro injury that is the reason for having these kind of unexplained
complications.
So of course we need to do more clinical study, but this was the insight that I had uh from
doing this research.
And of course, the learning curve, at least for the robot,
is very similar between the experienced and non-experienced.
Around 4 to 5 attempts uh makes the learning curve quite um reliable with a 100% patency and
of course you could see the accuracy under the electron microscope has a huge difference
comparing uh the hands on versus the uh the robot.
So I think using this kind of platform really allows us to provide better accuracy and better
precision. But what is the real insight here?
I think this video tells it all.
You can see this is a, uh, lymphedema, uh, lymphatic LVA and that's the robot on the on
the right with a similar uh dimension doing a vein to vein anastomosis and I tell you that I
didn't drink the night before and I'm still shaking like that although I cannot see it that
much in the in the microscope so.
So this kind of advantage in really providing a still stable,
uh, high dexterity and high accuracy, um, a suture I think will make a huge difference in
the outcome of the overall um super microsurgery in the future.
So a lot of people can criticise, hey, look, a lot of practise,
we could do the same as you guys, and yes, that is true,
that is true, but think of the hospitals that they don't have 200 cases a year.
Think about places where you know you're only exposed to this kind of surgery maybe 6 or 7
times a year, and that's where the beauty of this kind of new technology lies.
You don't have to practise 200 LVAs a year and nevertheless, the gap could be shortened.
So, to answer the question, will AI and robotic platform compensate for the lack of experience,
I think is yes.
So where are we now? Uh, these are all preliminary findings
supporting accuracy and precision and of course it's a master slave relationship,
and there are limitations. We cannot do long distance surgery because
there's a lag of few seconds and of course microsurgery is just one small aspect in the
art of reconstruction so there's still a long way to go.
As microsurgeons, we may be entering to a new dark age.
So, is AI and robotic platform friend or foe?
And I asked myself, Why has the evolution of reconstructive microsurgery has been taking so
long? And the answer is because we like our little
bubble. We like a little bubble and we don't like
change and this is why the exciting evolution really took centuries and centuries
to actually get to where we are today.
I think a lot of you who are practising DIEP flaps when you first heard of the concept of
the pulpator flaps, 99% were baffled or against.
We have good pedicle tram flap.
Why are we doing this kind of difficult surgery?
but nevertheless, that has become the mainstream of how we do surgery today.
But nevertheless, we don't like to get out of our comfort zone because we've been taught,
unfortunately.
Many things and we've been taught to find excuses like ah the impact of AI and robotics
will probably reduce employee commitment and motivation.
We're gonna create unrealistic patient expectation.
uh, the sense of self, especially for surgeons, is going to be undermined and of course there
are ethical issues, and we always talk about this.
We don't talk about what kind of bright future it will bring us and the patients.
We talk about why.
It's not going to work.
And you know, the thing is, it's very difficult to make that jump when you see new ideas,
when people talk about new exciting things because, you know,
we like to stay in our little cocoon.
And we've been taught, unfortunately, ever since we went to primary school,
we've been, we've been taught to stay quiet, not to ask questions and especially when you go
to med school, we've been taught.
To not challenge what the professors say.
And nevertheless learn only what works and learn how great doctors are,
how learn how great surgeons are.
And when something does go wrong, what's the first thing you do?
It's not my fault, it's the nurse's fault. It's the residents' fault.
And most of all, we hate, we hate criticism.
We're very poor listeners and I don't blame you because that's the way we were,
we were, we were taught and trained during med school and during residency.
But through this kind of literature and book, we, it,
we can change, and we can change because plastic surgery is all about innovation.
Kidney transplant started with a plastic surgeon, facial transplant.
Robotic surgery that you're just talking about now.
DIEP is creating incredible beautiful breasts, and I really learned something new,
the golden ratio of 4555. It's not, it's gonna change the way I look at
breasts from now. But anyway, You have to be inspired by these
new ideas and of course, when you do something new, we will fail,
we will fail miserably.
But you cannot let that determine.
Your will to go forward or not.
We have to accept failure is part of our job, but if you learn from it,
if you learn from failure, and of course you feel bad to the patient who failed,
but think about the thousands of patients afterwards that you'll be able to help.
So don't quit.
Be inspired, don't be jealous.
Learn, change, and most of all say I can do it and that's what a growth mindset is all
about. You know nothing that I say.
