‘A Procedure Without a Problem’, or the face transplant that didn’t happen. The Royal Free, the Royal College of Surgeons and the challenge of surgical firsts

Face transplants are an innovative and unusual form of modern surgery. There have been 47 face transplants around the world to date, but none as yet in the UK. Yet in 2003, the UK was poised to undertake the first face transplant in the world. The reasons why it didn't take place are not straightforward, but largely unexplored by historians. The Royal College of Surgeons, concerned about the media attention given to face transplants and the ethical and surgical issues involved, held a working party and concluded that it could not give approval for face transplants, effectively bringing to a halt the UK’s momentum in the field. This extraordinary episode in medical history has been anecdotally influential in shaping the course of British surgical history. This article explores and explains the lack of a face transplant in the UK and draws attention to the complex emotional, institutional and international issues involved. Its findings have implications beyond the theme of face transplants, into the cultural contexts and practices in which surgical innovation takes place.

1285 Reporting of Robotic Pancreaticoduodenectomy As A Surgical Innovation: Systematic Review and Narrative Synthesis

Aim Pancreaticoduodenectomy (PD) is most commonly performed using open surgical techniques. Minimal access approaches have reduced the morbidity of many types of surgery, however technical limitations have hindered the widespread adoption of laparoscopic methods for PD. There has been increasing use of surgical robots to facilitate a minimal access approach, motivated by improved visualisation, ergonomics and dexterity compared to standard laparoscopic methods. Methods for the safe introduction of novel techniques are lacking, and the way in which surgical innovations are reported may affect adoption into clinical practice. The aim of this study is to understand how robotic PD has been reported as a surgical innovation. Method A systematic review is being conducted by the trainee led RoboSurg Collaborative. A literature search was performed to identify primary research reporting outcomes of robotic PD. Articles are being screened in duplicate by title and abstract, then by full text review. The following data will be extracted: study methodology and rationale; centre, surgeons and patient details; governance and ethical considerations; learning curves; details of the intervention, including modifications; and how outcomes were reported, including use of core outcome sets. The data will be analysed using a narrative synthesis method. Results The search identified 1305 articles reporting on robotic pancreas surgery. An interim report of progress will be presented. Conclusions A rich narrative synthesis will enable innovators to understand how robotic PD has been reported. This will encourage transparent, methodical, and meaningful reporting of robotic PD, increasing the quality of clinical evidence.

1174 The Reporting of Centre and Surgeon Experience in Studies of Robot Assisted Cholecystectomy: A Systematic Review

Introduction Over 90% of cholecystectomies are performed using minimally invasive techniques. Robotic cholecystectomy (RC) has been developed to overcome technical limitations of laparoscopy, including improved range of movement and visualisation. Despite becoming increasingly widespread, the safety and efficacy of RC remain unestablished. This review aims to analyse the quality assurance reporting through centre and surgeon expertise in RC. Method A systematic search was conducted to identify all published studies reporting RC. Data on quality assurance measures were collected, including: centres involved, surgeons’ experience and training. Results Of the 1425 abstracts screened, 90 full-text papers were included. Sixty-four studies (71%) were single institutions. Of the thirty studies (33%) reporting centre type, 28 were conducted in specialist/regional/tertiary centres. Only four stated their caseload of RC. No studies described pre-specified criteria or minimum experience required for a surgeon to participate. Fifty-two (58%) reported the number of surgeons operating and 13 (14%) stated surgeons’ training grade. Two quantified previous RC experience, 7 stated prior laparoscopic experience. Only 21 (23%) described training prior to the surgeons’ first in-human procedure; animal based (n = 12), simulation (n = 12), observation (n = 4), lab-based (n = 3). Specific mentorship was reported in 8 studies, and 13 described dual operating. Conclusions Little information was provided about the experience and training of operating surgeons, making it difficult to ascertain whether replicable techniques were utilised which would allow development of a learning curve. This highlights the need for better transparency when reporting surgical innovation, to ensure the safe, evidence-based adoption of new technologies into clinical practice.

Adoption of minimally invasive mitral valve surgery in the NHS. A blend of science and psychology.

OBJECTIVES The objectives of this study were to understand the challenges faced by early adopters of MIS mitral surgery in the national health system in the United Kingdom. It was to (i) capture the significance of the scrutiny introduced by reporting surgeon specific results during the introduction of surgical innovation, (ii) understand how individual personality and behaviour helped these surgeons succeed despite, in many cases, little wider support, (iii) to help more surgeons adopt these patient-centred techniques. SETTING AND PARTICIPANTS The study is based on a qualitative exploration of the reported experiences of all ten early adopters of MIS cardiac surgery in the NHS between 2006-2016. Interviewees were recruited by invitation through their professional society (BISMICS). All interviewees consented to the process; ethical permission was not deemed necessary. RESULTS The experience of introducing surgical innovation into the NHS was unanimously noted to be difficult with few incentives and many systemic and institutional obstacles. Despite this there was a general belief in pushing forward with these patient centred procedures while accumulating the evidence to support it. CONCLUSIONS Individual determination, confidence, mental agility and self-reflection were seen as characteristics of those who were successful. All surgeons agreed that the reporting of surgeon specific results were not conducive to adoption of innovation in teams. Starting a new program as two surgeons appeared to help reduce perceived pressures. Surgical innovation and its early adoption are always likely to be difficult and needs to be recognised as such, within the NHS