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Surgeons: A Matter of Life or Death - Season 3 Episode 1
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00:00:00a serious life-saving operation he's at risk of dying from this procedure
00:00:09we can go from under control to emergency in a flutter of an eyelash
00:00:16beef means don't do that again
00:00:23it is very personal for me if you put a hole in here he'd be at risk of dying on table
00:00:30this is either life or death
00:00:37oh there you go
00:00:44i lost both my legs above the knee i get pain which is like election shots which they're the ones that
00:00:50kill me his kind of function is such that you wouldn't start out like this the risks would
00:00:56probably too high what's the chance of luke's survival now i mean he's at risk of dying from
00:01:02this procedure
00:01:05to open a little bit for me so i'm gonna have to relearn how to how to eat again and there'll be
00:01:10problems with my speech i'm just going to stab through the lip all the way so that in a second
00:01:18the jaw will hopefully break
00:01:19the biggest risk for julian is an artery in the neck will burst
00:01:27the last thing you want to do is to make a hole in the jugular vein
00:01:30you've got the emergency list there
00:01:39do that one
00:01:40go away it doesn't go anywhere
00:01:41today we're going to operate on um luke and so he's uh he's a chap was injured in afghanistan
00:01:5115 years ago massive blast injury he came through it but he's got very high amputations
00:01:56he's going fast
00:02:00increased control yeah so first came in to contact with luke immediately when he returned
00:02:06actually with a number of his colleagues who'd been injured around that time
00:02:11he's had some nerve pain which has been intractable operated on him in 2018
00:02:17and then we uh which got some relief and today we're hoping to really attack both the right and the left
00:02:24side everybody's in the burden of injury that these chaps had it was phenomenal the nurse will do it
00:02:34won't she oh there you go oh gosh gosh there you go and and often this level of injury was unsurvivable
00:02:47he's had nerve pain his pain has really made him suicidal at times he's don't even feel he
00:02:54has a quality of life good morning good morning my name's heather i'm one of the nurses here so
00:02:58we'll just get on with the admission and get you ready is that okay let me move that you wait
00:03:05you've been getting lots of pain yeah bad
00:03:13i was only young as 18 when i signed up instantly knew that i was a boy in a man's world when i rocked
00:03:20up to the training um but it was what i needed i think i needed a bit of discipline at that time
00:03:26of my life so i was uh 20 when we deployed to afghan it was in october 2011 um i weren't there long
00:03:36i was only there six weeks before i got injured my section in afghanistan
00:03:41there's me a young fresh uh fresh face buddy some good good good legs some big feet
00:03:59uh yeah i was quite tall i was six foot one
00:04:02it was just a normal day and normal foot patrol um we left our checkpoint quite early in the morning
00:04:15we patrolled up to where the rest of our team was staying trying to fight back where the taliban had a
00:04:22quite strong hold but as the lads started to search the compound they cleared the compound three of us got
00:04:29placed on overwatch looking and giving cover and i just literally got up and walked around and that's
00:04:36when i stood on iud
00:04:40last meet there and iud was around this area here unfortunately the bloke who searched it missed it
00:04:47well i think anyone to miss it it means you can't tell where it is but i've got up and walked around
00:04:53and stood on it and detonated there
00:04:54i lost both my legs above the knee straight away i had damage to my left arm and to my left hand as
00:05:03well i broke my pelvis in three places and and then i suffered a cardiac arrest for nine minutes
00:05:11it's weird talking about it in this much depth as well i haven't really spoke about it in depth like
00:05:21this before
00:05:26i think if it was anywhere else in the world i would have probably died but
00:05:30i think it's the fact that it was in in camp bastion that we had the best trauma doctors ever
00:05:35there's there's not many people with with my injury that survived
00:05:48i just love normal to normal life and i mean it's never gonna be normal we've been amputee and that
00:05:53but i love to be about to plan stuff and stick to it and enjoy it's enjoying my life again like it's been
00:06:01since november last year it's been the most challenging part of my life because it's been
00:06:07the pain has been pretty much constant from then
00:06:14i've asked one of our peripheral nerve surgeons sam george to help me with luke's operation today
00:06:21so and luke was injured in i think it was 2011. he um look at some of his original injuries from camp
00:06:27bastion um it was um quite dramatic uh lots of the uh ied blast was pushed up into the pelvis and
00:06:37created a very difficult um traumatic injury to treat so here we can see the right side of the pelvis
00:06:46with the with the nerves coming down the pain is being driven by what we call a neuroma so the whenever
00:06:53a nerve end is cut the nerve cells they they tend to form a chaotic ball of a swelling of the nerve
00:07:01which which then produces a lot of pain whenever you tap or knock a neuroma or you obviously sitting
00:07:08on it or it's on your prosthesis that can just keep driving pain from it what we do is we take this
00:07:13nerve end after we've cut the neuroma out and target it and direct it to another muscle nerve going to a
00:07:20muscle that that the person doesn't need the nerve grows into the muscle to give it something to do
00:07:27so it stops giving you pain the risks for this surgery are um are fairly broad and it's one might
00:07:37say fairly simple surgery techniques in a way that we're just going to connect up some you know small
00:07:43small nerves together or put small amounts of muscle around the nerve endings but the challenges for
00:07:49us are that we're actually quite uh close to his bowel we're quite close inside the pelvis
00:07:56got no blood pressure thank you and i think the other thing is that unfortunately as with quite
00:08:01a few of these guys he's got cardiovascular uh aging of his system and he's got a very large heart
00:08:07that isn't isn't beating as well as it um it might in someone of his age
