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00:00:01The clock is ticking.
00:00:03This is a serious life-saving operation.
00:00:07He's at risk of dying from this procedure.
00:00:13We can go from under control to emergency in a flutter of an eyelash.
00:00:19A beep means don't do that again.
00:00:27It is very personal for me.
00:00:29If you put a hole in here, he'd be at risk of dying on table.
00:00:34This is either life or death.
00:00:46It's a low chance, but there's also that chance that, like, he won't survive.
00:00:50That freaks me out.
00:00:52The fear of losing your child is the worst thing you could ever imagine.
00:00:59You can't ever predict whether the liver's going to work.
00:01:02That's the one uncertainty that we have in every liver transplant.
00:01:05If you don't get it absolutely right,
00:01:08you're going to lose litres of blood within a few seconds.
00:01:12And that can be life-threatening.
00:01:14Liver transplant is one of the biggest operations that mankind has invented.
00:01:22Every day there's a risk of some of that tumour breaking off and him dying suddenly.
00:01:27Every heartbeat for him is a ticking time bomb.
00:01:34He's clinically dead.
00:01:35It's like a controlled, artificial death.
00:01:39The tumour has grown these blood vessels so it can grow.
00:01:43You can get major bleeding if you put a hole in here.
00:01:46He'd be at risk of dying on table.
00:01:50Hold on, hold on.
00:01:51Where is it coming from?
00:01:53Hold on, hold on, hold on.
00:01:54Don't, don't, don't.
00:02:13We are operating on Leo who is 17 years old and he's suffering from a disease called biliratresia leading to
00:02:21end-stage liver disease.
00:02:23Biliratresia is a condition where children are born with absent bile ducts,
00:02:29which is a small tube which carries bile from the liver to the intestine.
00:02:34Since the bile is not draining like a normal bile duct system,
00:02:39so these liver keep on getting a low-grade damage and eventually the liver is completely damaged.
00:02:46It's shrunken, what is called as a liver cirrhosis.
00:02:51Leo is having a liver transplantation because his own liver is failing.
00:02:58Liver transplant is one of the biggest operations that mankind has invented.
00:03:04It requires a lot of skills and physical stamina.
00:03:10As an operation carries about five to ten percent risk of mortality.
00:03:16But his quality of life will keep on deteriorating and he can develop into a full-blown liver failure.
00:03:23And potentially his life is at risk if he doesn't get a liver transplant.
00:03:28Just come with me, your room is just here.
00:03:30Lovely.
00:03:36Yeah?
00:03:39Pardon?
00:03:42Just on the phone.
00:03:44On the phone, yeah.
00:03:49All I know is they are currently in the process of retrieving the liver.
00:04:01I don't think it really made much difference until college probably because that's when I started having all the problems
00:04:09and things.
00:04:10And that's when it actually felt like not a normal life.
00:04:15We noticed it was getting worse with just walking around the house, walking to the shop, needing to take a
00:04:21break.
00:04:22That's when Leo first got put on oxygen.
00:04:25For 17 years now it's been, are you going into failure? Are you going to need to go in? And
00:04:30now we're finally there.
00:04:33I think the thought of being put to sleep is scary to me.
00:04:37But like with a transplant as well, it's like, it's a low chance but there's also that chance that like
00:04:44you won't survive and things like that.
00:04:45That freaks me out.
00:04:49Big risks, but it's worth it for a better quality of life.
00:05:04So that's the NMR scan. That's the liver.
00:05:08But this is not normal because you can see this nodule and another one and another one and another one.
00:05:17This is called liver cirrhosis.
00:05:19In transplant operation, you have to remove the diseased liver, but you have to preserve the blood vessels which are
00:05:28taking blood out of the liver.
00:05:31And similarly, the blood vessels which are taking blood into the liver.
00:05:36Because liver cirrhosis is a process of ongoing inflammation and damage into the liver, the liver requires new blood vessels
00:05:45from the sides as well.
00:05:48If you injure these blood vessels, you can bleed massively during the course of the operation.
00:05:54You can lose liters of blood within a few seconds.
00:05:58And that can be life threatening.
00:06:01Especially in Leo's case, the nature of his blood vessels, his hepatic artery is small, his portal vein is small.
00:06:08All these things make the liver transplant technically more demanding.
00:06:16It will be a difficult operation by all means.
00:06:19But if Leo doesn't have a liver transplantation, his quality of life will keep on deteriorating and eventually he can
00:06:26die of a liver failure.
00:06:41So hopefully you will get the liver out in the next an hour or so.
00:06:47And how far is the liver from here?
00:06:56So should we set up around midnight, one o'clock?
00:06:59Yeah.
00:07:00Thanks, Esther.
00:07:02Speak to you.
00:07:03Take care.
00:07:04Bye.
00:07:04Bye.
00:07:07That was the transplant coordinator.
00:07:11So the donor has proceeded.
00:07:14They have started the actual operation to retrieve the organ.
00:07:18So the timing so far looks good.
00:07:22And we will get to know about the size and the quality and the look of the liver in about
00:07:29maybe 40 minutes.
00:07:33This is always a very emotional thing, you know, death of someone leads to a new life for someone, you
00:07:40know.
00:07:41So there are a lot of emotions involved in this.
00:07:45And the particular donor is a young donor, so it's very sad for that family.
00:07:50But at the same time, it's a new life for Leo.
00:08:00Hello, how are you?
00:08:03Yeah, I'm here to see Leo, who is going for a transplant.
00:08:13Hi, Leo.
00:08:14My name is Professor Dar.
00:08:16I am the liver transplant surgeon on call tonight.
00:08:20How are you?
00:08:21I'm okay.
00:08:22I think...
00:08:23A bit nervous?
00:08:25Don't worry.
00:08:26It's your day today.
00:08:28Hopefully the liver should be here in an hour or so, and then we'll call you to go to the
00:08:35operating room.
