E71 Mark Soliman On Robotic Colorectal Surgery And Video in Surgical Education

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:24

Dr. Mark Soliman is a colorectal surgeon at AdventHealth in Orlando, Florida. We got to talk to Dr. Soliman about his passion for robotic colorectal surgery and where he sees robotics going in the future. We then went on a deep dive on the use of video in surgery from how to edit surgical videos to how Dr. Soliman incorporates his fantastic videos into resident education. Check out all of Dr. Soliman’s amazing videos on his YouTube channel. Links are in the show notes.

Chad Ball  01:24

Dr. Soliman, we have been so excited to have you on Cold Steel leading up to this and we can’t thank you enough for for being on. For some of the Canadian listeners maybe who don’t know you, as well as this is follow follow you as closely as we do. Could you tell us sort of where you grew up, what your training pathway has been and how you ended up in your current position?

Mark Soliman  01:24

Yeah, sure. Thanks a lot. And Chad and Ameer I really do appreciate you guys inviting me to this this podcast. It’s it’s I’m really looking forward to it. Yeah, I was born and raised in Tallahassee, Florida, which is a capital of Florida, here in the United States. And I did my undergrad in Florida and then medical school also in Florida and went to Birmingham, Alabama, which is the deep deep south for residency and, and I was kind of bit with the minimally invasive bug when I was in Birmingham. Just because we did so much bariatric surgery and I got turned on also to to colorectal surgery at the time. So I ended up going back to Florida in Orlando, to the Colon and Rectal Clinic of Orlando, which is where I did my fellowship and actually there was a program of five fellows. And then I did my my colorectal fellowship there and actually was hired on as faculty to be the MIS surgeon for the group. And was there for 10 years and built up I think, a pretty good robotic colorectal curriculum and then also the MIS started the program. And, and I actually was recently recruited, in fact, actually just began in August of this year to AdventHealth, which is a large multi state hospital system, which is has one of the main hubs here in Orlando. So I was recruited into the AdventHealth System and I’m actually now the have two titles with the AdventHealth System, which I’m the Program Medical Director for the Digestive Health and Surgery Institute for colorectal surgery. And basically what that means is I’m in charge of colorectal surgery for the 17 Central Florida hospitals. In terms of research, in terms of education, the recruitment, hiring, firing effectively of surgeons. Just think of it almost like the division chief, for all for that for the 17 hospitals and in a lot of a lot has to do with business and strategy, which is a lot of fun. And then the the other side of this I am also the department chairman for colorectal surgery, which is an elected position, and it’s elected by the medical staff within the department. So it’s two separate but similar entities. One is the department of colorectal surgery, which is run by the medical staff who are not employed by the hospital. And then my other role is actually being employed by the hospital to develop colorectal surgery service line throughout the entirety of the Central Florida system. So um, yeah, I think that’s that’s kind of a summation of all it is right there.

Ameer Farooq  04:35

Congratulations on your your ongoing success. I noticed on your bio that you speak fluent Arabic. What’s your your background with that? And how do you know fluent Arabic?

Mark Soliman  04:47

Yeah, it’s my parents are Egyptian. They were they born raised of course in Egypt and they immigrated to the United States. Man is close to 50 years now. I think and and so they speak Egyptian Arabic at home. It’s a specific Egyptian Arabic. So funny story when I went to college, you know, I spoke Arabic at home, you know, conversational Arabic, no problems stuff at church, no big deal. And then I decided to take a foreign language credit. So I went to University of Florida. And they say, now what? I’m so good at Arabic. I was born and raised in Florida. So good. Let me just try to you know, exempt myself from this formula of credit. So I went to the to the Arabic department. And then I said, yeah, I don’t really need this. I just need the credit. Just sign off on me. And then literally, the lady, the professor of the class, I’ll never forget her, Ida Benya, looked at me and she made me read up a paragraph, and I did. She’s like, Mark, you read on the level of a kindergartener. I think I speak fluent Arabic. It’s I guess I speak for it relative to a kindergartener.

Ameer Farooq  05:58

That’s awesome. I actually, when I was finished high school, I spent four and a half months in Egypt, learning Arabic. And I quickly learned that there’s a difference between the Egyptian and classical Arabic. So as I feel a little bit of your pain, and it’s I love that the idea of an Egyptian boy in in Florida has quite an awesome place for your parents to land. Can you tell us a little bit about what that transition has been, like switching institutions and kind of what the thought process is in making a tough decision like that? Because it sounds like you had a great thing going with your your previous job. And now going to the AdventHealth, obviously, is, is a big change what what goes into making a decision like that it’s sort of 10 years into your career.

