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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 the flutter of an eyelash.
00:00:19The beep means don't do that again.
00:00:27It is very personal for me.
00:00:30If you put a hole in here, he'd be at risk of dying on table.
00:00:34This is either life or death.
00:00:45They have a constant, severe, debilitating pain.
00:00:49And that pain drives patients to suicide.
00:00:52It just makes you feel like you don't want to do it anymore.
00:00:59We're trying to just move further and further and further into the depths of the tumour.
00:01:10You feel the worst.
00:01:12You think this is the finish.
00:01:19This is like cutting wires of a bomb that is about to explode.
00:01:27This is really serious.
00:01:30And if it doesn't go right, this could really affect the rest of my life.
00:01:37This is a very complex operation.
00:01:39There's lots of potential for disaster.
00:01:42This doesn't look great at all.
00:01:44There's no connection to the spinal cord.
00:01:46There's no connection between the knots.
00:01:47I'll come back and hear you about him.
00:02:00There's noSI Top Lung.
00:02:01There's no connection between Greensboro and þe,
00:02:01they're going to 35 and 4t están.
00:02:03There's no connection between the nine of them moving forward.
00:02:03Don't look just about it.
00:02:03susr 로스트 rk
00:02:04yn
00:02:04pain from an epidermoid tumour compressing her trigeminal nerve.
00:02:10It's been growing in the brain over many years and her quality of life is so affected by the pain
00:02:16that we hope that we can try and give some relief and get her back to some sort of reasonable
00:02:22quality of life
00:02:22because at the moment she's really disabled by the severity of the pain.
00:02:28So the operation involves us going to an area we very rarely visit in neurosurgery.
00:02:34There's risk of injury to important nerves that move the face, move the eyes, involved in hearing.
00:02:42We need to preserve all of these nerves and relieve the pressure on the nerve that's causing the severe pain
00:02:48for her.
00:02:51About five years ago I started feeling like I had an ache in my jaw, I thought it was coming
00:02:56from a tooth.
00:02:57It'd go away for a couple of months and then it would return and it was worse than the pain
00:03:02from before.
00:03:03You know, I've got this problem that comes and goes.
00:03:06It's hard for people to understand because when they see me now, oh she looks fine, she hasn't got a
00:03:11problem.
00:03:12When I've got an episode and I'm crying and I can't get off the floor and I can't talk or
00:03:17eat, they don't understand that side.
00:03:19I've seen, it's just uncontrollable agony, there's no, it's indescribable.
00:03:26You can't do nothing to help. If I could do something to help, if I could swap your place, I'd
00:03:30do that.
00:03:30It's just nothing. There's nothing that you can do to help. That's the worst part.
00:03:34It is nicknamed a suicide disease, I've seen that. Yeah. I've seen that about it, it's nickname.
00:03:40You don't understand why people can't take it? Because there's only so much pain a person can take.
00:03:48It's going to make me upset.
00:03:58Because it just feels like it's ruining your life. You can't enjoy daily life.
00:04:08It just makes you feel like you don't want to do it anymore.
00:04:22There's only so much you can go through at the end of the day.
00:04:40This is Abigail's MRI scan. So, epidermoids are basically skin cells that become trapped in the brain during the development
00:04:50of the embryo.
00:04:52Over time, these form into a tumour that spreads like tentacles around the brain.
00:04:58This is the epidermoid all the way down here, coming down like this. Here.
00:05:05And this here, where it looks like somebody's punched a hole almost in the lower part of the brain stem.
00:05:14That's actually where the epidermoid is pushing and is leaning right into the brain stem.
00:05:22The epidermoid is also near the trigeminal nerve that supplies sensation to the face.
00:05:29And because the nerve is so irritated, then she's getting this terrible pain.
00:05:34So, the aim of the operation is to try and literally hoover out some of this epidermoid to take the
00:05:41stretch and the pressure off the critical nerves.
00:05:46The difficulty is the location in front of the brain stem is a difficult area to get to and access
00:05:51to this area is one of the problems.
00:05:55There is quite a lot of risk attached to it.
00:05:59If a vessel was damaged or injured during an operation or was bleeding, then that could be catastrophic and that
00:06:06could result in a stroke involving the brain stem.
00:06:10In terms of other complications that can occur after this type of surgery is that the nerve actually is more
00:06:16damaged.
00:06:18They have a constant severe debilitating pain that's even worse than trigeminal neuralgia.
00:06:24And that pain drives patients to suicide.
00:06:28Then we've achieved nothing and done a lot of damage to a young mum with a young family.
00:06:42So today we are operating on Abigail.
00:06:44She's a 28-year-old lady who's got a large right-sided epidermoid.
00:06:49There's potentially a risk for major hemorrhage.
00:06:52We'll cross match if we run into that eventuality.
00:07:01Yeah.
00:07:02Can I go?
00:07:03Yeah.
00:07:03Follow along.
00:07:07This is a good motorcycle.
00:07:10Oh, yeah.
00:07:11That's not good.
00:07:18Yeah.
00:07:19Yeah.
00:07:19Yeah.
00:07:19Yeah.
00:07:20Yeah.
00:07:20Yeah.
00:07:21Yeah.
00:07:24Yeah.
00:07:27Yeah.
00:07:27Ten hours, 12 hours, 24 hours.
00:07:29We don't know how long it's going to be.
00:07:31Operating on her brain.
00:07:32One tiny slip and it's game over.
00:07:36The main thing is, she comes out of it better than she went in.
00:07:40I think Gabby would take a lot of the risks going deaf, partially sighted.
00:07:44I think she would take any of that over what she's got at the moment.
00:07:51I'm scared of this operation, you know, I don't want to do it,
00:07:54but I feel like I've got to do it.
00:07:55It's my only option to try and get better.
00:08:02Just to warn you, that lovely hair of yours,
00:08:04you won't be impressed by the haircut.
00:08:05No, it's fine.
00:08:06Although, you know, some people...
00:08:07I'm going to show you off and embrace it, so...
00:08:10Yeah, no, no, exactly.
00:08:12And then I think we've spoken through the rest of it,
00:08:14but you'll be fast asleep.
00:08:16OK.
00:08:16They'll take you through the checks and I'll catch up with you later.