Master, moving stones around is one thing. This is totally different.
No different, only different in your mind.
You must unlearn what you have learned.
All right, I'll give it a try. No, try not.
Dude. Or do not.
There is no try.
Watching this movie and I didn't know it was such a deep deep philosophy when I went to look
back wow, this guy really knows we have to learn from Yoda because when you make that jump.
And put your faith in doing.
Wow, you're gonna be in a different dimension, a dimension of magic.
So it took us centuries to get to where we are.
And now we're living in an exciting age.
Where we have internet, where we have knowledge on tip of our fingers.
With our phones and now where we have chat chat GPT writing our love letters.
I'm sorry, mistake, looking at better surgical solutions.
And we have potentially robots going beyond what we're able to do.
So it's incredible, but you have to be willing.
To accept change and lead the change and not be fearful of changing because
Evolution It's about change.
She's a future
We don't know. We don't know what the future is.
But what we know through our experience and our research till now,
AI and robotic platform will definitely compensate for the lack of experience today.
But what about for the experienced surgeons?
You could make the argument, hey, come on, I could do 0.2 millimetre,
uh, anastomosis like Jay, you know, he's doing this every day,
doing this every day. We don't need uh AI and a robot to help us.
But this will allow even the experienced surgeons to reach a dimension
beyond what is real.
We're now doing pure skin perforator flaps. We're not taking any fat.
We're not taking any fat. We're not taking any fascia.
We're not taking any muscles. Can you imagine?
It's not a full thickness graft, by the way.
It's a flap with only just the skin.
We're taking pure fat flaps, so I think you guys are talking about fat graphs.
Imagine you you design a 3D fat flap.
We don't have to talk about absorb was it absorption, right?
Fat absorption? Yeah, maybe this is the way.
Who knows? There's incredible things that we could do with
AI and robotic platforms going beyond the reality.
And now we're in the realm of solving a problem that has plagued the human race for more than
5000 years, lymphedema.
And not only that, we're now looking more wider into the field of lymphedema surgery.
We call lymphatic disease, congenital chyothorax, which the patient did not live
beyond 2 years. Now by creating a bypass,
reducing the pressure of the lymphatic system, especially in the pleura,
we have possibly found a better way the patient can live longer.
And this is a lymphatic disease congenital chiyothorax.
Now we're seeing examples of patients improving congenital patients with protein losing
enteropathy. They don't need to have albumin supplements
every week. Glaucoma is a lymphedema disease.
irritable bowel is a lymphatic disease.
And you know what? What's really crazy is that dementia.
This is a lymphatic disease.
So this is great news for guys, OK? Because you don't need your wife to change her
diapers when you're old.
Anyway, now we know the brain.
The the metabolites of the brain are actually being cleared through a lymphatic system,
anterior and posterior lymphatic system, which drains through the cervical lymph nodes.
And if we create a bypass that allows to increase clearance for the dementia patients
who have dysfunctional clearance, maybe.
We're able to solve this problem of dementia and it's exciting because this is the project
that we're doing and we're seeing evidence that dementia is related to lymphatic degeneration
of the brain and neck.
So it's incredible how we all started just as a simple microsurgeon,
and now, We're looking at AI and robotic platforms that will enhance the
surgeon's capability to solve problems that has never been solved before and of course you
can imagine the cervical lymphatic vessel is 0.1 millimetres,
0.1, and now we are in the living in the world.
So will AI and robotic platform replace microsurgeons?
Probably not, but.
Microsurgeons without AI and robotic platform will be replaced.
So whether you choose to embrace this kind of new technique,
technology, new science.
I think it's up to you, but I'm very sure Doctor Cooper,
who started to study about breast, was faced also with criticism at that time,
was also faced with jealousy at that time, and was also faced with millions of
reasons why he should not be doing this.
And I think we have to learn from the pioneers in the past what hardships they went through
but decided to embrace change and allow evolution to continue in their hands.
So with that, I'd like to give you my last slide that I love.
There are 3 types of people in the world, I think.
The one who makes it happen.
The one who just watches it happen and the one who don't know what the hell happened.
I don't know about you, but watching is also not bad,
but I like to make it happen.
So with that again, it's been an honour and a privilege to be part of this,
uh, meeting, and I wanna thank Jian, Marlene, and Jiaomi,
uh, for the invitation right, party time. Thank you very much.