Mark Soliman  06:47

Yeah, no, that’s man, that’s a really good question. And, you know, I think this is good for the viewership of this to listen to it too. Because, you know, I had it all right, you know, as a full partner, fully invested partner and a highly successful private practice. I mean, I was doing six, eight colectomies a week, 100 patients in the office a week, 10-20 anorectal cases a week. I mean, volume was not an issue. Great partners. I mean, they were my faculty. They’re my attendings. And so they’re close to me, we kind of had everything, you know. For me, though, 10 years into the career, I almost got that itch, in which I was wondering what’s next. For me, you know, it was being private practice, although we were academically productive, we had fellows that we train with five fellows per year. There was only so much that you can do in a day without additional support. So if there’s research endeavors that were interesting, it was tough, you know, very difficult to get funding for that. If there was, for example, lectures that needed to be that you were invited to give a lecture in a different state, I mean, that’s time away from the practice. And that’s, you know, days that you’re not getting, you know, getting revenue for effectively. And so that, you know, I had fantastic support from my group. However, you know, when, when I looked at myself where I was, at this point, I felt like there was something missing. And I think that thing that was missing was a more formal leadership position. And I had always had a keen interest in clinical and administrative leadership with a hybrid in still practicing surgery. And AdventHealth actually tried to recruit me several years prior to build a robotics program. But I you know, wasn’t the timing wasn’t right, it didn’t feel right about it. I was happy where I was. But, you know, when they came to me with this, with this leadership role, with great faculty, fantastic support, and the stars kind of aligned and the timing was good for me, that I made the made the transition, difficult decision, bitter pill to swallow for some extent, because I’d been, you know, born and raised and bred in the private practice world. But, you know, I think that was some of the things that helped prompt the recruit, to some extent, and also, that helped breed me effectively for the new role, because there’s so much leadership on it. And being the Fellowship Program Director, my former program that you know, that that kind of helped in the leadership side of things, but also as kind of the, the kind of lead in a lot of things for the practice side of the hospital, you know, almost bringing the private practice mentality to how the office runs in terms of efficiency and metrics and cost effectiveness and really just kind of running. I don’t want to say a lean but running a kind of a lean and efficient machine is what what was really appealing to those that were recruiting me to it. I think we’ve had a thing got a pretty good and quick impact. There were some so you know, phenomenally open minded and very, very receptive leaders there when I showed up, and they’ve been, they’ve been really, really great in terms of welcoming me over. So it’s been been a fantastic transition.

Ameer Farooq  10:10

And you have some really amazing partners that AdventHealth, John Monson, Matthew Albert to name a few. What is that been like, sort of having partners like, like, have those that caliber? And how is that kind of, I know, it’s early days still, but how do you think that sort of shifts the way you think about things and the way you do things?

Mark Soliman  10:30

Yeah, no, it’s a good question. Because, you know, I have been basis, it’s interesting, I’ve been in direct competition with both John Monson and Matt Albert and George Nassif, Patrice [inaudible], all those in the group were there. Now we are 13 in the group now. We’ve been in direct competition for the past, you know, decade, but never let it, you know, get in the way of a collegial relationship, friendship, and just, you know, it was really just good camaraderie the entire time. I feel like we were all kind of cut from the same cloth of, you know, we’re all interested in, of course, high quality. It’s a meritocracy in terms of how well you do in terms of clinical outcomes. We all have a passion for medical education, as well as surgical education as well as pushing the envelope in terms of research, minimally invasive surgery. And, you know, specifically John Monson I mean, he’s, you know, the guys that he’s a he’s a bedrock in the colorectal world, and just having him be here in the city. And watching the amount of progress that he’s made itt within the AdventHealth System, on the colorectal side of things, just with his leadership acumen and his vision, over a relatively short period of time with him being in town was I mean, absolutely jaw dropping. So you know, the recruit also was important to me, because I looked at John as a mentor in that regard, because just seeing what he was able to accomplish, in again, such a short period of time was was phenomenal. And then, you know, being again, in the same group, as people like Matt Albert, and Teresa deBeche-Adams, and Justin Kelly, and George Nassif, and these guys, you know, again, we all have that same common vision of doing some ridiculously cool cutting edge minimal invasive surgery, taking good care of patients, but also having that balancing act of, of also having a good work life balance. And also the academic side of things. It was also nice to have.

Ameer Farooq  12:33

I love seeing you guys interact on Twitter, on social media, and you already get the sense of that they’re they’re proud to have you on and I just love the camaraderie between all of you. This is a good segue, you know, you’re talking about doing cool, minimally invasive stuff. And I think one of the things that you’re well known for is being a big proponent of robotic colorectal surgery. And you talked about getting inspired by by your your home program, and they’re they’re bariatric stuff, but can you can you talk a little bit more about why you’re so passionate about robotics in colorectal surgery?

Mark Soliman  13:05

Yeah, it’s a good question. You know, I often think I often times think about that. And I, you know, years ago, I gave a lecture. And my two childhood heroes were MacGyver and Mr. Inspector Gadget, was felt like, there was I always had this inclination to kind of, you know, rigging things up and, and kind of thinking through problems. And also I loved loved loved tech, always loved tech. And I remember when I was like 5 or 10, I was like, my dad was asking what I wanted to be when I grew up, I said I want to be a robotics engineer. And I don’t know, I didn’t want to put that even meant, but I loved robotics since I was a little kid. And, you know, it’s funny now that when I was in residency, this got this thing called a robot, and I never touched it never saw the console. But I felt like was a good marriage between my love for physiology, love for anatomy, and that enthusiasm I have for technology. And, and so it really, I just, I don’t know exactly what it was, if it was just one thing, or just a combination of many, that just seeing these slick endoscopic operations being done on invasive cases being done robotically, but just pushing the envelope in terms of tech really, really, really got me kind of lit that fire bug kind of bit me. And so it’s been really kind of an insatiable appetite from that regard. And so pushing the envelope with robotics with advancement in invasive tech, and also other robotics platforms that are out there is really exciting to me, this is a good time to be a good time to be a surgeon.