00:08:11it might not a get rid of all his pain it might not get rid of even a portion of his pain there's
00:08:28always a possibility that there's no change arthritis no so luke's pain has been very intractable at
00:08:37times i think it's really affected his dynamic at home he's certainly uh been very close to suicide
00:08:44at times um has often come to me and to see me in clinic often talking about suicide that he can't
00:08:50go on um that he needs something done because otherwise his life's not worth living at the moment
00:08:55because his pain is so intractable and even his daughter has um um sat with the clerk in tears
00:09:01you know it is which is quite hard for us to um to cope with in a way because
00:09:07at times it's felt like there's not many options for us
00:09:16i get two different types of pain i get one background pain which is sort of if you imagine
00:09:22the static on the tv if you imagine that as a feeling that's what i seem to get
00:09:2690 of my life and then i get another pain which is like electric shocks which like they're the ones
00:09:32that kill me it stops my life basically i haven't got a life at the minute um so we live day to day
00:09:40really oh yeah it's it's crippling
00:09:50simple things that most people take for granted is something that we don't have at the moment so
00:09:56this surgery hopefully is going to be the one that works and we can
00:10:00we can we can just enjoy being married and and and being a family if this don't ease today i can't see
00:10:11the next phase of my life being that bright to be honest
00:10:17it's hard to hear him talk if this doesn't work then how would we i don't know how we'd move forward so
00:10:30um
00:10:38hi luke you all right so obviously we're going to address the two nerves that are causing problems
00:10:43on either side what we're trying to do is we wrap a small piece of muscle around the end of
00:10:49the nerve and they really do seem to affect pain particularly so it's been caused by neuromas like
00:10:56this it's a little bit controversial because um with someone that's had his pain for such a long
00:11:01time uh i think there's a there's a belief that maybe this isn't going to work
00:11:05so what what could you know the potential that
00:11:13um one of the nerves is really close to the bowel so it's a chance we could damage the bowel
00:11:21that's our um concerns i suppose and i think for for us sharing um you know as partners in this
00:11:30you know it's something that we've spoken about quite a lot and you know you you have to understand
00:11:34that because nothing is without risk
00:11:37get the show on the road there yeah yeah yeah brilliant okay great is anything else you want
00:11:48to talk to us about there's always more pressure when you're treating someone that you know
00:11:55quite well for such a long time and also there's this bond between us that um that you don't get
00:12:02um elsewhere i've been um trained um within the army both in the uk and overseas uh culminating in
00:12:11my time at camp bastion treating soldiers like luke
00:12:14uh we all had this uh brother bond um that we were looking after our team that were trying to do their
00:12:22thing
00:12:23i've been fighting his corner for um for you know for such a long time and and that burden
00:12:30is not without some cost
00:12:32yeah it's um it's difficult isn't it you know these things weigh on your mind all the time
00:12:38it's not without risk i've carried through the responsibility of trying to bring everybody
00:12:56together to persuade them that um this chap really has just one last chance for us to operate on him
00:13:01to give him some level of normality um that we all enjoy
00:13:04um that we all enjoy
00:13:08can i just check in this family okay so if k0.4.0.2 i think as a family we hope for
00:13:30relief for luke he's had such a rough ride the last few years really that my dream would be that this
00:13:39works and can give luke relief of of the pain that would be my dream
00:13:45love you i love you see you later all right love you love you
00:13:52in my eyes he's got the heart of the lion and he copes with the pain very well even though it's excruciating i'm so proud of him been a long long road to this day luke's got every faith in colonel for say he's put his life in his hands really
00:14:00pray to god that he'll come through it all right
00:14:03here he is oh you finally turned up then i thought you'd gone for a fag or something
00:14:07i thought you'd gone for a fag or something
00:14:14we're gonna do the right side first get us all sorted and then we're gonna do the left side up
00:14:21i think well it'll be fine
00:14:23over the last few years this paint's got worse
00:14:24over the last few years this paint's got worse
00:14:28and then we're gonna do the right side first get us all sorted and then we're gonna do the left side up
00:14:43well it'll be fine
00:14:44over the last few years this paint's got worse and he's been very close to suicide a number of times now i think his family have found it extremely distressing
00:14:56i felt strongly that we we should have another try at this surgery where he would say to me even if i can get one more year of relief that would be better than you know my life at the moment which is which is not worth living
00:15:11if i didn't have the surgery today i think i would end up dead anyway it's like it's been the pain has been pretty much constant
00:15:25so luke's heart is already weak because of his traumatic injuries that he sustained in the bomb blast
00:15:35so we're going to need to monitor him very closely to see how he copes with the anaesthetic drugs
00:15:40what we may find is that his physiology is not coping and this will make the surgery more risky
00:15:47let me just get a little bit more information when we see what damo's spoken to
00:15:58okay okay i've just spoken to the news test luke's heart is not pumping very well
00:16:05has he reacted something then do you think he's now at serious risk of cardiac arrest
00:16:13his kind of function is such that you wouldn't start out like this the risks were probably too high
00:16:20but the risks are already up now do we carry on
00:16:23we can then do the operation we promised luke or are the risk of surgery now too great
00:16:28good start
00:16:35hello there you've got some cd drugs if you said yes
00:16:39i've seen the anaesthetic didn't you perfect thank you
00:16:43so today we're going to be operating on julian who's got a tongue cancer