00:08:36Okay?
00:08:37So if everything goes well, we should expect this operation to last anything between five to six hours.
00:08:44If any complications happen, obviously, these timelines can change.
00:08:49Any questions?
00:08:52Um...
00:08:53I can't think of any.
00:08:55I probably have some, but I can't think of any.
00:08:59No, I'm fine.
00:09:00Good luck.
00:09:01And I will probably see you once more, once you are back in the...
00:09:05Downstairs in the...
00:09:07Anesthetic room.
00:09:08Okay.
00:09:08And otherwise, hopefully tomorrow evening or a day after, with a new liver.
00:09:13Okay.
00:09:14Okay, good luck.
00:09:15Thank you very much.
00:09:16Take care.
00:09:16Bye-bye.
00:09:22You okay?
00:09:24I'm a lot more scared, but I'm okay.
00:09:26Are you a lot more scared because it sounded like it is going ahead?
00:09:30Yeah.
00:09:31And because I know it's going to be pretty soon, and I... yeah.
00:09:37When I'm awake and aware, I'll be glad.
00:09:41Just right now, I just really don't want it.
00:09:58So far, the information I have received, everything looks okay, but I need to see the pictures of the liver
00:10:06to make a final call whether I'm going to use this liver or not.
00:10:15So that's the liver.
00:10:17This is the hepatic artery.
00:10:21That's the portal vein.
00:10:23It actually looks very healthy.
00:10:37Hello?
00:10:38And we should go ahead with the transplant.
00:10:50Hello.
00:10:50Is this Leo?
00:10:51Yes.
00:10:52I felt like he was going to say no then.
00:10:54No, who's this?
00:10:56My name's Esther.
00:10:58Nice to finally meet you.
00:10:59I'm a transplant nurse.
00:11:00I'm speaking to each other.
00:11:01Esther, how are you?
00:11:02You've arrived.
00:11:03Feeling okay?
00:11:05Yes.
00:11:06I know the surgeon's already been in.
00:11:08Yes.
00:11:09So he's told you the good news that so far, so good.
00:11:12We're happy.
00:11:13So he's seen pictures of the liver, descriptions of the liver and things like that.
00:11:16So he's happy with that.
00:11:17And obviously, you know, we move forward.
00:11:20It's on its way in now.
00:11:22Okay.
00:11:24I know it's a scary process, but you're in good hands.
00:11:27Obviously, you used me being there, aren't you?
00:11:29Yeah.
00:11:31So what we'll do now is we'll get you onto that bed, if that's okay.
00:11:35You'll be chauffeured down to the theatre.
00:11:37Okay?
00:11:38It's on level two because we're going to lift, go down.
00:11:40Okay?
00:11:49Do you want us to take it when you fall asleep?
00:11:52Yeah?
00:11:54Okay.
00:12:00Okay.
00:12:01Take breaths.
00:12:04Hey.
00:12:05I love you.
00:12:11Hey.
00:12:14When you wake up, you can have lots of sleep.
00:12:18Okay.
00:12:19Yeah.
00:12:19Should we go and get it done?
00:12:24Okay.
00:12:27Yeah.
00:12:43Should we go and get it done?
00:12:47It's...
00:12:47It's a very big day where this is going to be the change for the rest of his life now.
00:12:54Hopefully.
00:12:58I'm going to be on edge all night and I'm going to be wanting to phone, but I know I
00:13:01can't just phone because they are here when they're ready to tell me what's going on.
00:13:07But, yeah, it's hard to see them go through that.
00:13:12His biggest fear is that he's not going to make it and that's obviously always a fear.
00:13:17I just want him to be okay.
00:13:19I just want him to be okay.
00:13:20Bye.
00:13:29Bye.
00:13:35Bye.
00:13:37Bye.
00:13:38Bye.
00:13:39Bye.
00:14:01Okay, on the roll then, ready steady roll.
00:14:09Yeah.
00:14:15Thank you very much, everyone.
00:14:24The first stage of this operation is removing the own diseased liver
00:14:29and keeping all the blood vessels intact.
00:14:32Once this is done, the second part of the operation is putting in the new liver,
00:14:38so you start joining the blood vessels.
00:14:42Once you have done all that, there is a blood flow to this new liver.
00:14:47The major concern is the difficulty in removing this liver
00:14:52because of the abnormal blood vessels all around.
00:14:56That can all lead to bleeding during this surgery.
00:14:59So you have to be very meticulous at each and every step.
00:15:09Secondly, since the liver is in cold storage now, there is a low-grade damage going on to the liver.
00:15:16So it's very important that the liver comes here as early as possible
00:15:20and we start the transplant straight away.
00:15:23That's very important for the liver to function.
00:15:28Because this operation is so complex, I will be assisted by another surgeon,
00:15:33which is Dr. Rehling.
00:15:35And my anaesthetist, Dr. Norman, will be playing a crucial role
00:15:39in keeping Lear's vital signs stable throughout the surgery.
00:15:44I'll be watching his heart on our ultrasound scanner
00:15:49and I'll be manipulating the medications that keep the blood pressure up
00:15:53to make sure that we've got everything as normal physiologically as possible.
00:16:01It could go very smoothly and we could have no issues at all,
00:16:04but equally you can't ever predict whether the liver's going to work.
00:16:08That's the one uncertainty that we have in every liver transplant that we do.
00:16:12And it's why we say to every single patient that comes in for a liver transplant
00:16:16that there is a risk of death associated with it.
00:16:29Hi Tess, are you OK?
00:16:31Perfect. Thank you. Thank you. Bye. Bye.
00:16:35The liver is here. Is that alive?
00:16:41Hello. Is this the liver?
00:16:43Yes.
00:16:48Hello, it's arrived.
00:16:49Oh my God.
00:16:51It is...
00:16:531.54.
