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Social media as a conduit for resolving surgical challenges

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

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

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

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

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

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

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

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


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5 replies
  1. Stacy Loeb
    Stacy Loeb says:

    Congratulations Justin on the excellent blog. I have recently been amazed by the power of “crowd-sourcing” through social media. When my laptop broke last week, I took advantage of this to ask my urotwitter colleagues for advice about switching to a Mac. Within a few hours, I received more than 15 responses from urologists across the US, UK and Australia. I have participated in similar conversations about complex surgical cases, such as prostatectomy after failed HIFU. The ability to get tips and tricks from experienced colleagues around the world within minutes is truly a major advance for patient care.

    • Keith Kowalczyk
      Keith Kowalczyk says:

      I assume you had your daily Starbucks today?

      “T” at the Georgetown Starbucks (which is now a full fledged store and not just a kiosk!) says hello to you!

  2. Keith Kowalczyk
    Keith Kowalczyk says:

    Nice points.

    “Sometimes small nuances of surgical technique do not get print space in the established surgical atlases or peer-review publications of surgical technique.”

    This is a great point, and couldn’t be more true. Bear with me, I have a lot or thoughts coming our of my head on this one….

    It is my belief that anyone can “remove” a prostate after 100 cases. As I have progressed and carefully followed outcomes, however, you note that there are most definitely small nuances that can make a difference between successful “removal” of a prostate and having good outcomes long after the perioperative period.

    However, on the other hand, surgeons in our field seem to be high on chest-thumping individual accomplishments, arguing over who does what better, and not really divulging the lessons and pointers learned along the way that lead to their outcomes. Also, as an outcomes researcher, I noticed that the majority of outcomes published are highly manipulated to get a headline that basically concludes that all men are continent and potent in the recovery room! We all know this is not true in the majority of patients, and will not be true as we start to treat more high volume disease.

    Finally, statements that suggest that “I am still learning after 3000 cases and therefore you can only go to surgeons who have done 3000 cases” are preposterous and laughable now that robotic technology is over 10 years old. In this day and age, trainees get a head start on the learning curve due to trail-blazers in the robotic field learning what does and does not work, and therefore they are told immediately what to do and what not to do. For instance, during my fellowship I was told by my mentor that by the time I was halfway through the year I was probably at the same point in the learning curve that he was at 500 cases, even if I had not yet performed that many cases. This was all due to a willingness of him to share what he had learned in the early days of robotics. My residents now are likely at the point in the old learning curve of about 150-200 cases, despite not having done that many, because they are told what to do and what works best. This just didn’t happen 10 years ago, leading to the historically longer learning curve that we hear about. Again, I have the utmost respect for those trailblazers getting to this point, and I do believe the learning curve to be steep when it comes to getting good sexual and urinary function outcomes, however sharing what we have learned has certainly made the curve somewhat less steep. Continuing to share these learning tips will further decrease the learning curve of becoming a successful robotic surgeon.

    Therefore, I agree that it would be a great to have a resource where we can share lessons learned and surgical tips with each other in a much easier manner than trying to get case series and videos published. A tips and tricks or difficult cases section of the blog, where one can submit video and commentary on how difficult situations were handled, would be invaluable. However, one must be careful in approaching this. If something goes wrong, you cannot give details on a case outside of a very confidential M&M type meeting.

    Thanks again!

  3. Faisal Ahmed
    Faisal Ahmed says:

    I usually relegate my use of social media to expressing my hilarious thoughts on current events, but I’m going to get serious here.

    Keith makes great points which I agree with wholeheartedly, especially the potential confidentiality issues.

    As I am about to venture into the real world, I am obviously a bit nervous about “continuing to know enough”. I feel confident in my abilities as a surgeon, but I fear the “attending syndrome” where I will continue to do things a certain way because this is how I was taught and I know it works.

    Barbed suture for the vesicourethral anastamosis for example. It seems like all the big shot Indian robotic surgeons use it. I like using it, but it definitely requires a slight change in your technique. Whether there is data to support it is another issue, but the technical changes in using it or the tips on how to use it well are things I’d love to hear from the surgeon themselves and not the rep for the suture in the OR.

    The Internet and SoMe especially should open us up for a free exchange of ideas that is recommended in this blog post.

    Recently at a review course I was thinking to myself, “man it would have been awesome to have access to the minds of these urologic giants lecturing to us while I was in training”…and then I thought “well I kind of will forever through the uro-twitterati”. Continuing education/exchange of ideas outside of planned conferences will lead to better care in the end.

    I agree again with Keith that the peer review process often takes the real “feel” out of surgical literature and the most valuable tips/tricks get left on the cutting room floor in favor of numbers, numbers, and more numbers

    I hope 5, 10 years from now we are all still so open to a free exchange of ideas and the fun collegial nature isn’t driven out by the objectivity police

  4. Justin Collins
    Justin Collins says:

    Good points Keith.
    Maybe the potential of social media is not just it’s accessibility but also that it is less ‘high brow’ than a publication and therefore individuals will be less inclined to chest-thump and more likely to open up with honest opinions and their insight into what they may do differently the next time.

    Social media when used regularly has the potential to form communities which share ideals as well as ideas and the resulting cliques have been defined as ‘tribes’ by research from RHUL and Princeton University

    Brainstorming solutions to tricky surgical scenarios on a blog is a nice idea, but it is the accessibility to join in and the willingness to share in the discussion, that enables the opportunity. Different models of social media are therefore likely to evolve to enable the functionality as well as the accessibility.

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