00:08:19See you later.
00:08:28So we've got a long day ahead of us and it's a complicated operation.
00:08:43The main risk from my point of view is the operation doesn't actually help her pain.
00:08:48And so a patient goes through all the risk of having an operation
00:08:52and then they have new problems that they did not have before the surgery
00:08:57and worse still, on top of that, they still have intolerable facial pain.
00:09:22So, on the word move...
00:09:24One, two, three, move.
00:09:26Thanks.
00:09:36Clip all the hair all the way back that way.
00:09:41It's a highly complex operation that requires two surgeons.
00:09:44Before I can remove the epidermoid, my colleague, Mr Irving, will drill a pathway through Abigail's skull,
00:09:49so I can reach the brain.
00:09:53We'll be doing most of the access to the bone of the base of the skull.
00:09:57She has normal hearing.
00:09:59We'd like that to be the case at the end of the operation.
00:10:03So we will be very carefully working around the structures of the inner ear without damaging it.
00:10:12We'll need neuro-monitoring.
00:10:14So can we monitor three to twelve?
00:10:17We've set up monitoring for all her nerves,
00:10:20the nerves that are at risk from the surgery,
00:10:23and that's needles that are inserted in the muscles of the face.
00:10:30If we are operating and the result of that action causes stimulation to a nerve,
00:10:39that will be recorded.
00:10:40It's our warning system.
00:10:42And it will tell us if we're working too close to the nerve
00:10:44and could end up damaging it.
00:10:46It's on there now.
00:10:57So, we're ready to start.
00:10:59Okay.
00:11:00Happy days.
00:11:10Okay.
00:11:11And the Colorado needle, thanks.
00:11:13So, having gone through the skin,
00:11:15I then use a diathermy to cut through the soft tissues and the muscle,
00:11:21going straight down onto the bone.
00:11:26So, I'm going to lift up the soft tissues to expose her ear canal.
00:11:36That's the ear canal.
00:11:43The craniotomy will be here, basically.
00:11:45Yep.
00:11:48So, we've identified the ear canal, which is the key landmark,
00:11:52and we're going to do the craniotomy into the skull.
00:12:00I'm ready for the craniotomy whenever.
00:12:01Yeah.
00:12:05We're going to take a disc of bone off using a special type of drill.
00:12:11That's a disc that we can then put back at the end of the operation.
00:12:15Get me a large red swab, please.
00:12:19So, that's come off really beautifully, actually.
00:12:25Bring the microscope in here.
00:12:30Okay, let's try that.
00:12:34We need the microscope now to give me magnification when I'm working around the inner ear.
00:12:42Drill, please.
00:12:46Now, I need to drill a pathway through another part of Abigail's skull to reach her brain.
00:12:53The aim is to take as much bone as we can around the inner ear,
00:12:57which is where the facial nerve is and the hearing and balance nerves are.
00:13:05We're a millimeter or two from those structures.
00:13:08If we damage those, Abigail could suffer permanent damage to her hearing and her balance.
00:13:14So, this morning, we have Kelly, who's a 50-year-old policewoman, and she had a devastating motorcycle injury in
00:13:35Italy.
00:13:36She suffered what we call a brachial plexus injury, where the nerves coming out of your spinal cord that operate
00:13:42everything in your arm have been significantly damaged.
00:13:45Today, we're going to try and restore function to it the best we can.
00:13:49It's a very complex operation.
00:13:52The nerves that we're exploring is in a nerve and neck full of complex, important structures.
00:13:58There's lots of potential for disaster.
00:14:02But if we don't operate, she may never be able to use her arm again.
00:14:12So, this happened about six weeks ago.
00:14:15This trip was a trip to Austria.
00:14:19I have hit another motorcyclist coming the opposite way, left side to left side.
00:14:26The first person from our group to come around the bend saw bits of motorbike flying through the air, and
00:14:36they knew it was me.
00:14:40This is after the crash.
00:14:42At the moment, I have no use of my arm and my hand.
00:14:46Because it's, you know, quite heavy as a dead weight, I can't even lift my own arm up.
00:14:53I can't shower myself.
00:14:55I can't even get dressed myself.
00:14:59It's just those little things that you take for granted all the time.
00:15:04So, it really has affected my life.
00:15:07I've been a police officer in West Mercia Police for 28 years.
00:15:12I am currently a detective chief inspector.
00:15:15I am responsible for a team, and suddenly I'm not there.
00:15:20And, you know, the team are having to cope.
00:15:24In my career, I've become experts in certain, you know, kind of things.
00:15:28But overall, managing crimes against vulnerable people, I'm now the vulnerable one.
00:15:37You know, when I'm having a moment, I just say, oh, for God's sake, let's just cut the thing off.
00:15:42Let's just cut it off and be done with it, because it doesn't work.
00:15:45It's, you know, I'm carrying it around. It's a dead weight.
00:15:48But obviously, I don't want that. I want to be able to use it.
00:15:51I want what I was doing back. I want to go back to work.
00:16:05So, what we're looking at here is an MRI scan of Kali from the front.
00:16:10There is a huge zone of injury on the left side compared to the right side.
00:16:14And if you look at her left shoulder, where the injury is centered onto,
00:16:18you can see a lot more thickened and lighter colored nerves here, which are the brachial plexus.
00:16:25So, the brachial plexus are these five nerves that come out of your spinal cord and go into your arm.
00:16:32And they control all the movements and sensation or feeling in the arm.
00:16:38I won't know the full extent of Kali's injury until I open her up.
00:16:43If we get in there and the roots are snapped very, very close to each other,
00:16:48and we can actually clean up the roots and repair them, that would be the best outcome for Kali.
00:16:55But if we find that the nerves have been pulled out of the spinal cord,
00:16:58so if, in essence, the body has been disconnected from the arm,
00:17:03and there's nothing that we can do to reconnect the arm to the body.
00:17:07To fix that, we'd have to do a second operation that's much more complex,
00:17:11and there's no guarantee it would even work.
00:17:21Kali, hi. How are you? Good. How are you? Good.
00:17:24So, what we'll do is we'll go through a few things, and I need to re-examine you again.
00:17:28I'm just going to ask you to try and bring your arm out like this.