00:16:53going to be removing part of his tongue and reconstructing it with skin from his arm
00:16:58um but because of the nature of the cancer and where it is we are going to have to split his jaw
00:17:03with what we call a mandibulotomy to gain access to the jaw morning
00:17:10julian's cancer has been acting quite aggressively so therefore this is quite a radical operation
00:17:16if you leave these cancers they are ultimately life-threatening and you can die as a consequence
00:17:24so julian's in this position where he's got this tongue cancer and this tongue cancer is right at the back
00:17:40it's at the junction of the front part of the tongue and the back
00:17:44we need to gain access to that area such that we can remove that tumor cleanly
00:17:51while at the same time allowing us to get in there to reconstruct the tongue
00:17:56that will be very difficult as you can imagine by just going through someone's mouth
00:18:00so while people can open very wide
00:18:04it can prove very difficult to get to the back
00:18:07from a visual perspective splitting someone's lip and then splitting the jaw
00:18:13even for us as in inverted commas seasoned surgeons
00:18:17it is impressive
00:18:19so we will cut the jaw in front of this little hole here
00:18:23and then that will allow us to open the jaw
00:18:27so it's going to be opened up a bit like a book
00:18:30so the jaw is sitting there in a u-shape
00:18:32and we will be able to swing this jaw out on the left hand side
00:18:37and it will pivot on the jaw joint here
00:18:40all the skin and the lip and the cheek comes out with it
00:18:44and then that will allow us to get a direct view into this area here
00:18:50so we do need to reconstruct this and we have to use this technique called microvascular surgery
00:18:55which is where we take skin from elsewhere in the body
00:18:58along with the blood supply that supplies that skin
00:19:02to reconstruct the defect and the blood vessels that supply that skin
00:19:06can then be plumbed into blood vessels that we've prepared in the neck
00:19:10but with all these operations there are going to be specific risks to what we're doing
00:19:16I think the biggest risk for Julian is infection or bleeding
00:19:24an artery in the neck will burst
00:19:26and consequently they'll either bleed externally or they'll bleed into the mouth
00:19:31and it will be a lot too
00:19:44too.
00:19:45Morning Morning.
00:19:46How are you?
00:19:47Yeah alright thanks.
00:19:48I'm Rachel.
00:19:49I'm just going to do a nurse commission on you if that's ok.
00:19:50Yeah yeah.
00:19:51Just to get your blood pressure done and do a few details
00:19:53Are you right or left handed?
00:19:54Right handed?
00:19:55It's going to be some radical surgery
00:19:59very weird having all this happen because i used to be a chef in the navy um you know food's always
00:20:04been such an important part of my life you know i love food i'll have anything to do with it
00:20:09um and so it's it you know to lose you know what your tongue does which you know you'll take for
00:20:14granted every day so i'm gonna have to relearn how to how to eat again um and there'll be problems
00:20:22with my speech yeah so it's going to be a bit of a journey and whatever happens afterwards when i
00:20:29come to um you know i'll just deal with it
00:20:56it's all about getting back to my daughter i love
00:20:57her very much and this has been tough for everyone um yeah this isn't just about me
00:21:06the wider family and the impact has on them which is dramatic
00:21:16even though i'm the one with the cancer it doesn't matter everyone else is going through it
00:21:25that's lovely will his head go into there
00:21:41and i'll get my gloves on while you put the arm outside that's all right
00:21:44the main risks um is bleeding we're operating in the neck next to the carotid artery and jugular vein
00:21:55and you know you can make holes in these vessels and and the bleeding can be significant
00:22:02so this is a complex operation i'm going to be working on removing the cancer from julian's tongue
00:22:07while my colleague sat will be raising the platform julian's arm that will be used for reconstructing
00:22:13the tongue we're going to take the skin from the arm with the blood supply and with it will be two
00:22:20tiny veins so basically we're taking that skin and the nice thing is you've got a tattoo there it'd be
00:22:26nice not to disturb it so we'll just make a straight line incision so we can get it back together fairly
00:22:32accurately duration uh six hours antibiotics thank you very much thank you
00:22:46it's a massive operation for julian and you always get a little bit nervous because you're putting the
00:22:52patient through something massive you always have that slight degree of anxiety which i'd like to
00:23:00think helps you perform better all right ready to start i'll have the lower premolar forceps
00:23:10to access julian's cancer i need to get right to the back of his throat
00:23:16we don't want to take out any more teeth than we have to i'm going to give it a wobble
00:23:20and we're just going to give it a little dab thank you
00:23:28so at the moment we're just cutting through fat in the neck what we find is that um in this bit here
00:23:36between the underneath the chin and the neck if you do a straight line as it heals you end up with a
00:23:42tight scar band and so by throwing this little zed in it tends to be a bit less obvious
00:23:51i'm going to be really careful about the nerve which moves his lower lip it's only a little nerve
00:23:59so if we separate those like that that's lovely so the nerve which moves his lip is going to be down
00:24:04here somewhere and the facial nerve is a nerve which supplies movement to the face
00:24:09if i cut this nerve julian could have permanent damage to his speech and swallowing so i'm coming
00:24:17onto the gland and then forward and this way i'll be protecting the nerve
00:24:22there's a 25 chance that julian has cancer in his lymph nodes so we're going to remove them
00:24:40unfortunately i'm working down a big hole where at the base of that hole is the jugular vein
00:24:50it's a big vein it's usually about the diameter of your thumb
00:24:53there's a big blood vessel that drains blood from the head and neck
00:25:02so i'm just being a bit careful at the moment because he's got loads of little veins
00:25:06but clearly the last thing you want to do is to make a hole in the jugular vein
00:25:10if i damage that it could lead to a serious bleed which could be a risk to julian's life