00:17:01Right mister.
00:17:02OK.
00:17:03So if you just take it all out.
00:17:12And if you don't mind holding this open for me, then I'm going to take the liver out.
00:17:17All right.
00:17:19There we go.
00:17:21Looks like a nice, healthy liver.
00:17:26Outside of a human, it's not being supplied with oxygen
00:17:29and you want to transplant it as fast as you can.
00:17:40OK.
00:17:42Let's start, hey?
00:17:47Start it.
00:17:49Nice to skin.
00:17:51Can we start the clock, please?
00:17:53Start the clock, please.
00:17:59Can I have a...
00:18:00Yeah.
00:18:04You just have to be careful while opening up the belly.
00:18:10You can expect big abnormal veins coming our way while you are getting excess.
00:18:18We're still in the phases.
00:18:19I'm covering what's what, really.
00:18:21We're still in the phases. I'm covering what's what, really.
00:18:22We have hands.
00:18:26Almost reached the liver.
00:18:30OK.
00:18:31That's fine.
00:18:39So we are just going to start the dissection around the liver.
00:18:45This is a very abnormal liver.
00:18:47Over time, the liver has kind of undergone remodeling.
00:18:52So the shape of this liver is not that of a normal liver.
00:18:57And that makes this operation a bit more different from a standard liver transplant.
00:19:03All right.
00:19:07Here we go, please.
00:19:09OK.
00:19:10Off, please.
00:19:11Water.
00:19:14Good hand there, please.
00:19:18Now we are going to look for the blood vessels going into the liver.
00:19:23Once we have found them, we need to divide these vessels without damaging them before we can take Leo's liver
00:19:28out.
00:19:32We are trying to find the portal vein and the hepatic artery.
00:19:42There. Hold that. Hold that. This one.
00:19:46That's portal vein, isn't it?
00:19:49I'm going to divide that.
00:19:55We do need to use these veins to plumb the new liver.
00:20:02So we have to preserve these veins.
00:20:04We have to be very careful here.
00:20:09Because they are very thin and fragile, a bit of a push and pull can tear apart these veins
00:20:16and can lead to massive bleeding.
00:20:19A bleat here will be life threatening.
00:20:23Please, gently.
00:20:25I can't afford the bleeding here.
00:20:34So I've got the prescription list in front of me.
00:20:41We're operating on Daniel.
00:20:43He's a 47-year-old gentleman and he's got a right kidney cancer that's gone into his heart.
00:20:52The plan is to remove his right kidney with the cancer in it and clear all the main vein as
00:20:58well.
00:20:58To do that, we're going to have to cool him down and stop his heart.
00:21:03This is major surgery.
00:21:05There's risks of bleeding, risks of death, risks of requiring dialysis, risks of strokes, risks of heart attacks.
00:21:12You name it, it's there.
00:21:15Hello.
00:21:16We need to operate on Daniel urgently because every day there's a risk of some of that tumour breaking off
00:21:22and him dying suddenly.
00:21:30Six weeks ago, I had a small operation. I had a varicose vein and a urologist came in and sat
00:21:37down in front of me and said,
00:21:39well, I'm not going to beat it around the bush, you've got cancer, which is like the one thing nobody
00:21:44wants to hear.
00:21:45And it's like, and you go, ah.
00:21:47And I think the only thing I did was my wife was with me and I turned around to her
00:21:52and apologised.
00:21:55It's not just my wife and kids, my dad, my mum, brothers and sisters, stepbrothers and sisters.
00:22:01We're all very close and growing up and being very close.
00:22:08And I don't want to be the one to mess that closeness up and why not, and strain it and
00:22:16make it awkward.
00:22:17Awkward.
00:22:18It's not a white word, but make it hurt them, I suppose the word is.
00:22:28Don't want to make everybody upset.
00:22:32Not making it, that's the biggest fear.
00:22:39So this is Daniel's scan.
00:22:42So if we look at it, these particular images are him sort of standing up.
00:22:46This is his left kidney and that's a right kidney and you can see that's a normal left kidney.
00:22:50This is a sort of a normal bit of his right kidney, but the rest of it's taken by this
00:22:55tumour.
00:22:56This is his renal vein and the cancer has moved into the renal vein and then it's gone into the
00:23:03main vein here, the IVC, the inferior vena cava.
00:23:07It takes the blood from the bottom half of your body and returns it to the heart.
00:23:13Because Daniel's tumour is in the IVC, there's a risk that bits of it can fall off and block his
00:23:20lung.
00:23:21So he's at risk of sudden death.
00:23:23Every heartbeat for him is a ticking time bomb.
00:23:28The plan is to remove his right kidney, which has got the cancer within it, to remove all the cancer
00:23:34within the IVC, both from the abdomen and from the heart.
00:23:37Now that sounds all pretty straightforward, but the problem is to do that, we're going to have to stop his
00:23:44heart.
00:23:44Can I borrow your response?
00:23:46Certainly.
00:23:47That would allow us, in theory, a bloodless field.
00:23:50So we can open up the heart, we can open up the IVC, to remove the entire cancer.
00:23:59Can you tell me what I'm taking you down to theatre for?
00:24:02Kidney removal, as well as opening up my chest and putting me on bypass, heart bypass.
00:24:09When his heart is stopped, there's a critical period of time, maybe about half an hour or so, where we
00:24:14need to remove the cancer.
00:24:16The problem is, the longer it takes to do this, then the higher the risk of causing permanent damage to
00:24:22the organs.
00:24:23If that were to occur, then the chances of Daniel getting off the table are slim.
00:24:33Morning.
00:24:33Morning.
00:24:34Morning.
00:24:34Okay, just pull the curtain across.
00:24:37Today's a day.
00:24:38All set?
00:24:39Yes.
00:24:40Good.
00:24:41I might point to you, I've just got to fall asleep, it's your guy's job that's the big bit.