00:17:32I can't do that. Okay, just try.
00:17:36That's not working. Try again.
00:17:40So, what I want you to do is just push down against my hand there.
00:17:48And now.
00:17:50Okay. So, you have five roots coming out of your neck, going into your arm.
00:17:54Yeah.
00:17:55Now, the top three for yours aren't working, basically.
00:17:59The bottom two are working to a degree.
00:18:02It's a bit of a spaghetti junction in there.
00:18:04It's all going to be a bit scarred from the injury as well.
00:18:08So, we will be in your neck, and you've got the carotid artery and the jugular vein there.
00:18:13Now, if there is injury to these vessels, there's always, you know, a theoretical risk that there's some catastrophic bleeding,
00:18:21which might cause you to have a stroke or even die.
00:18:28Okay.
00:18:29Yeah.
00:18:30There's a lot of other clockwork around the area.
00:18:32Yeah.
00:18:32Other nerves and things like that. So, there's always a risk of damage to them as well.
00:18:36Okay?
00:18:37All right. I'll see you soon.
00:18:47I was hoping to progress my career to the next level, and that might be prevented because of this.
00:18:57If it doesn't go right, this could really affect the rest of my life.
00:19:16One, two, three, four, five.
00:19:22One, two, three, four, nine, one, two, three, four, nine, one.
00:19:29So, we'll make an incision today on the neck.
00:19:34There will be a bit of dissection and a bit of exploring to get down to the actual brachial plexus,
00:19:40which is the spaghetti junction of nerves.
00:19:43We're going to lift her up and do it all in one.
00:19:46Yeah.
00:19:46Slowly move her down.
00:19:52Blade, please.
00:19:54Okay to start.
00:19:56We're going in through the left side of Kali's neck to get to the brachial plexus,
00:20:00where the nerves controlling her arm connect to the spinal cord.
00:20:06So, after we go through the skin, we have a layer of muscle going up the neck as well,
00:20:14so we're in the best position to see what we need to see.
00:20:20We're going into a minefield, and you have to tread very, very carefully,
00:20:25because a millimetre left, a millimetre to the right,
00:20:28you might get into a major vessel or a major problem with another nerve.
00:20:33I'm just going to divide this muscle.
00:20:35So this is the brachial plexus.
00:20:39Because everything is quite scarred, you're just clearing the tissue,
00:20:42so that we can see a bit clearer.
00:20:45I'm looking for the three nerves I know are damaged.
00:20:48The first one I need to locate is connected to a spinal cord at the C5 level.
00:20:53It might be damaged here, look.
00:20:55And that's C5.
00:20:57It has to be C5.
00:20:59This is the main nerve root that operates a lot of the muscles around the shoulder.
00:21:04Rupture.
00:21:06Yeah, so we can see a stump of the C5 nerve root.
00:21:12Very little, isn't it?
00:21:14It's damaged there.
00:21:16Yeah.
00:21:17So this is the other end of it.
00:21:19It's been pulled up and just snapped.
00:21:22Oh, bad injury.
00:21:26So we know C5 has ripped out.
00:21:28Now we need to keep going to see the extent of damage to the other tuners.
00:21:33We are operating in the neck.
00:21:36The carotid and the jugular are right in that area where we are operating,
00:21:40so there's always a risk.
00:21:42Bleeding is the main one.
00:21:47What we need to do now is look at C6 and C7, which seem to be missing.
00:21:57It's quite difficult to find nerves coming out from the spinal cord.
00:22:06This looks like rootlets.
00:22:08Yeah.
00:22:10So that's going to be C6.
00:22:15So the C6 nerve root is the second root out of the five that come out from the spinal cord.
00:22:21And what the C6 does is it operates your biceps.
00:22:25The C6 root has been completely pulled out of the spinal cord.
00:22:32I wonder what that is actually.
00:22:35C7.
00:22:37We just found another root, which is C7.
00:22:44It doesn't have any tension in it.
00:22:47C7 doesn't look great at all.
00:22:49There's no connection to the spinal cord.
00:22:53So these have been completely disconnected from the spinal cord.
00:22:56Hence, she's not going to recover down these.
00:22:59We can't repair them.
00:23:01We can't reattach a nerve to the spinal cord.
00:23:03The damage is far worse than we thought.
00:23:07So what we have to do is basically find healthy nerves and rewire them.
00:23:13That means a whole new operation, far more serious, far more complex,
00:23:17and there's no guarantee it will work.
00:23:21This is a devastating injury, and it's a very high chance that Kali won't be able to do her job
00:23:28again.
00:23:33Sorry, what was his name again?
00:23:36Okay.
00:23:37Let me find out.
00:23:56It's very close.
00:23:58I'm going to have to get as low as we possibly can down here.
00:24:02But I'm at skull base there.
00:24:05Yeah.
00:24:13Okay.
00:24:16So we've drilled to the limit that we can.
00:24:20Effectively, what's left behind are just the vital inner ear structures.
00:24:25So Mr. K is going to have to work around those structures.
00:24:28He'll be going into territory where he has to deal with the brainstem, the cerebellum, and all the cranial nerves,
00:24:37plus a major blood supply to those structures.
00:24:42So level of risk goes up.
00:24:47Can you just come around this way a bit?
00:24:49Mind yourself.
00:24:56Another medium patchy to begin with.
00:24:59Mr. Irving has tunneled through her skull, giving me access to the brain.
00:25:03Now I need to create a pathway between two parts of Abigail's brain to reach the epidermoid at its centre.
00:25:12So it's like coming in from the attic and we're going into the cellar to try and hoover out the
00:25:17epidermoid.
00:25:22Very crowded space, a lot going on, a lot of very important blood vessels that are very unforgiving if they
00:25:27are a problem.
00:25:28The main danger of a catastrophic outcome is in relation to these vessels.
00:25:34Another little clip now.
00:25:43It's a bit tough, isn't it?
00:25:47Can you go in that, please?
00:25:54Very gently, make sure we don't catch.
00:25:58So are we seeing it? Yeah.
00:26:02OK.
00:26:05So we've got the first glimpse of the tumour.
00:26:09Pearly white structure.
00:26:11And we're just trying to improve the exposure a bit.