Ameer Farooq  14:40

So was that sounds it doesn’t sound like that was actually something that you maybe were exposed to as much in residency. So is that something that you sort of took an interest in in took your passion towards and developed more on your own or is that something that you pursued formal training in?

Mark Soliman  15:00

Yeah no. So so I saw a robot in residency like saw it. And then my my attending I’ll never forget started doing he like was getting proctoring cases and I just watched him do a lap chole or robot chole. And just looking at the, the wrist articulation of the robot, the visualization, just the comfort that he’s sitting down, the 3D all that stuff. I was like, I want to do that, like that’s what it was, but then I graduated like a month later. Rather, I started ranking fellowships like a month later. So one of the things that I looked at very specifically was for a colorectal fellowship. I wanted to ensure that I went to a program that was able to train me in robotics. And and I selected the Colorectal Clinic of Orlando for that express reason it was one of the highest volume robotics program in the country at the time, which meant that we did about 10 cases per year. And so I ended up doing a lot of just self taught simulation work, a lot of the intuitive reps. were, you know, we’re kind of interested to see because it was never, there wasn’t a general surgery pathway. There definitely wasn’t a colorectal pathway. They were only interested in teaching urologist and gynecologists at the time, so I actually would, would hook up with a guy an Onc surgeon, Veronica Schimp, I’ll never, I can never thank her enough for letting me as a fellow scrub into her gyne onc cases and do hysterectomy and I was so on the cuff, I had no clue what the anatomy was when I was still doing it. And it was, it was great. And just, I really just kind of took off from there.

Ameer Farooq  16:38

I mean, I think you have to highlight the fact that you clearly had an interest and a passion for something and then just went after it, no matter where those opportunities were. So I think that’s like, that’s an important thing that all of our listeners should really kind of pay attention to and keep in mind. So now in your practice is or do you do all your cases robotically? Are there certain cases where you’ll go, Straight six sticks, so to speak? Or how does that mix play out?

Mark Soliman  17:04

Yeah, you know, I’m fortunate now to have enough robotic access that I’m 100% robotic, on the elective stuff. So there’s, of course, an occasional emerging case that has to be open or, you know, multiple recurrent multi visceral section, that’s going to require an open approach. But those thankfully, are few and far between. So now if I’m doing a case, it’s going to be robotic. And if I don’t, if I can’t do a robotic, it’s going to have to basically go open. The straight sticks are kind of reserved for if I ever have to do for example, let’s say an emergency diverticular resection on the weekend, then use I guess straight sticks then but that’s really the only time.

Ameer Farooq  17:42

You know, for, for Canadians, we don’t really, I would say, apart from maybe one centre have a really robust robotics program set up for colorectal surgery. I mean, as you say, the urologist and gynecologists do use it in a few select centers. But because of costing issues, most Canadians really don’t have access to a robot. Can so can you describe to us how what the setup is like just the logistics in terms of actually running an efficient robotics program? Because one of the things you know, I’ve noticed just from watching videos is that it does take some extra time, kind of getting things set up and getting things docked. So can you describe sort of the key components that are needed to kind of make that program run efficiently?

Mark Soliman  18:30

Yeah, it’s a very good question. Very good point, too. I think that the, the most important thing to facilitate an efficient system is volume. Pure and simple. I think if you do one hemorrhoidectomy per year, that’s going to be a very slow hemorrhoidectomy. But if you do 50-60 hemorrhoidectomies per month, that’s a very different story. Right? So same thing for robotics. You know, if you’re doing one to two cases, per year, per month, or whatever the cadence and the frequency is, those touch points are typically not going to be that efficient, they’re gonna cost more because you don’t haven’t quite got the cobwebs out of the system, you don’t really know what your routine is going to be yet. And so the more you do anything, the better you get at that thing, the better you get, the faster you get, the faster you get, the cheaper you get. And it really kind of happens in an order. And so for us here in Orlando, you know, I just actually have a lecture coming up talking about learning curve and, and what how to set up you set yourself up for a successful practice in robotics. And it really has to do with categorical binding if the buy into the idea that you’re going to do this. You have to have your why as to why you’re doing this. Is it a ergonomics thing? Is that a patient outcomes thing? Is it a Is it a marketing thing? You know what, what is the thing that’s gonna make that happen. And then then and only then once you fully commit to it, can you build the program around it. And that program can be built in a highly efficient, highly structured, highly reproducible manner. But it requires dedication from the surgeon, the faculty, him or herself, and also the surrounding team members, the circling nurses, the scrub techs, the leadership in the in the operating room, that’s the only way that it makes sense. And to the cost point, there’s no doubt no doubt that the robotic op for colorectal surgery, the robotic operation in and of itself does yes, certainly cost a little bit more, usually around anywhere from three to $500 more per operation and then when you compare it to a laparoscopic case. But if you look at the downstream effects of able, you know, offering more patients minimally invasive surgery reduce conversions, are able to offer more patients better and more minimally invasive type operations like it’s colon anastomosis, fully intracorporeal mobilization of of sigmoid colectomies, splenic flexure takedowns and Interpol, anastomosis of a left colon, for example, those patients end up transiting to better downstream effects, lower hernia, lower readmission, lower ileus rate, quicker length of stay, and so on and so forth. So if you look at the event of the offering them, yes, it’s more expensive, no doubt. But if you look at the clinical outcome improvements, that we’ve seen pretty much across the board, then it makes financial sense, it makes a lot more financial sense when you do it back that. And one other one other point that there’s robotics is expensive because of the maintenance contract as well. But if you do one case per year, then that whole maintenance contracts for the year is distributor diluted over one case. But the more cases you do, the less you dilute, or the more you do, rather, the maintenance contract. And so that’s kind of how that that ends up spreading the cost a little bit more.