00:24:46Right, so the plan is, kidney cancer starting from the right kidney, take that out, unblock, take out the tumour
00:24:51that's going up on its way to the heart, take all that out.
00:24:54We'll need the heart surgeons to help as well.
00:24:56It's a long operation, you know, there are lots of complications.
00:25:01We've been through it with you, I'm just going to touch on it very briefly.
00:25:04The risk of not making me through the operation, risks of temporary or permanent dialysis, risks of strokes and cognitive
00:25:11change, etc.
00:25:12So I'm not going to depress you with all of these, but it's a big operation.
00:25:16Without treatment, outlook is measured in probably days and weeks.
00:25:20And if we do have successful surgery, then we can change that to multiple years.
00:25:25We're good at doing this operation.
00:25:26You're good, yeah.
00:25:27And you're the right kind of fit person that we can do it on and we should do it on.
00:25:30So, yeah, we're ready to go?
00:25:32Yes, all ready.
00:25:33OK, all the best.
00:25:34Thanks again.
00:25:35Bye.
00:25:38You're happy to go ahead, yeah?
00:25:40Yeah.
00:25:40OK.
00:25:42I know you know.
00:25:43Trust me, I've been there.
00:25:45OK.
00:25:46All right, well, your chariots are right.
00:25:48I can just do one thing.
00:25:54Right, yes, you guys, I'm going down and optimistic.
00:26:01It's going to be all right.
00:26:04But all you need to know is I love you all so much.
00:26:09And I do.
00:26:13I love you all.
00:26:18OK.
00:26:19I'll do.
00:26:20I'll do.
00:26:21That's enough.
00:26:22OK.
00:26:23All right.
00:26:33Daniel's only 47.
00:26:35He's married.
00:26:36He's been married for 20 years.
00:26:37He's got two young kids, a 14-year-old and a 19-year-old.
00:26:40Are you ready?
00:26:41Yes, thank you.
00:26:43So, he's got a lot to live for.
00:26:59The fibrillator connected?
00:27:01Connected.
00:27:01Do we have gloves available?
00:27:04The spacing box, do we have any in the room?
00:27:06Yes.
00:27:07Lee, are you happy with your equipment?
00:27:09I'm happy, thank you.
00:27:10And that's it, thank you.
00:27:17There are a whole myriad of risks for Daniel.
00:27:21The big one is death mortality.
00:27:24The mortality rate for this is about 5.7%.
00:27:28So, call it 6 in 100.
00:27:31In the UK, the mortality risk of doing a kidney removal is probably one in a thousand.
00:27:37But it's incredibly high.
00:27:39We have checked and confirmed that this is Daniel.
00:27:42Without treatment, really, his sort of life expectancy is unfortunately measured in anything from possibly days, weeks, or maybe a
00:27:54month.
00:27:57Yeah.
00:27:57Can you just turn it on, please?
00:28:00Yeah.
00:28:00Right.
00:28:01All the way.
00:28:03Cheers, please.
00:28:04Well, let's get in there.
00:28:06Expected blood loss?
00:28:08Two litres.
00:28:09Expected duration of surgery?
00:28:11Nine hours.
00:28:13Okay.
00:28:13Thank you, everyone.
00:28:15Nice skin.
00:28:19So, we're cutting right from the chest bone all the way down to his pelvis.
00:28:25It's a big incision.
00:28:28You need access to get all of the operation done in the abdomen.
00:28:32You don't want to be doing this through little keyholes.
00:28:36Let's have the graze, please.
00:28:40So, all we're doing is we're just going to...
00:28:41We're putting the retractors in, so then we can get both hands free.
00:28:45So, we can open the abdomen nicely and wide.
00:28:51We've not seen the cancer properly yet.
00:28:56Okay, good.
00:28:57Beautiful.
00:28:58Let's go.
00:28:58Large wet pack, please.
00:29:04So, what we now need to do is fully mobilise the right bowel
00:29:08and what's called the diadenum.
00:29:11That will get us to where we want to be.
00:29:15What we're trying to do is we need to separate the bowel from the kidney
00:29:19so we can get to the kidney.
00:29:21The kidney, it sits in the back of the abdomen
00:29:24and the bowel is in the front.
00:29:25And because we're approaching it from the front,
00:29:27we have to move away the bowel first
00:29:29if we can get to the kidney.
00:29:31But there's lots of abnormal blood vessels.
00:29:37The tumour has grown these blood vessels
00:29:41to feed it, so it can grow.
00:29:44Can we get sure, please?
00:29:47The problem with them is they can cause a lot of bleeding,
00:29:50but they're always difficult to stop
00:29:52because they're not as robust as normal blood vessels.
00:30:00Straight leg equipment.
00:30:03As soon as you're a millimetre in the wrong plane,
00:30:05it starts oozing and bleeding.
00:30:11Careful, mate.
00:30:12We're in dangerous positions here.
00:30:16You can get major bleeding if you put a hole in here.
00:30:22He'd be at risk of dying on tables.
00:30:37It's your wine, aren't you?
00:30:38Yeah.
00:30:39Do you have to request a pint, then?
00:30:41I will.
00:30:55Can we get Robert's place for a minute?
00:31:04Now we just have to mobilize it from the surroundings.
00:31:09We are ready to detach Leo's blood vessels from his own liver so we can take it out.
00:31:15But first we need to stop blood flowing through them to wide a massive bleed.
00:31:22Very careful, very careful here.
00:31:26Can I get the clamp?
00:31:31That's the clamp which is called a vascular clamp.
00:31:34We are going to put this onto the top of the liver, onto the veins.
00:31:39What I can do is clamp it like that.
00:31:44This stops the blood flow while we cut the vessels.
00:31:47And we need to make sure the clamp stays on.
00:31:51If the clamp goes off, then you can have a lot of bleeding.