00:26:19So we're just going to start to try and take some of those white flakes away.
00:26:23We haven't really seen any nerves clearly yet.
00:26:26So we're going to have to tread cautiously.
00:26:30My colleague Sakaba and I need to carefully suck out as much of the tumour as we can, piece by
00:26:34piece.
00:26:35But the tumour's wrapped around the brainstem.
00:26:38And if we damage that, it will be catastrophic.
00:26:44We're trying to just move further and further and further into the depths of the tumour.
00:26:48Above the brainstem, yeah, just gradually sucking around, creating space for yourself.
00:26:53So just get all the low-hanging fruit, basically.
00:26:57That's it.
00:26:59The more tumour we remove, the closer we get to Abigail's trigeminal nerve.
00:27:05We're in dangerous territories, so must be extremely careful.
00:27:11Easy, careful, because it could be nerves that have gotten more.
00:27:13Don't do something you just end up regretting and she lives with the rest of her life.
00:27:19There's some bits that are a bit firmer than others.
00:27:21There's some bits that are a bit more stuck to, you know, membranes and layers and things like that.
00:27:28Microsystems.
00:27:29Microsystems.
00:27:38Microsystems.
00:27:43A blood vessel is bleeding close to the brainstem.
00:27:46Bipolitic.
00:27:47Very good, good bipolitic.
00:27:50Sucker, please, left hand.
00:27:51Put it clean.
00:27:54If we can't stop this, it will lead to a catastrophic stroke.
00:28:04Good morning, theatre reception. That may help you.
00:28:10So today we are operating on 81-year-old Brian, who's got stage 3 kidney cancer
00:28:15that has spread to the lymph nodes around the kidney.
00:28:19We're doing a robotic radical nephrectomy to remove the tumour and remove the lymph nodes.
00:28:27The robot allows us to do this big operation, but to do it with keyholes and small incisions.
00:28:34It's got the manoeuvres to go around the bends and do complex stuff that you can't really do with conventional
00:28:43laparoscopic surgery.
00:28:45This is quite a risky operation, but if we don't do it, the cancer will progress, probably spread, and eventually
00:28:54affect his life and kill him within a year or two.
00:29:08So, on this scan, you can see both of Brian's kidneys.
00:29:11This is the left kidney, which looks healthy and normal.
00:29:14And on the right side here, there is a rounded tumour sitting there, probably the size of a big apple
00:29:21occupying half of his kidney.
00:29:23And if we look further up, there is a round shadow here, which is the lymph node.
00:29:30Brian's only chance to get rid of this disease or cancer is to remove the entire right kidney, but also
00:29:39remove the lymph node that is involved with the cancer.
00:29:42On this occasion, we're going to use a robot that will help us to do this with keyhole surgery.
00:29:49With the advantage of doing it with a keyhole, Brian is not the youngest of patients, and a bigger operation
00:29:55can have a big impact on his physiology, on his post-operative recovery.
00:30:03The tricky part is the location of that lymph node, which is sitting in a very awkward position behind a
00:30:11major vein in the body called the vina cava,
00:30:13which needs a really delicate dissection to make sure we don't cause bleeding, which can be catastrophic.
00:30:21And we may have to do an emergency conversion.
00:30:25That will mean that we will have to open him up, try to control the bleeding.
00:30:29We'll have to do it within seconds to stop any bleeding and save his life, if it was to happen.
00:30:38And how are you feeling about today?
00:30:41Blood pressure might be up a bit, but not too bad.
00:30:44I'll check that for you in a moment, if that's all right.
00:30:47Yes.
00:30:50I had a hernia, and they did a scan.
00:30:54I said, we're very sorry that you've got a tumour on your kidney, and it'll have to come out.
00:31:04It's happened about two months ago, so it's moved pretty quickly.
00:31:12You fear the worst.
00:31:14You think this is the finish.
00:31:17And cancer is an horrible word for anybody.
00:31:19But I've got to be positive and look for the future.
00:31:31You all right?
00:31:32Yeah.
00:31:33Got your gown on?
00:31:33Yeah.
00:31:34Have a love anyway.
00:31:36I love you.
00:31:36I love you.
00:31:43Here you are.
00:31:44Dad.
00:31:45Here you are.
00:31:46I think you'll be all right.
00:31:47I love you.
00:31:48It's OK.
00:31:48And you.
00:31:49Look after you, Mummy.
00:31:50I will.
00:31:51See you in a bit.
00:31:51Bye.
00:31:53Everybody's brokenhearted.
00:31:55They're just devastated.
00:31:5848 years ago, we got married.
00:32:02It's just my world, really.
00:32:05Yeah.
00:32:05Come on.
00:32:08He's my hero.
00:32:09He is.
00:32:11I don't know what I'd do without him.
00:32:14He's got faith in the hospital, and the doctors, and the surgeon, and that's all.
00:32:18Yeah, hopefully everything's going to go well.
00:32:20So, when was the last time you had any help?
00:32:24That's the most of it.
00:32:25Thanks, God.
00:32:29I have to get through this operation because I've got so much love for my wife.
00:32:34She's a world to me.
00:32:36My world, I really, really adore her.
00:32:41We're a very, very close family, and I live for the family.
00:32:46OK.
00:32:47You all right?
00:32:48Yeah.
00:32:49You're doing good.
00:32:59Well, there's a lot of things going in my head.
00:33:03First, can we get in safely without damaging any bowel?
00:33:11Second is how accessible that lymph node will be.
00:33:14Will we be able to see it?
00:33:16Will we be able to move the cave away from it safely without causing major bleeding?
00:33:22If you're not very careful, the bleeding could be so severe.
00:33:26If we can't control it, there is a risk of him dying on the table.
00:33:33OK, let's do the checks.
00:33:37Any potential significant blood loss?
00:33:39Yes, potentially we could have a big bleed.
00:33:41We've got cross-match four units.
00:33:43Duration?
00:33:44Three hours.
00:33:50Have a knife, please.
00:33:53OK.
00:33:54Knife to skin, guys.
00:33:56So we're going through the muscle layer now.
00:34:02I need to create incisions in Brian's stomach and fit several ports in.
00:34:06These will allow me to insert the instruments into his abdomen.