Chad Ball  22:07

That’s, that’s very well said, there’s no question you need an entire program. I think that’s the that’s the key term for Canadians that are listening to, or thinking with the prospect of a robot in their hospital, you know, we certainly have them up here, on the urology side and on the gynecology side, but my experience was was similar to yours. When I did my HPB fellowship, we were, you know, pretty well trained, felt pretty good about doing even robotic wibbels. But, you know, since being up in Canada, we haven’t even attempted one of them. And there’s a whole host of reasons why that isn’t, as you know, it’s a very different economic model. That’s, that’s quite siloed. So for example, your budget is completely separate from the inpatient budget, and they don’t, they don’t cross over unfortunately, doesn’t really follow the patient. I’m curious if you could outline those, maybe some of the challenges that come with the robotic approach to things. You know, guys like you make it look so easy and elegant. And in my world, that would be Kendrick at Mayo, for example, superb, you know, he’ll do portal veins like they they look like art with a robot. But there is certainly some some challenges as well. Can you outline those for us?

Mark Soliman  23:21

Yeah, I mean, there’s there’s definitely challenges with anything. And I think that’s usually in your first in the learning curve. I mean, the learning curve is steep learning curve is steep. And I think that there’s several studies have shown that the robotics colorectomy learning curve is there anywhere from 35 to 45 cases. And, and only once you get to, like 45 cases, are you starting to get you know, decent, like, you’re sucking less, if you will. And so that’s a challenge because those learning curve cases, they come at a cost, they come at a financial cost and emotional cost to me, I mean, that there’s. Listen, we’re highly qualified, highly trained surgeons, and we humble ourselves in front of our staff in front of ourselves in front of our fellows or our fellow faculty members to do these cases, and it really takes the truth is a emotional hit on the surgeon and an emotional investment to do that. So that’s that’s a huge ask right there a huge toll right there. The other things of course, you can have definitely have a drop in efficiency when you’re starting out. Because you absolutely it takes more time to dock. The team isn’t there yet. In terms of the the efficiency of the team, the your efficiency in the operation, operating room is not nearly where it was probably in  the lapro in case. There’s tremendous, tremendous challenges that are there. But kind of like you’re saying, like you know, you know, you end up getting better. Once this is kind of your thing. And, you know, I’m sure that Dr. Kendrick when the had a billier side of things probably didn’t start out looking looking like he did or she did. But the more that he or she did, the better he or she got. And those challenges that were initially there go away, or at least are minimized to a certain extent. I’m not sure if they answered your question, though.

Chad Ball  25:13

Yeah, that’s, that’s exactly dead on. I think that’s, that’s perfect. You know, there are two things I wanted to ask you with your massive robotic experience, maybe one a little bit more negative or one a little more positive. That on the negative side, the company that that you mentioned, the sort of the premier robotic company has a very interesting business model, and is generally perceived to be extremely aggressive with regard to, you know, the reps and their and their interaction in general. And in some ways, I think that’s sort of put off Canadians being maybe a little bit different than than Americans in some ways. I’m curious if you would comment on, on that. The business model in general. And then the second part really, more optimistically, my sense is that this is a transition technology in the current platform that that you become such an expert in. Where do you see robotics,  in general, going in the future? And that’s, you know, maybe in 10 years, and maybe in 20 years? I’m curious, where a visionary like you sort of sees that future?

Mark Soliman  26:17

Yeah, I mean, you know, I think that, you know, talking about the business practices of a, of a company, that, you know, it’s kind of a major player in the market is, I think it’s a unique position to be in I mean, you’re effectively a monopoly. And you’re, you’re, it’s, it’s, I think they’re, they’re condemned to the business practices that they think they once had. And I hear horror stories of how their reps used to handle hospitals pitting one hospital system against another and giving access to one against and not another, just because of the way relationships were worked out. And I think that those from I, you know, I was the all those issues, at least in the United States, predated my exposure. And so I’ve honestly had nothing but a positive experience, in terms of educational outreach in terms of scholarships, and funding and grants that we want to do and for for robotics training grant, that it is it’s the goals are aligned in that in that respect. But I think that I think that, you know, when you’re, you’re in Europe, you know, a device company, you’re in the business of selling devices, you’re in the selling, you’re in the business of selling widgets. And I think that, unfortunately, just like any one of us, the the weakest link in our, in our clinical practices, is sometimes the medical receptionist that’s answering the phones or greeting our patients. And if that person is, you know, the least paid or, you know, having the worst day that makes everything upstream or downstream however, when I’m looking at it look terrible.