00:31:56So you can knife, please.
00:31:59We are about to cut the vessels and take this liver out, very gently.
00:32:07This dissection is teasing us now.
00:32:17This liver is now off its blood supply at a point of no return.
00:32:25Now it's crucial to transfer in rogues.
00:32:37Hello.
00:32:38Hello.
00:32:38This is the main reception.
00:32:39How can I help?
00:32:40Thanks a lot.
00:32:41Bye-bye.
00:32:53One there.
00:32:54Yeah.
00:32:55One there.
00:32:56One there.
00:33:02We'll just keep going here.
00:33:04Yeah.
00:33:06There's another big vessel too.
00:33:09So, at the moment we've got the duodenum stuck onto the tumour and with a lot of abnormal
00:33:17blood vessels stuck onto it as well.
00:33:19We're doing a very delicate dissection, trying to free this from the kidney tumour itself.
00:33:26If it gets an injury there, it can be quite dangerous.
00:33:36OK, we've just made some good progress there.
00:33:40Now that we've got the blood supply sorted, we're able to move a lot faster.
00:33:49There we go.
00:33:54Now the bowel is free from the kidney tumour, we can get a first look at it.
00:33:58Just keep it very careful there. Can you see that?
00:34:03I've had the first glimpse of the kidney cancer.
00:34:07Ugly looking bastard.
00:34:10A bit like Medusa's head at the moment.
00:34:13That's a home base. Ugly little git, isn't it?
00:34:18It's probably about twice the size of a normal kidney.
00:34:21I'm going to take that out.
00:34:24Before we can do that, we need to separate the part of the IVC that's stuck to the tumour.
00:34:31This is the IVC here.
00:34:34The IVC is the big vessel that returns your blood from the lower part of your body right back to
00:34:40the heart.
00:34:41It's wearing this chap, he's got tumour in it.
00:34:46I'm now dissecting and trying to clear the IVC.
00:34:52But it's quite a tricky dissection.
00:34:55So, we've just got to do it carefully.
00:35:01You're going to have to go through it, aren't you?
00:35:02Yeah, yeah, yeah.
00:35:03Okay, Lehi's please, Gemini.
00:35:07It's proving an access challenge.
00:35:10So, we're just taking some lymph nodes away to try to give us a bit more access.
00:35:16The problem with this kind of work here, where we're doing it now, is if you make a hole in
00:35:19the back of one of these structures,
00:35:22then we've got no access to stop it, so then it'll keep bleeding.
00:35:28Hold on, hold on. What's happening there?
00:35:33Where's it coming from?
00:35:34Okay, hold on, hold on.
00:35:36Don't, don't, don't take that off.
00:35:43This needs stopping.
00:35:45Otherwise, he bleeds non-stop.
00:35:55Okay, don't want to take that back.
00:35:56Hold on, hold on, hold on.
00:35:59If we can't control this bleed, there's a risk Daniel could die.
00:36:22Let's come on this side now.
00:36:31The liver is coming out.
00:36:34Now, the liver is coming out.
00:36:36That's the old liver.
00:36:37Water blue.
00:36:41Leo's liver is out, and there is no going back.
00:36:47We need to get the new liver in as quickly as possible.
00:36:50The longer it is off its blood supply, the higher the chances of permanent damage to it, which could be
00:36:57fatal for Leah.
00:37:00Okay, let's get the liver, please.
00:37:05Ready?
00:37:08Okay.
00:37:10Come here, please.
00:37:11Come here now, please.
00:37:16Okay.
00:37:21Can you hang out, please?
00:37:25Okay.
00:37:27Let's start.
00:37:31Now we need to attach the blood vessels of the new liver to Leo's blood vessels.
00:37:40We just need to put everything back in place slowly and gradually.
00:37:46If you don't get it absolutely right, the flow out of the liver won't be appropriate, and that leads to
00:37:54congestion of the liver, which can be catastrophic in the post-operative period.
00:38:00If you damage the artery in any way, you might jeopardize the new liver going in, because it might jeopardize
00:38:05his blood supply.
00:38:10It's very difficult, isn't it?
00:38:13You can just be careful all the time.
00:38:20Let's have a look now.
00:38:24Okay.
00:38:25Okay.
00:38:28Now the new liver is connected.
00:38:30We need to restore its blood supply as quickly as we can.
00:38:37This is the most critical step in this operation.
00:38:41I'm going to check the portal flow.
00:38:45That's it.
00:38:47Portal vein was starting now, so it should be reperfusion in a couple of minutes.
00:38:58At the point of reperfusion, it's probably the highest risk phase in any liver transplant.
00:39:06We'll just manage it with bolusine, some albumin, but we'll put another one up.
00:39:11The new liver is a foreign protein to Leo's body, and you can sometimes see sort of an extreme reaction
00:39:19when the body rejects that liver.
00:39:21So we're looking there for big changes in blood pressure.
00:39:27At that point, you can see the heart going into funny rhythms, and in extreme circumstances, it can slow down
00:39:33and even stop and have cardiac arrest.
00:39:40Okay, come back to you.
00:39:42So are we ready?
00:39:43Yeah.
00:39:45Now I need to remove the clamps from Leo's blood vessel.
00:39:48This will send his blood into his new liver.
00:39:52Okay, I'm going to take the clamp off now.
00:39:55Okay, come out, come out, come out.
00:40:02Okay.
00:40:04Abangu's punch.
00:40:05The liver is perfused, now stuck on the back of the Hyundai.
00:40:094-0 stretch.
00:40:09Right hand, right hand on the liver.
00:40:12Okay.
00:40:124-0.
00:40:19Leo's blood pressure is dropping dangerously low.
00:40:22So we have to get it back up, or he could suffer fatal organ damage.
00:40:28Oh, my God.
00:40:48Two units should be downstairs, please.
00:41:04Just a mess, isn't it?