00:34:10I'll then use the robot to control these instruments and remove the tumour.
00:34:15Can I have the port, please?
00:34:20We'll put the camera in and have a look.
00:34:25So let's see if we've got enough space.
00:34:34Yeah, it's fine. We're good, we're good, we're good.
00:34:41So now we're going to connect the robot to the ports.
00:34:45Point the scope at the target anatomy.
00:34:47Then press and hold the targeting button.
00:34:52Targeting complete.
00:34:53So these are my surgical instruments.
00:34:56Some of them are graspers, some of them are scissors.
00:34:58And some of them are connected to a heat where it can cause cauterization
00:35:02and you can seal tissue inside.
00:35:07So now I'm done on the bedside.
00:35:09I'm just going to move to this console where I'm going to start to control these instruments now.
00:35:19Somebody has checked the blood, the blood bank.
00:35:21Yeah.
00:35:23Yeah.
00:35:26Now I need to work my way past Brian's liver to access the kidney tumour and remove it.
00:35:32It's crucial I don't damage the liver.
00:35:34That could cause major bleeding.
00:35:37So my colleague on the bedside can now get an instrument to come in.
00:35:43As you can see on the right hand of the screen.
00:35:46And then he will retract that liver out of my way.
00:35:49Yeah.
00:35:50If you grab a bit, yeah.
00:35:53That's good.
00:35:55There we go.
00:36:00This is the tumour there.
00:36:03You can see it now.
00:36:09I need to carefully separate the cancerous kidney from its blood supply before I can remove it.
00:36:14This is out and I have a robotic tumour, please.
00:36:18First, I need to clip the artery to stop the blood flow before I cut it.
00:36:25So I'll just clip.
00:36:38Beautiful.
00:36:40Good.
00:36:42Excellent.
00:36:45I've disconnected the blood flow going into the kidney.
00:36:47Now I need to disconnect the blood flow going out, which is the renal vein.
00:36:51But it's in a very dangerous position.
00:36:57Now I've just managed to see the big renal vein.
00:37:00Coming to there is the inferior vena cava.
00:37:06I'm going to cut the vein very close to the inferior vena cava.
00:37:09If that fails for any reason, we will suddenly see nothing apart from blood filling up all his belly.
00:37:18So this needs to be done without any tearing of the vena cava, otherwise we will have a blood bath.
00:37:29Staplers coming in.
00:37:31Yeah.
00:37:33Okay, you've got control.
00:37:37This is like cutting wires of a bomb that is about to explode.
00:37:43So trying to defuse it.
00:37:46This is where it can all go wrong.
00:37:59Is somebody keeping on us like that?
00:38:06There's love around the brain still.
00:38:15It's very difficult to sort of control it.
00:38:17Um, and it's just, the angle's a bit difficult.
00:38:22We need to act quickly to stop the bleed.
00:38:25Mark the patty clip.
00:38:27Mark the patty clip.
00:38:37There's a little hole here.
00:38:40We'll coagulate that.
00:38:43I'm using a coagulant applied directly onto the bleed.
00:38:51Can you pat it quickly?
00:39:00Yeah, that's good.
00:39:03Lovely jubbly.
00:39:06Now that we've stopped the bleed, we can continue on towards the triageminal nerve and clear the epidermoid off it.
00:39:15We're working down a tiny little corridor and then we want to create a bit more room so that we
00:39:20can then navigate the nerves and the vessels and try and find the trigeminal nerve that's causing all the grief.
00:39:35Shall I hold it here and see, are we seeing it?
00:39:39Yeah.
00:39:41Can you see it okay?
00:39:42Yeah.
00:39:44So we've got the epidermoid that's on the trigeminal nerve there which is causing all the pain.
00:39:49There's a layer on the outside of the nerve and that's quite stuck to the epidermoid because they've been together
00:39:54so long.
00:39:56We're just trying to peel it off.
00:40:00This is the crucial moment of the operation.
00:40:03We're peeling the tumour off the nerve to stop her pain.
00:40:05But if we damage the nerve, she could have permanent pain for the rest of her life.
00:40:19I've got it off the lateral part of the trigeminal nerve fine.
00:40:24We just now need to clear it from the southernmost area where it sits.
00:40:32I'm close to the brain stem, so I'm going slowly, freeing it up bit by bit.
00:40:44There's quite a few little vessels around the place.
00:40:49You should have the lower cranial nerves coming into view and you really don't want to damage those.
00:40:56We've just got to work around here and then release things up here.
00:41:07That's fine, thank you.
00:41:09Okay.
00:41:12We're at the final stages of the operation now.
00:41:14The key thing is that we've been able to clear the tumour off the trigeminal nerve as far as we
00:41:19can see.
00:41:20That was our principal aim in the operation was to free that up and I think we're going to be
00:41:23able to do that.
00:41:25Jonathan and Alex are teasing the last little fragments out from the bottom.
00:41:32Now we need to use the monitoring to check the nerves.
00:41:36Let's see, stimulating there.
00:41:38Sorry?
00:41:40Stimulating there, let's see.
00:41:42Say that again.
00:41:52We have seen a reduction in the hearing signal.
00:41:57A strong indication that the cochlear nerve has had some stretching or manipulation that will result in hearing loss.
00:42:07Nothing at 0.2.
00:42:09Now lowers.
00:42:30Nothing at 0.2.
00:42:33So we're going to see Kelly.
00:42:35I'm just going to tell her what we found during the operation.
00:42:40The damage was far worse than we thought.
00:42:41Three of the main nerves going to her arm have been ripped out or pulled out of the spinal cord
00:42:45or torn.
00:42:46And she has lost function to her arm.
00:42:49Today what we aspire to do is use healthy nerves that are working and rewire them so that she can
00:42:54regain this function.
00:42:58Hello.
00:43:00Hello.
00:43:01Hello, good morning.
00:43:02Hi.
00:43:02Hi, Kelly.
00:43:03Hi.
00:43:03How are you doing?
00:43:04I'm okay.
00:43:05Good, good.
00:43:06So, essentially, five nerve roots that come out of your neck.
00:43:10The second and third completely pulled out of the spinal cord.
00:43:13Okay.
00:43:14And the first one was snapped, was ruptured.