Chad Ball  28:02

Yeah, for sure, for sure.

Mark Soliman  28:05

But to that, what was the second question? It was a good one. I forgot what?

Chad Ball  28:12

Yeah, I’m just curious as to where do you see the future of all this. Because my my sense is the current platform is is truly a transition technology to see how good it is, you know?

Mark Soliman  28:21

Yeah, yeah, no, absolutely. I mean, you’re right. I mean, all what today, what are we doing? I’m doing basically laproscopy with wrists, pretty much is what it is. I mean, if you distill it down, that’s pretty much what we have right now. So you’re exactly right. I do think you said it. Well, transitional technology. And I think, you know, there’s the the there are iterations of robotic technology in the pipeline, that I think the most dramatic thing that we’re going to see different is that it’s no longer going to be what’s called line of sight technology, where it’s just between you and a straight shot to the pathology directly in front of you that line of sight, the direct access, it’s going to be more of a securities route, something that will be more applicable to say endoluminal surgery or natural orpha surgery, where you can choose your extraction site as an example. And then, and then, you know, basically, deploy a single, a single armed instrument that has multiple tentacles, almost like an octopus that can come out and do whatever operation that you’d like to do in whichever quadrant that you want to do intra abdominally or intrathoracically or, or endoluminally for example. So I think that’s, that’s one of the things that we’re gonna certainly see, I think that there’s also going to be, I know there’s going to be lots of machine learning. That has already been it’s in active development now between many of the robotics companies that are out that use pattern recognition, based on the operative video feed that you’re seeing to alert you to, for example, no fly zones, note of caution, don’t go too far. Immediately because there’s a aorta there or carefully about the cut across the tumor edge or oh my goodness, watch out, there’s some hypogastric nerves or you want to avoid that, based on predetermined algorithms that are built into the system. So that stuff is actively being worked on right now. I can only imagine, say, for example, what another 10 years is going to look like. So I think that, like we were saying earlier, the future of robotics, I mean, we’re definitely in the infancy right now. And I can only imagine what it’s going to look like, you know, farther down the road.

Ameer Farooq  30:29

It’s a really neat time, as you said to be colorectal surgeon and a surgeon in general, is particularly with regards to rectal cancer, because there’s been so much changing from treatment modalities to tools and technology like you outline. Without belaboring this too much, I’m curious where you see all these sort of different tools like taTME, TAMIS, robotics, maybe even old school stuff, like SILs? How do you how do you see those technologies playing out? And, and sort of spreading? Do you think, do you think they’re complementary or distinct? Sort of how do you foresee that changing in the in sort of the landscape of, of tools over the next few years?

Mark Soliman  31:15

Yeah, you know, in my transition of jobs, I had the amazing blessing of being able to take two months off of work. And, and I had a lot of projects around the house, I wanted to get done. I had a lot of things I wanted to learn, a lot of books I wanted to read, a lot of trips I wanted to take, and one of the hobbies that I’ve been trying to pick up was that of woodworking. And it always fascinated me, you know, I love creating things on my hands. But one thing I immediately realized was that every single project requires a specific set of tools. There’s not a single tool that works for everything. And I think that’s an obvious corollary to just take one disease process rectal cancer. So I think 100% these are very complimentary platforms. taTME has a fantastic place to be played. TAMIS I just did one today.  TAMIS has a great role. I have taTME combined robotic, lower low intersection and taTME coming up next Thursday, in fact. And so I think that there are, as you’re saying, with these different ranges of the new paradigms in rectal cancer and the new technology, I think that you really have to as you do in woodwork, you choose the right tool for the right piece of wood or the right tool for the right job that you’re trying to do for that day. Now, taTME, specifically is not something you can dabble in. That’s, that’s a very unique skill set. It’s a very, very unique and very confusing anatomical vantage point. So I don’t want the those that are listening to this to think that you should just kind of dabble in taTME. But I do think that again, to circle back to the original question, it is definitely a complimentary approach for rectal cancer management.

Ameer Farooq  33:07

Yeah, I mean, I work with Carl Brown and the crew here and just watching them do some taTMEs and getting involved a little bit, you realize it’s not something that you can dabble in. But I really do if I could make an editorial comment, I really do like your, your thought that that using the right tool in the right place is going to be so important going forward. And it just speaks again to being the importance of having high volume so that you can really know what what tool to use when and know what technology would be best in a certain scenario. I wanted to shift gears here a little bit and talk about your videos and those you know, I’ve tweeted that to you before and and I just love watching your videos. I watched them during residency and I still watch them. Now in fellowship, they’re just fantastically beautiful. And we’ll put some links in the in the show notes below so that people can go to your YouTube channel and watch them for themselves. But they’re really quite beautiful. Can you talk a little bit about how you got into making videos of your colorectal operations?