00:41:11What are we going to do?
00:41:13I don't need to make progress, yes.
00:41:14Give us a piece of surgery so it cuts into half.
00:41:18There's a vein which is bleeding, and we're just trying to stop it.
00:41:24Nothing subtle has to go yet.
00:41:27Scissors, please.
00:41:37Yes, yes, yes, yes, yes.
00:41:40Got it.
00:41:47Done.
00:41:51Clip, please.
00:41:53Now you'll find that this is stopped.
00:41:55Yeah, pretty much settled.
00:42:00This bit is now stopped because we've stopped the blood coming into the kidney.
00:42:06Yeah, you're perfect.
00:42:08Good, nice.
00:42:12Now I've got the bleeding under control.
00:42:14I can remove Daniel's cancerous kidney and a bit of tumour that's going into his main vein to the heart,
00:42:19the IVC.
00:42:25That's the tumour.
00:42:27Front.
00:42:28I can feel this is hard as wood here.
00:42:32This is what the IVC should normally look like.
00:42:36And what's happened is that the tumours come in here and it's expanded here.
00:42:41So this is all, what, two to three times the width of this.
00:42:45So this is cancers along here and then thrombus here.
00:42:53I've separated the tumour from all the surrounding organs.
00:42:57So everything is ready to go.
00:42:59Then it goes on bypass.
00:43:01So we've still got a long way to go.
00:43:09Now we're going on to the most dangerous part of the operation.
00:43:12The cancer is ready to come out.
00:43:14But before we can remove it, we need to put Daniel on bypass, stop his heart and drain all the
00:43:19blood out of his body.
00:43:20This is going to allow us to operate inside the IVC without blood running through it.
00:43:26That's off.
00:43:27Bridget's clamp.
00:43:29Rat dyes clamp.
00:43:31Mr. Rooney, the cardiac surgeon is going to come in and he's going to put the cannula into the heart.
00:43:38The cannula will allow us to connect Daniel's heart to the bypass machine.
00:43:43So what we're going to do here is divide the sternum, which is the breast bone, the front of the
00:43:49chest,
00:43:51which is going to let us put the patient onto cardiopulmonary bypass.
00:44:12So the next step is going to be that we're going to connect the patient up to the machine.
00:44:16And the machine will take the blood out of the patient, start cooling it down and then returning to the
00:44:22patient.
00:44:22That way the patient's core temperature goes right down to about 18 degrees centigrade.
00:44:28What that does is that it stops the heart.
00:44:32It allows us eventually to take all the blood out and it protects all the important organs from damage.
00:44:40It means that we have a lot more time to open up the IVC and take all the tumour out.
00:44:50OK, so I'm wrapped and apt and ready to go on bypass.
00:44:54OK, going on bypass.
00:44:57And cooling to 18.
00:45:03As we get colder, that will slow down more and this rhythm will slowly start to change more and more
00:45:09and more until the heart just stops.
00:45:13When we reach 18 degrees, what I'll do is I'll switch my pump this side off, will drain within the
00:45:22space of about two minutes and then the patient will have no more blood left inside them.
00:45:28It's risky.
00:45:30The patient is technically medically dead.
00:45:42We've got the body temperature down to 20 or 18 degrees now, so it's cold. The heart would have been
00:45:47stopped.
00:45:48So now we're going to do the cancerability operation where Mr Rooney is going to open up the heart.
00:45:52I'm going to open up the abdominal IVC and take the tumour out altogether.
00:45:58That's the next bit.
00:46:01Lee?
00:46:03Yeah.
00:46:03Will you turn the pump off and drain the patient, please?
00:46:05Yep.
00:46:06OK, so pump is off.
00:46:09Draining the patient.
00:46:13Start the timer as well, please.
00:46:19Time is on.
00:46:21Daniel's been cooled.
00:46:23His blood's been drained.
00:46:24We're good to go.
00:46:30OK, knife, please.
00:46:33OK, this is it.
00:46:34Watch yourself, yeah.
00:46:40While Daniel's on bypass, we need to remove the cancerous kidney and the tumor.
00:46:44The tumor from the IVC.
00:46:46It's now a race against time.
00:46:50This is one of the most critical parts of the surgery.
00:46:53They have a small window in which they can do the surgery, and then we will have to re-establish
00:46:58the patient's circulation again.
00:47:01If we were to keep them switched off for kind of longer than 25 minutes, you would potentially have permanent
00:47:08brain damage and permanent organ damage.
00:47:12That's one of the worst, most disastrous things that can happen and could cost the patient their life.
00:47:47We need to give Leo medication to get his blood pressure back up, otherwise blood won't be getting to his
00:47:52organs and they could fail, which could be life-threatening.
00:47:56Ten mics per mil, a hundred mics per mil.
00:48:07Are we OK?
00:48:08I'll just give the adrenaline a moment to get round.
00:48:12So now I'm looking at the heart rate, looking at the blood pressure, trying to get that optimised.
00:48:20Time will tell.
00:48:34The heart looks good.
00:48:36You seem to be settling down.
00:48:39OK.
00:48:41I've been watching this heart on the screen.
00:48:43It's been pumping away nicely.
00:48:44It seems to be settling now, and I'm able to be coming down on the support.
00:48:48So, yeah, I feel a bit of a sigh of relief, yeah.
00:48:52Yeah.
00:48:52Yeah.
00:49:04So, the blood flow is now established in a normal way now to this liver.
00:49:11So, this liver should ideally start working now.
00:49:16OK, let's have a Doppler now.
00:49:18Out of the sound, please.
00:49:27We are doing an ultrasound of the liver to check the blood flow in the blood vessels.
00:49:37This is the moment of truth.
00:49:40We need to make sure that blood is flowing well inside the liver.
00:49:48If it is not, the liver will fail, and that will be catastrophic failure.
00:49:57The sound you hear is actually the same as the heartbeat.