00:43:17Right, okay.
00:43:18So what we need to do now is we need to reconstruct the functions of those first three nerve roots.
00:43:24We'd have to go into your ribs, basically, to take your intercostal nerves.
00:43:30Okay.
00:43:30So those are nerves that travel between your ribcage.
00:43:33We take those out, bring them out here, reroute them into the arm, into the nerve that we need to
00:43:40reconstruct.
00:43:40Wow.
00:43:42So we'll need two or three of those.
00:43:44It's going to take all day.
00:43:45Lots of microsurgery, lots of work under the microscope and things like that.
00:43:50Once you're all rewired, it'll take a while for everything to recover.
00:43:55Sure.
00:43:55So just be aware of that.
00:44:04There's no guarantees that this will work.
00:44:07We know that from the previous nerve transfers that we've done, there are good outcomes from them.
00:44:12But there's no guarantee with anything.
00:44:15And if it doesn't work, Callie's quality of life will be significantly affected.
00:44:22Yeah, that's good.
00:44:23That's fine.
00:44:23Yeah, that's good.
00:44:24Can you bring the height of the bed up?
00:44:25Yeah.
00:44:27I've come to realise just how bad it is.
00:44:31It doesn't look bad on the outside, you know, but the damage internally is pretty significant.
00:44:40Yeah, that's come home.
00:44:45Is that painful?
00:44:46Do you want to sit up?
00:44:47No, no, no.
00:44:48It's fine.
00:44:49I'm just getting one of them.
00:44:51And the fact that there's no guarantees that they can fix it.
00:44:59Yeah, let's come home.
00:45:09Go and live life, you know.
00:45:11That's the whole point of this, isn't it?
00:45:14Is to try and get back to some semblance of normal so I can go and live life.
00:45:25And do the things that I've always wanted to do.
00:45:29I don't want them taken away from me.
00:45:46Ready, steady.
00:45:48Wrong.
00:45:50So there are quite significant risks in this operation.
00:45:53You'd have to go in between her ribs, right on top of her lung to get the nerves there.
00:45:58There's a risk of causing what we call a pneumothorax, which is air in the lung, or a hemothorax, which
00:46:04is blood in the lung.
00:46:07To restore Kali's arm function, my colleague Leela Saeed and I need to find healthy nerves to connect to the
00:46:13damaged nerves.
00:46:14So I'm just marking some landmarks out.
00:46:19So we're going to take this nerve, rewire it to this nerve, basically.
00:46:29Starting.
00:46:38So what we need to do now is get through the muscle that will find the nerve that we need.
00:46:44We've got the nerve stimulator there.
00:46:50So we'll now go and see if we can find the nerve.
00:46:54And we should see a jump once we get close to the nerve.
00:46:58There we go.
00:47:00So we know it's going to be in this vicinity here, because we can see the shoulder twitching.
00:47:04Okay.
00:47:06So the yellow slip's going around the shrugging nerve.
00:47:10And now we've found that.
00:47:12The next step is now to find the nerve that we're going to reconstruct.
00:47:17It's quite difficult to find this nerve.
00:47:19There's a lot of feel involved in this.
00:47:21There's a ligament, and the nerve travels under this ligament.
00:47:30So we found the nerve.
00:47:36We're going to stimulate this.
00:47:38So that's not working.
00:47:39And if we stimulate our donor nerve, yeah, nice good function there.
00:47:45So we're going to cut the nerve now.
00:47:48So we're going to put this nerve onto our donor nerve, basically.
00:47:53Cutting the nerve.
00:47:54Okay.
00:47:57Happy?
00:47:57Need the microscopes?
00:47:59So Lila's just going to put the two nerve ends together.
00:48:04We just need a couple of stitches just to hold it together.
00:48:08The stitches are very, very fine.
00:48:11They're thinner than someone's hair.
00:48:14And then we use some glue to basically keep everything intact.
00:48:21We're done with the first nerve transfer.
00:48:23Now we're going to close the back up, turn around, and move on to the front.
00:48:28For the next stage of the operation, we must turn Kali over and go in through her armpit.
00:48:34It's very risky.
00:48:35We'll be operating right next to the arm's blood supply.
00:48:43Our plan is to get into the nerves underneath here.
00:48:50What we're now putting a sloop around is the main artery supply to the arm.
00:48:56So this is, you can feel a pulsing there.
00:48:57So the danger of damaging this is she loses the blood supply to her whole arm.
00:49:04So we need to get to the ribs.
00:49:07So this white bit you see here is Kali's rib.
00:49:13Now we need to get underneath the rib and behind the rib, essentially,
00:49:16to get to the intercostal nerve that we're going to use to re-innovate the triceps.
00:49:21That will make Kali be able to straighten her elbow.
00:49:26So this is probably the most tricky part of the operation in terms of trying to harvest these nerves.
00:49:33You've got the arteries, the nerve, all underneath the ribs, which means we're right on the lung.
00:49:38If you make a hole in the lung and you've injured those arteries, you can cause blood to enter the
00:49:42lung.
00:49:44If blood enters the lung, Kali could suffer catastrophic respiratory failure.
00:49:50That's the nerve, the intercostal nerve, and that's the lung.
00:49:55It's going under a big vein.
00:49:58Right on the edge.
00:50:02It's trying to reduce the tension on the repair by, you know, getting it from point A to point B
00:50:07in the least distance.
00:50:11All right, we'll need the microscope in.
00:50:17This is the last thing we're doing now.
00:50:19We're joining two intercostal nerves to the triceps nerve, which is the nerve that operates your triceps.
00:50:25That will make Kali be able to straighten her elbow.
00:50:30So what we have now, we've cut one nerve which is functioning.
00:50:34So that's a live wire.
00:50:36And we've connected it to a nerve that's not functioning, so that's the other wire.
00:50:44There we go.
00:50:51We've finished the operation now and we've managed to do all of the nerve transfers that we set out to
00:50:56do in the first place.
00:50:57We managed to do that without causing any major bleeding.
00:51:02We can't test it at this stage because the nerve cells need to grow down the new nerve and form
00:51:07new connections, which will take a few months, basically.
00:51:12So we're just going to close the skin.