00:25:27so i need to go and speak to the patient hopefully those are the haemophilters
00:25:35you want to go down there
00:25:51we just we need to make a decision but we need to make a decision quickly yeah yeah
00:25:57okay so timelines do you think um 11 at the moment so just have to sure okay
00:26:04if we don't try now i don't think he'll do very well afterwards because
00:26:10he can't carry on with the pain like he is and he's been so close to suicidal a few times that
00:26:17he would want us to carry the risk with him luke is now at significant risk of fatal cardiac arrest
00:26:26we need to have a chat with the medical director to see if we should proceed
00:26:29hi peter sorry i just wanted to sort of let you know that this was going on he's been anacitized
00:26:37but um we've now um he just wasn't responding very well there's a risk of death that there wasn't
00:26:42before and you know i know luke really well you see he's been he's been with me for 10 years more
00:26:47than 10 years now so we've kind of gone through in our minds really that you know luke want us to
00:26:55carry on i just wanted to make sure that you were aware rather than anything else rather than
00:27:00you know you know you know so that you know what it's like with these decisions it's always a bit
00:27:05tough um you know what i mean it's one of these things that um you know no
00:27:14yeah great no no okay yeah sure okay thanks thanks b okay cheers yeah okay bye bye okay just bye
00:27:32okay all right let me phone her then and let's just i'll put one speaker yeah i need to have a call
00:27:38with luke's wife abby i need to make her aware that the risk of luke dying on the table is much more
00:27:43significant hi hi abby yeah and so you've got myself and damien in the room we're just going to
00:27:50sort of talk to you um effectively we've not started his operation yet but we've we've come
00:27:55on to a few hurdles mainly around his cardiac functions his ejection fraction is probably you
00:28:01know if i'm being very optimistic 20 but running between 10 and 20 and we've got a lot of monitoring
00:28:07down to work that out um so in an in a ideal situation we'd cancel him now and we'd sent him
00:28:17to the cardiologists um you know to work out what to do um and how we could optimize him but i think we
00:28:26all feel that the chances of us getting him back here in this state right now of um next to nil um so
00:28:34this is this is where we are he he's i suppose the way to say i mean he's at risk of dying from
00:28:42this procedure more than we thought okay yeah so what what's the chance of luke's survival now i don't
00:28:53know yeah it's actually you know we've never seen this yeah this kind of case before i can't actually
00:28:58give you a number what i can tell you is it's not as good as it was before yeah i mean it's impossible
00:29:04for us to put your fingers on things that's not what we're after now we just you know what what we
00:29:09need to impart to is that you know if this is what you could what yeah oh yeah i think luke wants surgery
00:29:18he wants to try and get a normal life back we don't have a lot luke doesn't have any form of life
00:29:23at the moment anyway and i think that's important for us to understand so that we can share this with
00:29:29the team so that the team will feel um it's the right thing to do yeah okay so luke's new one is
00:29:35if surgery doesn't kill you the pain and meditation and will kill yourself if he carries on like this
00:29:44and i think that's the understanding it was kind of our decision to make and i think
00:29:49me and mark decide i think that's the way to go uh given all the things we've said to you
00:29:56yeah all right yeah i'll um are you good job me to give gary a call i'll give his dad a call now
00:30:03yeah okay and and just try to keep yourself busy uh i'll give you a call afterwards all right okay
00:30:09okay are you going somewhere else no i'm just hanging around a couple of minutes
00:30:24time we have made a decision that um with knowing him and having a conversation with his wife that
00:30:39although he's under significant risk now i'm sure he would be telling us to carry on and to you know
00:30:48i certainly don't want to put him through anything that is unnecessary but of course now we feel that
00:30:53this is life saving right down this way as well ready great move
00:31:10and just someone grab the consent form for me
00:31:14and so plan procedure is that we're going to do this bilateral sciatic nerve explorations
00:31:19just to bring the team into the discussion
00:31:27i think beforehand we didn't think there was a significant risk of death as part of the procedure
00:31:32i think we now think there is a significant risk i've discussed this with his wife
00:31:39i've also spoken to the medical director as well who supporting our proceeding based on the fact that
00:31:45this is probably the only time we're going to get luke here in this position and he's already at
00:31:50significant risk but we feel that is worth it it's what he would want and that's what we've gone down
00:31:55i mean is there anybody that really feels strongly about proceeding
00:32:03great i think it's important that we all feel together on this
00:32:06there's definitely a pressure that you know i do feel that making decisions for him have to be very
00:32:15circumspect which is completely why i've involved many other members of the team try not to allow any
00:32:21relationship that might have developed between us as friends to to cloud what we are and what we're
00:32:27trying to do to help him well i think he's he's placing all of the success on this
00:32:33he's at the point where he's willing to try anything yeah let's hope we can find the bloody
00:32:38nerves quickly as in when we make the first incision okay how are we doing then are we ready to
00:32:46the bomb blast damage to luke's thigh makes locating the nerves particularly challenging and we only have
00:32:51a limited amount of time under anaesthetic the neuroma's somewhere there yeah okay we go a bit like
00:32:56that we are going in at the top of luke's thigh on the right side of his remaining pelvis great
00:33:03and knife please i'm going to make it this big i think we don't want him under anesthesia for too
00:33:10long time pressure acutely to the surgery now is more because of the anesthetic risk and the longer
00:33:15he's under surgery the longer his body is experiencing trauma
00:33:23well the right leg is going to be is easier this is the right that we're doing now this is slightly