00:50:12That's the sound we're waiting for, that.
00:50:36So, that liver now has a nice uniform colour, which is what we like.
00:50:41Shows it as well, perfused and happy.
00:50:44We are just going to close up.
00:50:52We expected that this will be a difficult transplant.
00:50:56But it went well.
00:50:58The new liver is looking good, and it's functioning as well.
00:51:04But for the first, I would say, week to ten days, you can have vascular complications, like the bleeding, thrombosis
00:51:13of the blood vessels.
00:51:15Then you can get acute rejection.
00:51:22There's a lot of complications which can happen within the first two weeks.
00:51:28So, he's got a long way to go before we know if this operation has been a success.
00:51:44You can't do this.
00:51:48I'm sorry.
00:51:48You're off to get stickers.
00:51:50There's no one at the desk there yet.
00:51:52Yeah.
00:52:01You're off to get stickers.
00:52:02There's no one at the desk there yet.
00:52:02Yeah.
00:52:07We've got the timer on, haven't we?
00:52:18Let's get in here.
00:52:21That's five minutes.
00:52:24This bit where he's got the heart arrested and the circulation stopped is the most critical part of the operation.
00:52:30He essentially has got no blood flowing.
00:52:35He's clinically dead.
00:52:36It's like a controlled artificial death.
00:52:44I've got about 20 minutes left to remove the whole tumour.
00:52:47I need to detach it from the structures nearby.
00:52:53Let's get to this side.
00:52:59Got it. Easy.
00:53:00Okay. Scissors, please.
00:53:06We want to remove the tumour all in one piece, what's called en bloc.
00:53:12Because if we cut it, then there's a chance that the tumour or pieces of the tumour might go up
00:53:17into the heart.
00:53:19Careful, careful.
00:53:24We need, we need, uh, space here.
00:53:28It's in a very tight corner close to the liver.
00:53:31So it's very difficult to get to.
00:53:35I don't want to go any further up.
00:53:37The angle's wrong.
00:53:38I don't think we're going to be able to get it out in one piece.
00:53:41I think we're just going to have to take it into two pieces.
00:53:44Switch your fingers, mate.
00:53:48This is exactly what I hope to avoid.
00:53:51Taking the tumour in two sections really increases the risk of a piece going into his heart.
00:53:57We're going to have to be really careful now.
00:54:01I think we're asking for trouble.
00:54:02Yeah.
00:54:05Careful, careful.
00:54:09Got it.
00:54:13Okay, here we go.
00:54:16Tumour's coming out.
00:54:24It's bleeding a little, but we'll sort it.
00:54:29Yeah, that's good.
00:54:32I've taken out the main piece of the tumour, but there's still some tumour thrombus left in the IVC, and
00:54:37time's now running out.
00:54:40It has been nine minutes so far.
00:54:48Okay, I need a finger in there.
00:54:52So, yeah, finger, can you do 12 o'clock first, please?
00:54:57At the minute, he is trying to meet Mr. Rooney from the top end.
00:55:02They are trying to pluck out that thrombus from the major vein that have in a caver.
00:55:08It's a bit stuck to the wall, so they are just a bit of struggling to freeze from the wall
00:55:12of the caver.
00:55:13This is stuck like hell.
00:55:16Yes, I've got it.
00:55:17Okay, go this.
00:55:18I think you're above it.
00:55:19Yeah, we go this side.
00:55:22We're almost there.
00:55:25It's like delivering a baby.
00:55:27There you are.
00:55:27The baby's out, almost.
00:55:30Just to see if she can pluck it out that way.
00:55:34Oh, yeah, here we go.
00:55:36Yeah, it's free.
00:55:37The thrombus has just come out now.
00:55:43Okay, I'm going to start closing it, yeah?
00:55:45Yeah.
00:55:52It's quite a big incision that we made through the caver, so we've got a large hole in it.
00:56:00So he's got to stitch that really quick, so we can start pumping the blood back into him.
00:56:07The longer his brain is deprived of oxygen, the higher the risk of having a stroke.
00:56:15We are at 12 minutes.
00:56:18It's bleeding from that area, so we're trying to over-sew it to stop it bleeding.
00:56:27We're stitching quite deep in his body, so it's technically quite challenging.
00:56:33I told you what would help is, can you move this gallbladder, yeah, hold on, that's better.
00:56:43Excellent.
00:56:45Done.
00:56:49You've got the entire tumour out, and we've stitched the hole in the IVC.
00:56:53We're just getting the blood back in now.
00:56:56Okay, going back on.
00:57:03We're at a litre, do you want me to just slowly go up to full flow?
00:57:06Yeah.
00:57:10I'll send that blood back to the patient, and then start the re-warming process.
00:57:15And then once we're back at 36.5 degrees, we'll separate from this machine, and then that will be it.
00:57:22Re-warming!
00:57:29Can we have a look at this video?
00:57:32Tumour, tumour, giving a good tug on it.
00:57:35Finger.
00:57:36Was that my finger?
00:57:38It's my finger.
00:57:39It's your finger on the toe.
00:57:40Your finger on the toe.
00:57:41Excellent.
00:57:42And then that's after.
00:57:45So that's before, that's after.
00:57:47Liver, liver.
00:57:49IVC with tumour thrombus in it.
00:57:50IVC clear.
00:57:51No tumour thrombus in at all now.
00:57:53That is good.
00:57:54Before and after.
00:57:55It's lovely.
00:57:55Well, good pictures there.
00:57:56So, yeah.
00:57:58Okay, I'm going to have a coffee.
00:58:03We've removed the tumour.
00:58:05We've cleared his IVC.
00:58:06So we've stopped him from sudden death.
00:58:09That risk that he always had, the Damocles sword above his head about dropping dead at any time, that's now
00:58:14gone.
00:58:17His prognosis, depending on the histology, might be years, he might be cured.