00:51:18You will have quite a few scars and quite long, significant scars as well.
00:51:33Having a brachial plexus injury like this is devastating.
00:51:36And, you know, getting her back to about 50-60% of her function is actually a very good outcome.
00:51:46We just have to sit and wait now for the nerve cells to grow down these new nerve transfers.
00:51:51But because they're nerve transfers, the distances are quite small that they need to grow back.
00:51:55So hopefully we'll start to see something in about, you know, three months or so.
00:52:04It's not guaranteed at all that we'll be able to fix this problem, so we're trying to do the best
00:52:09that we can for her.
00:52:20When the patient's ready.
00:52:22Oh, right.
00:52:22Okay, yeah.
00:52:23Transfer the patient in and they'll call you when they're ready.
00:52:26Okay, that's okay then.
00:52:31You want me to do anything with a sucker?
00:52:33No, thank you.
00:52:41This is really like walking on egg shells.
00:52:51Any wrong move, we can end up with a hole and the tiniest hole in this vena cava will cause
00:52:58a massive bleed.
00:52:59We can suddenly have a whole abdomen full of blood in no time.
00:53:04He could lose all his circulating blood in seconds.
00:53:11Slowly, delicately.
00:53:20Phew.
00:53:22Now the kidney's disconnected from both the artery and the vein.
00:53:27Okay, everything is so far under control.
00:53:31Stapler out, please.
00:53:36Now the kidney with the tumour in it is completely detached from its blood supply.
00:53:41I can remove it.
00:53:42But it's crucial that I take the lymph node out as well.
00:53:46Otherwise, we could be leaving cancer behind and that could be fatal for Brian.
00:53:51Down here, this is where the lymph node is.
00:53:56I'm trying to dig it out now and take it out with the kidney.
00:54:00Going into a dangerous territory now.
00:54:07This is where the veins can become a nightmare and can grow in the whole thing if it bleeds.
00:54:13It's quite stressful to work around this.
00:54:18We don't want that last part of the operation to be a blood bath.
00:54:33I've just managed to remove the lymph node and it's now hot up here with the kidney.
00:54:42This is the tumour there, you can see it now.
00:54:46Take the instruments out now.
00:54:52We're now done with the robot.
00:54:54We will carry on the operation manually using the ports and tools to get the kidney out of Brian's stomach.
00:55:00But it won't be easy because it's so large.
00:55:08Can I have the bag piece?
00:55:13This is the bag that we're going to use to extract.
00:55:15So it goes inside like this.
00:55:20So now I'm going to deploy and open the bag.
00:55:24It's opening now.
00:55:28It's vital we take out the kidney tumour in one piece along with the cancerous lymph node.
00:55:32So I'm using this bag to collect everything together.
00:55:41We don't want the tumour or the cancer to touch the skin.
00:55:45Otherwise it will spread.
00:55:48Okay.
00:55:50Gas off.
00:55:56Another empty stretch to take down.
00:56:02Now we'll make one of the keyholes in Brian's stomach bigger and pull the bag out through it.
00:56:08You can actually see the bulge of the kidney there in the bag.
00:56:15So now you want to take the shots.
00:56:33This is like delivering a baby.
00:56:39Yeah.
00:56:40That's not small.
00:56:42Okay.
00:56:43Fine.
00:56:44Here's your specimen.
00:56:47All right.
00:56:49So now I'm done.
00:57:05So this is the tumour there.
00:57:08All of this here is a tumour.
00:57:12And this is the lymph node in question that we managed to take out.
00:57:21People can live with one kidney without major problems.
00:57:24And I hope that would be the case for them.
00:57:27His other kidney looks fine on the scans.
00:57:30So I'm not anticipating major problems with living with one kidney.
00:57:36Brian will go to recovery now.
00:57:38The operation has gone well, but you never know what kind of complications could happen.
00:57:42Time will tell.
00:57:47C19.
00:57:48C19.
00:57:49I'll take those.
00:57:56Simulating.
00:58:02Dropping slowly.
00:58:08These were the bass lines.
00:58:10Yeah.
00:58:11It was sort of okay.
00:58:15Okay.
00:58:16And then there we got a 50% reduction here.
00:58:21The reduction in signal that we've seen was enough to make us concerned.
00:58:26There will be some impact in terms of hearing loss.
00:58:29But the time will tell.
00:58:3270%.
00:58:34And then we're going to start thinking about trying to put it all back together again now.
00:58:43So where we've removed bone, the lower part where we've drilled out, if we didn't put something here, it would
00:58:50leave a dead space.
00:58:53Earlier in the operation, we harvested some fat from Abigail's belly.
00:58:57Now we're going to use that to fill the dead space.
00:59:00And leave it at the front where the soft tissues are thicker.
00:59:03Yeah.
00:59:06Yeah.
00:59:08Looks good.
00:59:10Now we'll replace the bone flap back into the hole in Abigail's skull.
00:59:17Oh, wow.
00:59:19Awesome.
00:59:24Looks good.
00:59:26So we're finally getting to the end.
00:59:30Bone flap has been replaced.
00:59:32Now we're going to close the soft tissues.
00:59:35Now, whether or not we've relieved the trigeminal neuralgia is clearly going to be the big question.
00:59:41We have removed all the disease from around that nerve.
00:59:45But if that irritation was caused by a permanent damage intrinsic to the nerve from the disease,
00:59:52then even removing the disease might not necessarily reverse it.
00:59:56And she knows that.
00:59:56But this is her best chance.
00:59:59There's a long way to go on this because, you know, she's got to heal, recover, wake up,
01:00:04and get over the operation.
01:00:05So this is just the beginning, really.
01:00:18So we're going to see Kali today.
01:00:21It's been five days since a very complex operation.
01:00:23And we're just going to see how she's doing in terms of pain.
01:00:27I just also want to check that some of the donor nerves that we used hasn't compromised her function.
01:00:35Hello.
01:00:36Hi.
01:00:37Hi, Kali. How are you doing?
01:00:38Good, how are you?
01:00:38Good, good.
01:00:39Well, it's nice seeing you sitting out.
01:00:42It's good.
01:00:43So...
01:00:44I'm ready to...
01:00:45Ready to...
01:00:45Heal.