Mark Soliman  34:12

Yeah, thanks a lot for the kind words it’s been certainly been a labor of love. And honestly, I think that the kind words that I hear from people I’ve never met before are the thing that really kind of helped me keep going on it. You know, it’s an interesting story, I think. Great things like that just kind of happened all times, fortuitously. I was giving a course actually at the ASCRS several years ago, I was leading the robotics course. And the challenge of the robotics course is we only have four hours to do a right colectomy and a low interoception. And I had previously gotten tired of telling my fellows the exact same anecdotes in the operating room and teaching them the same wristing maneuvers and teaching them the same exact, these are my instruments, this is what I do. So I recorded for my fellows a, a, basically a course a whole course on right colectomy and another course on low interoception. And then when I taught this course at the, at the ASCRS meeting, I think I was like 2016, or 15 something like that. I said, you know what, guys, we only have four hours through everything, I want everyone to pre watch these two courses so that we don’t waste any time with any didactics, we just got to go directly to the lab. And it was crazy how much positive feedback I got from these private videos that I had created at that course, for my fellows, that I just anecdotally and accidentally out of convenience, in almost out of desperation shared with the faculty at this ASCRS meeting that I started uncloaking them and publishing them. And then I really just kind of took on a life of its own. And a lot of things that I struggled with was like, you know what, no one ever taught me how to do medial to lateral, let me make a video on that. You know what, I’ve struggled with this so many times, I nearly, you know, hate to say this, but I’ll say it, I nearly killed a woman by missing this enterotomy, I never want anyone to make that mistake, let me publish that video. And I felt like it’s actually had a much broader reach than publishing it in any one clinical journal. And so it’s been a it’s been a great venue, and avenue. And so I feel like it’s been really a tremendous blessing for myself to be able to kind of put that and really just, it’s really humbling to see that people actually watch it. Since I appreciate it.

Ameer Farooq  36:37

We interviewed another surgeon for the podcast, who does the same things for his trainees. And what kind of baffled me after that conversation. And talking to people like yourselves is is actually why we don’t do that more often. It’s not like we don’t have the technology to do it. Even for open cases, you know, head mounted cameras, like mounted cameras, that all these that technology exists. And, you know, I wonder why we don’t do that more often. And if you’ve you have any thoughts about why that doesn’t happen more often?

Mark Soliman  37:06

Yeah, I think you’re right. It’s, it’s almost sad that, you know, we have more more powerful computers in our pockets nowadays that can do this type of stuff, and that we don’t take more advantage of it. You know, I think one of the main things is just bandwidth, at least for me, you know, I’d love to just have a crew of editors sitting in, you know, with me, and editing videos left and right all day, it’s just, you know, just the realities of clinical practices, you don’t get you know, you get the touchy feely part of it, you’re definitely helping people and helping a lot of people, in fact, doing do making those videos and teaching that way. But I don’t think that I don’t think enough emphasis is placed on that, on doing it, and there’s not enough, I guess, incentive to do it, unfortunately. So it really just takes takes initiative, in leadership to just start doing and get it done, I do actually applaud the ASCRS, the Society of Merck colorectal surgeons, has an American side of colorectal surgeons has really pushed heavily in this direction, to allow the community of surgeons to create a video library to submit to the ASCRS, and they get a DOI they actually get they get a publication from it. So I hope that this is the beginning of a much brighter future for video library and collaborative video sharing.

Ameer Farooq  38:36

Yeah, I think a lot of journals are going that way. And ASCRS certainly has done a lot of really cool work in this area as well. One thing I wanted to highlight about your videos was the fact that you really go over the anatomy, I really like you’ll have these series of videos and you’ll start by just like breaking down the anatomy and you even get these like nice animations that will show the anatomy, you know, sort of spin in 3D and really show you that the relationships of the of different structures to each other things that like, you know, you you would assume that everybody would know, doing these operations, but isn’t really explicitly taught. And I wonder, like, what sort of made you do that and why did you focus so heavily on on the anatomy?

Mark Soliman  39:24

You know, it’s funny, because although you hit on the on the nail, you hit the you hit the nail on the head, it’s, you would think that it’s taught, but a lot of people it can get through fellowship and residency and fellowship and not really understand, you know, why why do we make that incision, right? They’re like, they’re not really explicitly taught exactly the why behind some of these approaches and what it should look like. And for me, the biggest issue was, I didn’t know what good was supposed to look like and like in a robotic prep platform as an example. So for me the biggest, the biggest thing was also training my fellows like they just, they knew, of course basic anatomy, they didn’t know really that next level three dimensional anatomy you’re taking through a meal plane. And, and for me, it’s a lot of just like, I’d have to close my eyes and visualize the anatomy in 3d and, and rotate things around. So that video that you’re talking about where it says, actually, it’s an app on my iPad, where actually I’ll zoom in and kind of rotate around and telescope and, you know, peel layers of tissue back is, it’s kind of how I think, especially in the operating room, when I’m trying to basically detach and reconstruct anatomy in the operating room. So thinking in that way certainly helps. And I was never afforded that coming through medical school or residency or fellowship. I just I think that a lot of that not not against the people that trained me. Of course not, I think just the technology didn’t exist at the time. And it certainly wasn’t available on like your iPhone or iPad. And so I feel like it almost, you know, that’s how I think I have the tech have the, the, the, the, you know, the desire to do it. Like, I think it’s almost my obligation to let me share it that way, then.