00:33:29easier as opposed to his virgin territory bigger the better yeah prior to this the risks were from
00:33:36the operation itself risks of his to his bowel risk of bleeding and things like that now it's
00:33:42risked his actual whole body because of his heart
00:33:45i made the incision we've just gone through the skin and we're just into the subcutaneous fat now
00:33:59so we're now going to raise tissue to allow us to to see the nerve i think we've got
00:34:05we might be close to the nerve we're just trying to orientate ourselves a little bit so we can feel
00:34:09you can feel the bone there is that nerve or the scar we need to find the nerve that has the neuroma
00:34:18on the end of it which is causing luke's pain that's right how is it there
00:34:24yeah so so we're just i'm just exposing the nerve now i think you can see it
00:34:29that's the neuroma yeah you can feel it yeah the body of the nerve is in the spinal cord
00:34:35or in your brain you know the cell body so the nerve doesn't die when the nerve gets cut
00:34:41it's like a starfish trying to regrow its its its legs so the when you cut the nerve
00:34:47the ends the nerve cells are still alive at the end of the nerve and they try to
00:34:51regrow but there's nothing to regrow too so they they grow in a chaotic fashion and they and that
00:34:57causes a lot of pain sam is going to give the nerve that is causing the pain something to do
00:35:03by stitching the freshly cut end into some muscle the hope is it will grow into the muscle and stop
00:35:08giving him pain and particularly these muscles that we're choosing aren't really doing very much
00:35:14now and so if we can give them something to do it will really help
00:35:21yeah we'll remove the neuroma cut it back to where the nerves healthy take a nice good chunk there make
00:35:27sure a couple of centimeters from the neuroma and then just make a nice clean sawing cut there
00:35:33and you can see how healthy the nerve fascicles are there
00:35:40yeah you can see this this lump that's formed where where these fascicles at this end have tried to
00:35:48form new connections and not been able to
00:35:50and then that is very exquisitely sensitive so as soon as you bash on that a tiny little bit it
00:35:58will send a big electrical signals down the nerve and cause him intense excruciating pain
00:36:05this is quite big so i'm going to just wrap it with muscle as it is it's kind of a belt embraces type
00:36:09thing so microscope is it ready uh i should get this one turn this to 62. the anaesthesis is especially
00:36:18important in this operation they're keeping a close eye on how luke's heart is coping at every stage
00:36:25yeah
00:36:32so we're just doing microsurgery just to join up that branch we found
00:36:37to the main sciatic nerve we really want to make sure that the cut nerve iron securely with the
00:36:43muscle to form a healthy connection that will grow otherwise there is a risk that luke's pain comes back
00:36:49so it's it's tiny stitches that's why we need the microscope and we orientate it to the correct
00:36:56sort of fascicles as well
00:36:57well we're going for third one here yeah actually i like that idea yeah
00:37:06just to orientate it a little bit
00:37:09looks great sam yeah brilliant right brilliant really good
00:37:17okay yeah we're done we're just going to close up
00:37:21back out back on please great so part one done we've done the right side
00:37:29yes we managed to excise the neuroma then now on to the left side the bigger challenge yeah
00:37:37we've successfully completed half the operation but now we're moving on to the more difficult left
00:37:42side where there are more risks
00:37:43it's very close to the parent and very close to bowel so it means us inadvertently tearing a bit
00:37:51of scar tissue that's attached to the bowel that would then open up the bowel which obviously is full
00:37:57of bugs this could cause a life-threatening infection like sepsis so we've been what have
00:38:05we been two in a we've been two hours haven't we really
00:38:08the longer he's under surgery it's a load on his heart which is already compromised
00:38:16i'm worried that luke's heart could stop at any moment
00:38:19just as we're about to go into the most risky part of the operation
00:38:24is he okay
00:38:29if he did end up going into cardiac arrest we'd have to obviously stop what we're doing
00:38:33um get the drapes off turn him onto his back as quickly as possible and start
00:38:37cardiac compressions
00:38:51yep uh e park we've got two all right thanks h
00:39:01medium swap please
00:39:07we're trying to get low in the neck and access is always tight and difficult julian has a survival
00:39:22advantage by us removing the lymph nodes in his neck that may have cancer in them so i'm just going
00:39:28to come onto the jug from above we're avoiding all the named blood vessels but there are plenty of
00:39:37little blood vessels that don't have a name which are big enough to spoil your day in a way
00:39:42so now i can finally get access to his lymph nodes and remove them as a whole
00:39:57in the neck is all the fat and the glands that have got cancerous cells in there
00:40:01we've removed all the lymph nodes in the neck and in doing so we've come down to the jugular vein
00:40:13so we've separated the jugular vein we've taken all the tissue out from around it
00:40:16the first stage of the operation is over so now i need to split julian's jaw to get to the cancer in
00:40:24his tongue 15 plakies and we're going to split the lip and do a mandibulotomy
00:40:30i'm just going to stab through the lip all the way and then carve through the lip lovely so squeezing
00:40:44the lip and pulling it up and out and so i'm going to cut through that muscle in a minute
00:40:51and then come above it just going to go straight through blade back to you so we're going to go
00:40:56straight down straight down the middle
00:41:09and when we do our bone cuts we need to do our bone cuts such that we don't
00:41:13injure the teeth and we don't injure the nerve um saw into me please
00:41:31so we're just completing the bone cuts now
00:41:36so that in a second the jaw will hopefully break
00:41:38and a mallet please
00:41:48so we're just doing some little tap taps
00:41:51and you can just see the beginning it's beginning to open up
00:41:56now you've got good movement so you've got to be careful that we don't tear this too much because
00:42:01obviously here it's all about preserving function