01:00:46Heal. Good. Excellent.
01:00:48Just want to check that everything's working okay, where we took the nerve from.
01:00:51Sure.
01:00:51So can you just shrug your shoulder.
01:00:52Yep.
01:00:53Shrug's working.
01:00:53Good, good.
01:00:54So that's working.
01:00:55Okay, if I just support it there.
01:00:57Yeah.
01:00:58Can you try to bring your wrist in?
01:01:00Okay, that's good.
01:01:02Great.
01:01:03So it's all a waiting game now.
01:01:05Yeah.
01:01:05Okay, so it's waiting for the nerves to recover and grow into the muscle that we've re-innovated.
01:01:09Yeah.
01:01:10You won't see anything happen for a good couple of months.
01:01:13Three months' time you might see something.
01:01:15If I can work towards a target...
01:01:17Yeah.
01:01:18It just makes it easier.
01:01:19So in terms of, like, not moving my arm, what's my kind of target?
01:01:24Okay, you can't move your arm until...
01:01:26Another...
01:01:27If I give it a month...
01:01:27Three weeks.
01:01:28...from the start of the surgery...
01:01:29Yeah.
01:01:30And then we need to go...
01:01:31Then we need to hit it hard.
01:01:32Move you as much as we can.
01:01:34Okay.
01:01:34Okay.
01:01:35Great.
01:01:35Brilliant.
01:01:36Bye.
01:01:38I think I can see the road to recovery now.
01:01:40If I'm given milestones, it's like anything.
01:01:43If you're disciplined and you're given milestones to achieve, you've got to achieve them.
01:01:51Life is short and you've got to get on with it.
01:01:55I am determined that I will get as much function in my arm and my hand back as I possibly
01:02:02can
01:02:02because I want to go back to work and I want to be able to do the things that I
01:02:08love doing.
01:02:31So now we're going to find Brian's family and talk to them about how the surgery went.
01:02:36Hello.
01:02:37Hi.
01:02:38You all right?
01:02:38You okay?
01:02:39Yes, thanks for you.
01:02:40Yes.
01:02:41So we managed to do it all through keyhole.
01:02:43We didn't have to open up.
01:02:45Overall, the outcome is great.
01:02:48The kidney and the lymph nodes are all out.
01:02:51Brilliant.
01:02:51And I've checked it after taking it out and it looks all...
01:02:54It's all gone.
01:02:57Overall, it went really well.
01:02:58I'm quite pleased with it.
01:03:00Thank you so much for what you've done.
01:03:03No worries.
01:03:04Thank you so much.
01:03:05All right.
01:03:06Take care.
01:03:07No worries.
01:03:11Yeah.
01:03:13Yeah.
01:03:13Brian's wife was quite emotional to hear about the outcome of the surgery
01:03:17and it's probably one of those reasons why you do this job.
01:03:21It's just to see that you've managed to help people, get people back to their families
01:03:25and enjoy the things that we take for granted for life.
01:03:28Yeah.
01:03:28That was good.
01:03:30Yeah.
01:03:31Oh!
01:03:31Oh!
01:03:33It's just a home for you.
01:03:50Hello.
01:03:51Hello.
01:03:51Hello.
01:03:52Hello, Mr. Faye.
01:03:52How are you?
01:03:53Doing well, thank you.
01:03:54Are you OK?
01:03:55Yeah.
01:03:56Survived your operation?
01:03:57Yes.
01:03:58Are you feeling a bit sick, I would imagine?
01:04:00Yeah.
01:04:01Quite a bad sickness.
01:04:02Dare I ask about the face?
01:04:04Yeah.
01:04:05The face has been fine.
01:04:06Any pain or anything?
01:04:08No pain, no.
01:04:09Right.
01:04:10OK.
01:04:11Now, obviously, after the operation, the nerve could swell up a little bit and then hopefully
01:04:15it'll then settle back down.
01:04:16And the brain stem that was all pushed across, that started to move back into a normal position.
01:04:22Any sore or anything?
01:04:23It feels quite full.
01:04:24Yeah.
01:04:25Really full.
01:04:26Really blocked.
01:04:27Yeah.
01:04:27So that when we prepare the skin and clean it and everything, you probably find there's
01:04:32some prep solution.
01:04:32And quite often what happens is it gets all dry and crusty and it feels a bit full.
01:04:36Yeah.
01:04:37All right.
01:04:38Good.
01:04:38You're welcome.
01:04:38No problem.
01:04:39Pleasure.
01:04:39Pleasure.
01:04:42During the dissection around the hearing nerve, we had a reduced signal.
01:04:46It was reduced enough to make us concerned that the nerve was stretched whilst manipulating
01:04:52the tissues in that area.
01:04:53Now, if she's got stuff in her ear canal that we need to get washed out by the ENT surgeons,
01:05:00that could be causing some of the hearing reduction that she's got.
01:05:03So her hearing actually could be a little bit better than we feel it is.
01:05:08But she's definitely got serviceable hearing at the moment.
01:05:11The main aim of the operation was to try and relieve that intolerable facial pain she
01:05:15had.
01:05:16So far, that seems to have been successful.
01:05:20Hello.
01:05:22Hello.
01:05:23Maddie.
01:05:25Maddie.
01:05:26Maddie, hold me.
01:05:26Hang on.
01:05:27Oh.
01:05:29Oh, that's lovely.
01:05:33Oh, it keeps kissing the screen.
01:05:35Say bye, Mummy.
01:05:36Bye.
01:05:37Bye.
01:05:38Bye.
01:05:40That was a big relief, waking up and not having any pain.
01:05:43Because that was a fear before the operation that I'd wake up, that would have set the nerve
01:05:48off and I would have woke up with that trigeminal neuralgia, constant pain.
01:05:52But I didn't have any of that.
01:05:55It was a big risk, very big risk.
01:05:57But I am glad that I chose to go ahead with the surgery and had it done.
01:06:02Just to know that I might not have that pain ever again.
01:06:06Once fully recovered, hopefully start for baby two.
01:06:13Bye.
01:06:14Bye.
01:06:16Bye.
01:06:17Bye.
01:06:17Fingers crossed.
01:06:43Bye.
01:06:45Bye.
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