Ameer Farooq  41:13

Again, like one of the things I also really liked about your videos, and many people have talked about that I think, even in the comments, is that you’re really specific and detail oriented, like, you need to retract the colon at this angle using this arm in this way. And you know, the way you’re talking about it sounds like a lot of this stuff was was self taught was that just something that you you learn from trial and error? And and I’m curious if making the videos actually maybe helped with that process a bit as well, when you try to explain it to your fellows. And just looking over your own videos. Again, maybe that did that at all help in your learning process?

Mark Soliman  41:51

Yeah, absolutely. Absolutely. I mean, you know that that level of nuance does not come from the operating room. It doesn’t I mean, you you’re not there long enough, in the operating room, you can’t really you’re so intensely focused on the moment, you have a you have a patient in your in your hands right there, it’s difficult to really reflect on what’s happening in that moment. Because it’s just so intense. And that, that kind of level of reflection, that level of nuance, that level of refinement effectively happens purely by video review, which is why I’m such a huge proponent of it. And honestly, I kind of, I almost accidentally stumbled on a video review. And it was really I have to really credit, credit my, my fellows for pushing me, and that YouTube channel for pushing me to review more videos and, and watch myself over and over and over again, realizing how terrible I mess things up and how barbaric I looked in that dissection technique. And, you know, I think it was, it was a combination of many things of zillion presentations and requests and lectures and podium presentations and book chapters, little things here and there that just allowed me time to privately reflect on what I was doing and different operations. And I keep reiterating that because being alone without the stress of a fellow being next to me, or the nurses chatting next to me or the patient, nearly dying, for example, or not dying, but you know, you know, person’s life being in my hands, you’re allowed to kind of just take a step back and really take a different vantage point on what you just did, and how you can do it better next time. And that that growth mindset knowing that today’s Tuesday, I can be better on Wednesday, I can be better next Tuesday, I can be better the following Thursday. That growth mindset I think is critical in surgery, I think that it’s critical in life. And I think that the day that any one of us decide that we have made it and we’re done and we have no more to learn is the day we need to retire surgery. And I think that a lot of that rupture that reflection and that self introspection, I think came again a success. I’m crazy, but a lot of came a lot a lot of it came from me watching my own videos.

Ameer Farooq  44:22

I think it’s really beautifully said that one of the things that you alluded to is how challenging it can be to make videos when you’re a busy clinical surgeon and you’re operating a lot you have 100 patients to see in a clinic and also when the incentives really, as you said aren’t there. Do you have any tips and tricks for making good operative videos like do you record all your all yours operations and that’s how you kind of get good footage. Is there someone that’s dedicated to doing that, like what are the mechanics and logistics of you recording videos to make sure that you get you have good high quality to use to publish and to teach from?

Mark Soliman  45:02

Yeah, that’s a great question. I mean, so I mean, from a technical standpoint is every of the the robot room in air quotes, the robot room has the capability to record directly into the room on a hard drive into a, like a centralized unit there. So there’s a sign every year, there’s a, it’s universally known that 100% of my cases are recorded. So everyone knows, before I even talk the robot, like you guys ready to record, so we record everything. And then practically what I do is, you know, as much better about this years ago, where I would download every single video, after every single case, watch that video back every single time on my laptop, or whatever, and critique myself and do it that way. No, nowadays, we have a platform called C-SATS and C-SATS. It’s actually a company owned by Johnson and Johnson now that all my cases are automatically uploaded to the cloud, to the C-SATS website. And then and so now I don’t have to do anything to upload it, it’s automatically uploaded. And then if I go and then I do still literally watch every single one of my videos, whenever I get around to not not like you know, I don’t have a time to do it. It’s just if I’m, you know, sitting at the house on board, or, you know, if I’m, you know, waiting on case turner, or whatever it is, I’ll pull up a video and watch it in 5x speed, you know, fast forward to a part to the TME rectal cancer case or iliac pedicle takedown, whatever right colectomy. Now watch this specific part of the case. Because I remember I struggled here I, you know, didn’t know what I really I didn’t like how I did that. Let me look at look at it back again. Let me watch it back again to see. And that was the time that I would do that. And so but nowadays, the workflow is, if there’s a specific thing that I want to do, like, for example, I did a robotic subtotal colectomy with async colonic inversion and anastomosis or Deloyers procedure. So that one is going to be a video, I think I’m going to probably turn that into a video. So that’s the specific thing that I want to show I want to show the inversion technique. So I’m going to find the video I’m going to the sector down that maybe 32nd clip of how I do the robotic inversion, how do I sew the anvil into Coralie how I do the anastomosis and so there has to be a specific ask. And I think that’s the most efficient way to do it. As opposed to taking say a two hour video or a six hour, whatever it is, digest it down to this is the 30 seconds that I want to tell the story from and and once I know what story I’m trying to tell, it’s much easier to effectively tell the story by just clipping that small bit of video out, trimming it up, narrating it, putting some putting some manuscripts and articles around it to support the discussion, and kind of take it from there.

Ameer Farooq  47:54

It is I think, again, worth noting that a little thing like that, like having the video, automatically upload to the cloud again, just in full disclosure, like I have never used C-SATS. But just the idea of having something seamless, makes a lot of sense. Because even in my own attempts to try and record my own video that is often a stumbling block when you really have to remember to get your own hard drive every time and make sure that someone presses record and getting it off the OR computer sometimes can really be a challenge. You know, it shouldn’t be but when you actually just started doing it, it often can be a major stumbling block and barrier. How do you use video with your trainees? Now now that you sort of built up a library, is it do you do you want you get the trainees to watch video before they come into the OR and then you review their footage as well. Like tell us how you use video with trainees?