00:42:06there will be a muscle on the inside called mylohyoid which we're going to need to cut as well
00:42:12so you can see us opening the jaw
00:42:14so i can cut through this now and then we'll be able to swing the jaw out
00:42:29now i can get to the back of julian's tongue where the cancerous tumor is
00:42:43we want to make sure that as much of julian's tongue as possible functions normally
00:42:48two forceps to me please could you grab hold of that bit there
00:42:57so i must remove all of the cancer with a clear margin so it doesn't grow back
00:43:01so now we're going into the tongue
00:43:12so unfortunately the nerve which gives sensation to the tongue on that side is going to go
00:43:17it just means that the tip of his tongue is going to be numb
00:43:21it's still going to have taste
00:43:27suction please so i'm just going a little bit deeper here so i'm going to come across the base now
00:43:34just coming right to the back
00:43:49and it's right at the base of the tongue
00:43:54so this is the base of the tongue
00:43:57and that's where the positive margin was and we need to get a centimeter on that that's why
00:44:01we've had to go back as far and so we've removed here almost half of julian's tongue and if we
00:44:07don't reconstruct this he's going to find it very difficult to eat and speak again properly and his
00:44:12quality of life would be intolerable so basically i'm done sat's going to have a quick look at the blood
00:44:19vessels
00:44:24so we're going to use a flap of skin from julian's arm with its blood supply
00:44:29to reconstruct his tongue medium like it so i've divided the two veins that travel with the artery
00:44:38and then we'll divide the other major vein
00:44:44when you're using muscle flaps the amount of time you can survive without blood supply is markedly
00:44:51so here you can just see everything detached we must connect the flap as quickly as possible as the
00:45:09longer it is without a blood supply the more likely the flap will die and then we may have to abort the
00:45:15reconstruction
00:45:21where is the patient going back to abscessing oh my god i'm looking full of facts
00:45:29so obviously i mean his health concerns are there they're more relevant now than yeah yeah
00:45:43and so now we're going to do the more challenging side getting the nerve out it's going to be a little
00:45:48bit more difficult is it's going to be close to big vessels within the pelvis and close to bowel which is
00:45:55obviously one of our concerns luke's pain is unbearable and it's brought his life to a standstill
00:46:02we need to locate the nerve at the top of the left thigh to give him the best chance of a life worth
00:46:06living yeah yeah happy everyone all right yeah yeah we're doing the left side now this side is slightly
00:46:13more complicated because we don't have the normal landmarks anymore in this side um that we would
00:46:19normally follow to get to the nerve so it's much more difficult to make things even more complicated
00:46:25this is the area where the nerve is right in front of the bowel and all the big vessels as well so
00:46:34what's that rim is that i'm not sure so there's something sharp here can you feel that where my
00:46:40fingers exactly so you see that thing there can you see this is muscle you see this here yeah i know
00:46:48what that is at the moment the challenge is first finding the nerve this just can't this all gets a
00:46:58bit red doesn't it you can't quite work out what's going on probably like all these things is that
00:47:06everything looks the same i'm finding it's quite hard now because i can't work out
00:47:18where it goes
00:47:22every time i do anything it's just bleeding that's probably
00:47:25everything's everything yeah oh it's just all red and horrible there's some there's a sort of something
00:47:32there there's
00:47:36i think we've got to find some anatomy that we're familiar with at the moment because
00:47:43but we're making very slow progress at the moment um i don't feel we're getting anywhere
00:47:51luke's anatomy is almost unrecognizable as a result of the bomb blast we're struggling to identify the
00:47:57crate nerve to operate on oh my god i might have to stop and look at the anatomy in a second you know
00:48:04on that scan again i'm worried if we can't find the nerve on this left side luke's entire operation
00:48:10may have been wasted i just can't get myself oriented at the moment do you want to have a
00:48:14little go and i'm going to just describe a second because i want to have a look at the scan and get
00:48:18the scanner all right um i can't find that so i want to look at the um scan again just get myself
00:48:28orientated i'm not sure i've got many more of these cases in me to the nasty luke's been under
00:48:33anaesthetic for three and a half hours every minute puts more stress on his heart time pressure acutely
00:48:41to the surgery now is more because of the anaesthetic risk the load on his heart which is already
00:48:45compromised so the longer we take the higher the risk is
00:48:58the problem is it just can't uh can't really difficult to identify the anatomy we can't
00:49:28he's only got half a pelvis
00:49:33it all looks like scar tissue
00:49:43i still think it's that do you think you've got it i found something i thought might be it but
00:49:50i don't know if that's the stump there try cutting it but
00:49:53the one scanner wanted to look at i can't it doesn't say it's well you just can't see it
00:50:01yeah let me really scrub and the problem is the scar looks very much like nerve
00:50:10and it was there before so it's it's very it's quite hard at the moment
00:50:13i'm cutting away at the scar tissue from luke's injuries to give me a better view of the nerve
00:50:20that's causing him pain
00:50:24i was just wondering if this is the stump of the nerve here
00:50:29and this is the notch
00:50:35oh that's what you mean yeah right there yeah yeah
00:50:38yeah you're right on you can you see that yeah that's it the nerve is here
00:50:43so you could go around it a bit more and then we could cut it then and put some and just put some
00:50:53muscle around it yeah i think we've got to go on this bit of bone as far as we dare we can either
00:51:00put some muscle or something in there and cat sport these and then i think i think we've got right
00:51:08where it's all scarred up onto the bone god yeah and um i the problem is now is what i'm a bit nervous
00:51:15about is that as we as i pull this i'm feeling that there's stuff you're pulling abdominal contents