00:58:23If the cancer's all gone, then those risks are low.
00:58:26But if the cancer does come back, then obviously, you know, we need to manage that.
00:58:30This chap's not out of the woods at the moment.
00:59:02This chap's not out of the woods at the moment.
00:59:06If you need to, okay?
00:59:12Leo is not doing very well.
00:59:15His bile duct, which was joined to his intestine at the time of a transplantation, has kind of fallen apart.
00:59:23And he was leaking bile into his abdominal cavity.
00:59:28Unfortunately, the bile duct has completely gone necrotic into the liver, actually.
00:59:35And there was no room for us to kind of reconstruct this bile duct.
00:59:41So we are at a point where he has to go through another transplantation, unfortunately.
00:59:49But that's the only way to save his life.
00:59:55So something broke on your liver, which made the bile, the nasty stuff, just leaking your stomach, which is why
01:00:01you had really bad pains.
01:00:03That Sunday that daddy was here.
01:00:08And they've had to clean all that out and try and fix it.
01:00:11But the liver has got a bit damaged.
01:00:13So your liver is not looking too good at the moment.
01:00:19Generally, when a liver transplantation fails within the first two to three weeks,
01:00:24the patient can be automatically relisted for an urgent or a priority transplantation.
01:00:32But unfortunately, Leo is out of that window of first three weeks.
01:00:37So he automatically does not qualify for a super urgent transplant.
01:00:41But considering his desperate situation and his age, we have put a kind of a compassionate request that he should
01:00:51be given a priority to save his life.
01:00:55I am really worried.
01:01:00I'm holding it together the best I can.
01:01:04This is the first time I've seen Leo so awake.
01:01:08I've asked him if he knows what's going on and he said no.
01:01:10So I've kind of explained that he needs another transplant because the one he's got isn't working so well for
01:01:15him.
01:01:17He's squeezing my hand at the moment.
01:01:21To me, it seems like it's a lot riskier to have this transplant.
01:01:25So it's a harder transplant to go through and scarier.
01:01:32The fear of losing your child is the worst thing you could ever imagine.
01:01:52When you're ready, just have a stand.
01:01:55If your head feels, then we can go.
01:01:58All right, looking forward.
01:01:59Yeah.
01:02:01OK.
01:02:03Money, that's perfect.
01:02:04Thanks, mate.
01:02:04Just have a sit on that chair there.
01:02:14The surgeons have done their bit, so I've just got to do my bit by getting the recovery going and
01:02:18just keeping moving, you know, resting when you need to and doing all the bits I can do.
01:02:27My wife, she's been holding everything down at home and looking after the girls.
01:02:34I was under a lot of pain-killing drugs and that, and it leaves you very woozy.
01:02:39And she came and I said, come to visit me.
01:02:43And I keep nodding off and falling asleep.
01:02:45And she said, I don't care, you're here.
01:02:50And I'll watch you sleep.
01:02:51And that was it.
01:02:52And it was nice.
01:02:53And it was, and just feel, yeah, I felt like we'd achieved something.
01:02:59I think I've been very fortunate to still be here, really.
01:03:03I am.
01:03:04I did have this chance, you know, and everybody's put a lot of time and effort into giving me this
01:03:10chance, which I will cherish.
01:03:35Were you worried when you found out you needed another one?
01:03:38I don't remember.
01:03:39You don't remember, which is good.
01:03:41I think I'd prefer not to remember that sort of stuff because, like, for me it was quite scary not
01:03:47knowing what was going to happen, knowing that you were really poorly.
01:03:51Because whenever I spoke to them, a lot of the nurses would say you're very poorly.
01:03:56I was more nervous of you having your second transplant than I was with your first.
01:04:01Yeah, that makes sense.
01:04:02Um, purely because I knew how unwell you were, but you had it and you're here.
01:04:10We're making steps closer to getting home.
01:04:17The only thing I could think was I was about to lose my child.
01:04:21I think that was probably the toughest part of the whole journey, not knowing if Leo was going to make
01:04:26it or not.
01:04:28It feels much better, though, to know that, you know, the surgery's gone well, everything's working the way they want
01:04:34it to.
01:04:35And Leo's only really here for rehab.
01:04:44I don't really remember it, but it was kind of scary.
01:04:48And I was just upset that I didn't go how I wanted it to.
01:04:52It sounds kind of dark, but I was really scared that, like, I was going to die.
01:05:00Now that I have the reassurance that I won't, it's like, I, yeah, I just appreciate life a lot more.
01:05:12Even family that I don't talk to that much, they've been sending me cards and gifts, and I didn't realise
01:05:21how much people actually cared about me.
01:05:23So, I think having the transfer made me appreciate it more.
01:05:31Well, I was thinking of maybe going to an art college and going into being a tattoo artist, because I
01:05:39really like art and I really want to do that.
01:05:43I want to make my mum proud.
01:05:48I'm extremely proud. I couldn't be prouder. He's fought so much. Um, I'm, I am very, very proud, and I
01:05:54tell him that every time.
01:06:10You just notice you feel like you don't want to do it anymore.
01:06:14We're trying to just move further into the depths of the tumour.
01:06:17Oh, no, no, no.
01:06:20If it doesn't go right, this could really affect the rest of my life.
01:06:24It's a very complex operation. There's lots of potential for disaster.
01:06:30This is like cutting wires of a bomb that is about to explode.
01:06:38Catch all that new next Wednesday at nine.
01:06:41And if you or someone you know has been affected by anything in tonight's programme,
01:06:45head to channel5.com slash helplines for information and support.
01:06:51New tomorrow at nine, how a canal boat in Cheshire has given a man the space and peace to heal.
01:06:57Join Ben Fogel for new lives in the wild.
01:06:59Next, new Ambulance Code Red.
01:07:01Now that is what you did.
01:07:02You did.
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