Mark Soliman  48:50

Yeah, that’s a good question. So um, during actually before fellowship begins, I have something called a robotics boot camp that I do for all the fellows. And what that looks like is basically they they go through basic training, which basically covers docking specifically, there’s a prescribed list of things that they end up doing. In fact, I have a YouTube video on that, but how to train, how to incorporate robotic training curriculum into your residency and fellowship. And part of that is the first little bit where before you even start, you’re walking them through specific simulation modules, specific videos that they need to review how I do this, how we do that. And within that kind of the preamble essentially to their fellowship. I say these are the videos I need you to watch. And these are the simulation exercises I need you to watch. And, and I won’t let you scrub into the case until these simulation modules are done. You have to score at least a 90% on it before you’re even allowed in the operating room. And that gets their attention real fast. And then usually, for example, like, like if I had to, two left colectomies or two sigmoids, that actually, the fellows are extraordinarily motivated. I mean, these are some of the best fellows I’ve ever trained. And they they’re reciting the the, what I’m saying, in my YouTube video in the opera, I’m like, oh, you’re gonna do this, you’re gonna hold it at this angle. So it’s become a prescriptive part of the fellowship curriculum, both on the, quote unquote, mandatory side, but it’s really they’re just kind of doing it because I think they, they, it’s helpful. And then to the second point about the videos have you incorporated now because all the videos go to C-SATS. And even if they didn’t go to C-SATS, 100% of the videos get reviewed, for the fellows. And what that looks like is they they get sent off. And either it used to be I used to do all this by myself, but now C-SATS is going to offload this from me, is I would give each of the fellows a quantitative and qualitative score, quantitative score and qualitative feedback rather, about how they did in the operation, what tips and tricks I can offer them for the next operation that they do. I make them bet that watch their videos, and we discuss it before we basically go to the next case. So this is done informally, of course, usually, it’s kind of conversation on rounds, or in between clinic patients or at the scrub sink. What do you think about last case? How’d you do? What do you wanna do for this one? Because I know you’re watching your video, you know, and so that’s very helpful. And now, the other side of this, though, is this very clear that when fellows are not engaged, and not invested in their robotics progress, and they don’t watch their videos, there’s a very clear deficiency, that becomes incredibly apparent. Because they don’t learn from the mistakes. They don’t learn from the issues that they struggled on and on case say, for example, 2 and then their case there in case number 10, are still struggling with they struggled in case number two. And so there’s a there’s a tremendous amount of onus is placed back on the fellows to watch their videos, to watch my videos, to do the curriculum, to do this simulation. And if they don’t, then then that’s they know it’s their,  it’s their loss effectively.

Ameer Farooq  52:25

We sort of jumped into this without really talking about C-SATS. Can you tell us again, what what is C-SATS? And what are some of the other you’ve talked a bit about the sort of the seamless way that they upload videos and using it for review. But are there any other tools that you use C-SATS for?

Mark Soliman  52:44

Yeah, yeah. So C-SATS it’s a it was a startup at a Seattle. And basically what it is, is they take a take operative videos, and it’s uploaded to the C-SATS cloud call it. There’s a crowd, that’s, that’s not medical, they’re not medically trained, but they’re trained to judge your video, and how it looks from slickness and certain domains in terms of what’s called a gear score. And gears is basically, it’s an objective scoring system based on something called O-SATs. And then the gear score is a rubric based on a one to five Likert scale, you can get a maximum score of 25, a minimum score of five. So it’s one to five rating and five different domains for robotics, based on C-SATS. And so you get an a, you get a crowd based score, nearly immediately based based on what how that operation, the entire concept context of the operation went, you get a second score from a blinded expert surgeon in your field that doesn’t know you and you don’t know them, just watching the video. So you get a similar gear score that’s usually coordinate with the crowd sourced score. And then the final thing that you get is qualitative feedback from two expert reviewers in your field. And those expert reviews are saying, okay, I loved how you wristed around that structure. I love how you did this. I loved how you did that, I didn’t like how you did this, try this on the next case. And then in addition, what you end up having is on the website as curated and edited videos, from those expert reviewers showing say what good looks like showing what like a 23 on the gears score for the total mesorectal excision and look like you got a 21. But here’s what a 23 looks like. And it’s kind of machine learning that shows you the different videos to really kind of help build up your repertoire really show you what good looks like. But that and that’s that’s just a commercialized version of it. Same thing that we have, though, for free on Facebook, Twitter, YouTube, not so much on Instagram, but there’s lots of social media outlets to do this entirely for free. And there’s other upcoming websites and apps that do the very similar thing, but it’s not quite as seamless and structured say as C-SATS is.

Chad Ball  55:09

You’ve really helped motivate us to try and use these video aids in particular as teaching tools and you’re exactly right. Of course you and one of our preceding bariatric guests, Scott Mora, use them so eloquently and they’re such powerful teaching devices and concepts. And we can’t thank you enough. We’re we’re gonna try and do better.

Ameer Farooq   55:31

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.