00:51:21this way or certainly peritoneum so yeah because we can't really free it up any more here without
00:51:27damaging the peritoneum and there's bowel there that is causing us and lots of big veins we are
00:51:33now operating deep inside luke's pelvis very close to his bowel there's a risk that we can inadvertently
00:51:39put a hole in it which could cause luke lots of problems after surgery there look there's some
00:51:45decent muscle there look oh yeah yeah so i think take a bit of that muscle there so we're taking some
00:51:55a small amount of piriformis to wrap around the end of the nerve that's quite scarred we've freed
00:52:02it up as much as we can from the bone but we can't really get any deeper without risking damage to bowel
00:52:07now we we we want to try and minimize his time under anesthesia if we can it's not too bad what time
00:52:13are you on now half five so we're we've we've done five hours so far what we're going to do next is
00:52:20we're just going to cut the uh as much of the scarred nerve as we can and then we're going to
00:52:24parachute around the end of the nerve this bit of muscle we've just taken
00:52:33i think what what we're trying to do is is hopefully allow the nerve to have some muscle
00:52:40around it that is protecting it from scarring up to the bone again and that will be really important
00:52:45um that looks great there's a there's a few little bits to do but we're very close to starting to
00:52:53close and that's it done we're really hoping that we'll get some relief from this because at the
00:53:01moment every time he jolts down onto his pelvis remembering he's an amp amputee and has to sit
00:53:07it jars the nerve and hopefully this will then stop that cycle we've got through it it's really
00:53:15challenging surgery i'm pleased that luke's heart has managed to get him through this lengthy operation
00:53:24this really is the last chance of improving luke's pain
00:53:26all right abby it's mark foster are you okay yeah yeah yeah very good yeah um so we just finished
00:53:43everything's gone really well he's fine um hopefully you can rest um a bit easier he's not completely out
00:53:55the woods as you can imagine it will now be an eye to you and they'll be able to keep everything
00:53:59uh and very tight from my perspective i just think you know you know we've done exactly what
00:54:03we can um but yeah it's taking it's taking its toll today i have to say
00:54:11the left side has caused us some um not problems so much but we i couldn't get as much around the
00:54:17nerve as i wanted to it's just far too deep so we've got on to the end we think
00:54:22i don't know how successful this will be i have to say i think we've not been able to see the nerve
00:54:29as clearly as we wanted to we're really hoping that we'll get some relief from this
00:54:36so thank you yeah go keep going okay it's got it what we'll do now we're just going to move back uh luke if we may that's all right
00:55:00so this is going to be the front and the back and these two blood vessels we're just going to lay
00:55:12into the neck like this there the skin that we've used to reconstruct the tong is quite thick the problem
00:55:21is it's so thick that it needs a blood supply without this blood supply basically the flat would die
00:55:28within a number of hours and it's got to have an inflow and an outflow and we're just going to
00:55:34start insetting the skin here three ovicral please if we don't get this plumbed in in a timely manner
00:55:41the skin will start to die off if the skin flap dies then the reconstruction wouldn't work well that
00:55:46would mean that julian would be left without a functional tongue and this would affect his ability
00:55:50to speak and eat and i know stitch so the stitch we use as you'll see is quite small they're about
00:55:58one and a half two mil this is where you see how badly we all shake
00:56:04you try and get a nice little stitch in got to be a bit careful i'm just lost where i am there's one
00:56:12more i think just at the top just got to kind of pull that there that's it it's all right this is the
00:56:23last stitch so that's just tying this off and then i think fingers crossed will be done
00:56:33it looks quite nice here doesn't it the important thing is the artery in the neck you can see pulsating
00:56:39really well so you've got a lovely pulse into the flap i think fingers crossed so hopefully it'll be
00:56:48watertight and be able to just lift it up all we've got to do then is just close it with the
00:56:57flap now in place we can start putting julian's jaw back together again so we're going to be using
00:57:02metal plates and screws to hold the jaw in place so we're not doing this rigid yet we're just going
00:57:11to get these screws on one more thing we're going to plate it together and then i'll just try and get
00:57:16the stitching at the back so needle to you thanks screw please manipulate it into a good position and
00:57:25tighten up so his teeth are in a good bite that's it and you'll feel it lock but the jaw is all together
00:57:36in one piece and we've got that skin on the side of the tongue going right into the back so what we
00:57:45need to do now is just a little bit more closing here the skin stitches should really just be gently
00:57:52holding together what your deep stitches have done the patients have no idea what you've done on the
00:57:59inside they don't know if you've done a good job or a bad job so all they see is the stitching that
00:58:06you've done and if your stitching looks poor then quite rightly they've probably got to think to
00:58:11themselves well hold on if they're not that bothered about what it looks like on the outside
00:58:16what have they done on the inside
00:58:24happy guys ready steady down type yeah
00:58:36you just relax julian just let everyone do the work for you you just lie there and relax it's all gone
00:58:42well okay you just relax and let yasmin do all the work for you
00:58:51you walk away thinking there shouldn't be any problems however you never know really until the
00:58:57patient goes home which will be about 10 days time you never truly relax
00:59:02you
00:59:19good morning
00:59:22great so we're going to see luke today he's um two weeks following his surgery now it's been a bit
00:59:37of a bumpy road actually following his um his surgery certainly with lots of conditions uh that have kind
00:59:44of revealed themselves as we've gone on uh but yeah we'll see how he is today
00:59:49you know knock hello how are we doing hello all right wow we've got everybody here today including
00:59:56the frog excellent great to see you good to see you guys nice to see you again hello you all right
01:00:03hi dad all right yeah very good well um so we're i think we're two weeks down the line now um it's been
01:00:11a rocky road um with pancreatitis pees uh that we've had and you've had you know had some problems on one of
01:00:18the days of um uh developing a chest infection as well uh and that um i really put you back a little
01:00:24bit um and your pain's been intermittent over that time yeah um but last day or two i hear that things
01:00:30are getting a lot better how are you feeling i'm good at this the pain that i'm getting is more from the
01:00:36from the scar i think um i am i am getting a bit of nerve pain on the right but nothing fantastic no so i
01:00:45think it's more just from the wounds yeah it's touch wood sure and then the left side that's fine
01:00:52yeah and that's quite surprising for me actually that the left side has been done so well and
01:00:57and because we pulled quite a lot of the nerve away from the bone and and the scar and that would
01:01:03probably explain why um actually that's done okay yeah whereas the right side was very much a fresh
01:01:08cut through the nerve that's why it really does cause a bit of pain to start with uh but then that's
01:01:12that's eased now great we won't really know whether it's absolutely worked for a number of weeks
01:01:18yet and maybe even months it's just to see how it goes and i think you know as every week goes on
01:01:23every month goes by um that's a good sign that um we'll get things and what happens is the nerves
01:01:28got to grow down it's got to re-innovate right and that does take weeks to happen it's early days
01:01:35i don't want to give you any false hopes but i think you know we're going to go the right way um
01:01:40and then you know i think the hard work for you is now on as well we want you to you know really
01:01:44get yourself as healthy as you can you know um because that will help everything settle down
01:01:48yeah help um the the pain that was um happening not reestablish itself yeah
01:01:54on behalf of my family and abby and everybody else i'd like to thank you and the team for the great
01:01:59job you've done with me it's a team effort um absolutely i have to say i felt i've earned my
01:02:04money with you it's truly amazing we probably wouldn't have luke if it weren't for you guys
01:02:10all right well um thank you very much it won't be goodbye i know what this is like so we'll see
01:02:15you in a few weeks in the clinic yeah um i think probably about the six week point okay great
01:02:19catch on me later yeah thanks sir cheers thank you i'm excited i'm uh hopefully i can get back home
01:02:29today there's good news about my uh my surgery i think um this this one might be the one that works
01:02:39i've been i've had about four or five days now where i've not really had any pain it's like
01:02:43it's completely flipped it on it it's always quite mad to see he's definitely um turned the corner now
01:02:52as um we hoped and predicted uh yeah so he's doing much better uh his pain's now really settling and i
01:03:00think um we i would expect him now to have a good period of relief you can see from him he's
01:03:07dramatically different this has made a massive difference in just in the short term now
01:03:13i think we're all very cautious um i've been through this with luke a few times now um i'm
01:03:21i'm yeah i'm really pleased with how he is i'm really pleased for him um we're always humbled at
01:03:26being in this these scenarios we don't really do it for um for the reward we do it because it's the right
01:03:32thing hi julian if you come into my clinic over here um i'll have a good look in your mouth
01:03:49and just touch base with you about where we stand
01:03:52you did remarkably well obviously the starline doesn't look particularly good at the moment
01:04:01because you've got hair growth around it um so um you've got a little bit of um you've probably seen
01:04:07yourself that um the skin is just overlying and overlapping a little bit underneath and all this
01:04:13neck is going to settle down the bit that we really want to get right when we stitch it together is
01:04:18that little junction between your lip and the skin and that's spot on but should i have a look inside
01:04:24your mouth so if you can make yourself comfy i'll put some gloves on
01:04:30so i'll have a quick peek inside if i may just open a little bit for me
01:04:34so we did go a long way back actually you can let your tongue relax let it all go soft and floppy
01:04:41so i can see the flap at the back you've got some purple stitches in there we've got the skin there
01:04:47always swells up a bit i'm just going to pull it right back it's looking really nice everything's
01:04:53going the way it should be statistically the most likely outcome is going to be you know all being well
01:05:01no residual cancer there are things you probably weren't expecting um but this will go the right
01:05:07way lovely lovely i'll let you go and you have done remarkably well as i say it is going to be peaks
01:05:12and troughs it's all about regaining as much form and function of my tongue as i can and yeah you've
01:05:18done an amazing job on that you know it's a team yeah thank you so much cheers mate thank you all right
01:05:22i'll let you go cheers julian thank you very much um i will let you go thank you all the best cheers
01:05:29then see ya bye now
01:05:33the main thing for me was quite simply was how this graft took on my tongue taste is all right
01:05:41actually amazingly so it hasn't really impacted my taste which is great
01:05:47towel done for you okay oh it's so good to get that off i bet it's all stepping stones for me this now
01:05:54sets me off on my journey to getting back to health get through this major major surgery and come out
01:06:01the other end okay is it's huge yes i'm really happy with that thank you okay
01:06:07not everyone will survive a heart operation but this operation is really the only chance that matt
01:06:19has and the heart is out all the breast has been replaced by the tumor itself we are a racing against
01:06:29time
01:06:32it's possibly one of the most significant moments of their life
01:06:35we are in the tumor now this is inside the belly of the beast
01:07:05this is inside the belly of the beast
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