- 6 hours ago
tele: https://t.me/TopFilmUSA1
#film#shows#usa#usashows#hot#filmhot
#film#shows#usa#usashows#hot#filmhot
Category
😹
FunTranscript
00:01OK. See you later, darling.
00:03You're in safe hands.
00:04Good luck.
00:05Well done.
00:06Bye-bye.
00:07In the UK, some five million major operations
00:10are carried out every year.
00:12And we'll give you some of the good stuff.
00:14We can do it.
00:15We're going to be with you all the time.
00:17But some patients' procedures are so complex,
00:20only the most skilled surgeons can perform them.
00:24You prepare.
00:25I'm starting.
00:26You think you know in your mind what's going to happen.
00:29That's knife to skin.
00:30When we go into the operation,
00:32it's never quite the same.
00:34Wow.
00:36Serving Edinburgh and the surrounding area,
00:39NHS Lothian pioneers techniques to treat conditions
00:42that few others dare to take on.
00:46Massas.
00:46Fire away.
00:47The margin of success could be the thickness of a scalpel blade.
00:52You've always got some nervousness or trepidation.
00:56Something is wrong.
00:59That's worrying.
01:00Angry.
01:01That's trying hard not to let that little voice of fear creep in.
01:05The pressure is quite high.
01:11Jump.
01:12Jump.
01:12The surgeons...
01:15...are the ultimate responsibility.
01:17I need to keep this under control.
01:20Cut.
01:21You've got one chance.
01:23This is what really happens behind the closed doors.
01:26That's the specimen.
01:27Here.
01:28Of their operating theatres.
01:29We're almost there.
01:30If you think that you're a good surgeon and nothing can challenge you,
01:33something will come along to bite.
01:35Anyone who thinks that they've seen it all is kidding themselves.
01:46The Western General Hospital in Edinburgh is one of only two centres in Scotland able to treat certain very rare
01:54male cancers.
01:57Consultant urologist CJ Shukla takes on some of the most complex cases.
02:03I grew up in East Africa and in the 80s you were either a science or a non-science person
02:09and I was very much into sciences and I liked all the sciences.
02:12So it was either going to be something engineering related or something affiliated to healthcare.
02:17I felt healthcare has a more direct impact on people and helping people, which is why I decided actually medicine
02:26was for me.
02:29CJ's next patient has an advanced cancer which, if untreated, will spread and become inoperable.
02:37The next case we're going to do is a 48-year-old man who actually came to see me a
02:42few weeks ago with a newly diagnosed penile cancer.
02:47Cancer of the penis affects an average of around 700 men each year in the UK.
02:53So this is his corpus cavernosum, which is his penile body.
02:57This is the head.
02:58Yeah. And that is his tumour.
03:01When it comes to penile cancer, most people are taken aback that there is such a thing.
03:08This is such an unknown entity that most of my patients become completely surprised that you can get a cancer
03:14on the penis.
03:16Registrar Sabine Ugozova will be assisting CJ during the operation.
03:21The tumour has progressed in the short time that I've known him and that's the nature of penile cancer.
03:27How far do you think you'll need to dissect?
03:30What we're going to do is a partial amputation where we're going to take the glands and the very tip
03:34of the body of the penis.
03:41CJ's patient is Alistair, a construction engineer from Inverness.
03:47The first thing I noticed, it was actually Boxing Day last year.
03:52I went to the toilet and I passed a lot of blood in my urine.
03:56But I never really thought anything of it because it only happened once.
04:03Then after that I noticed there was a small lump in my penis.
04:08But I ignored it for about six weeks.
04:11Just kind of kidded myself that the lump was always there.
04:17You ask yourself, why did it happen to me if there's so few people get this type of cancer? Why
04:22did it happen to me?
04:32At least someone's in the fairway. Good shot.
04:36His lifelong friend Richard has been supporting him since his diagnosis.
04:44We've grown up together. We played football in the park together.
04:48Played our local sports shinty together.
04:55It was a good shot.
04:57As a friend, I can only be there for him and I'll phone him up, he likes to talk.
05:03I just like to listen and try and be a good friend for him.
05:10No, it's obviously a very sensitive part that they're going to be, you know.
05:15The one good thing that you did was you went to the doctor. You did the right thing.
05:20You need to have a good play and feel of your willies.
05:26Well, us men are all good at that.
05:30I'd be lying if I said I wasn't very anxious.
05:33No, I know.
05:35A worrying time, innit?
05:36It's been too much recently, innit?
05:38Aye.
05:39But, you know, these surgeons are very good and you will be in great hands with them.
05:43You've got to remain positive and hopefully they do a good job.
05:48Yes.
05:53So that's the lymph node on the left, which is suspicious, and on the right, they're borderline.
05:59Scans show Alistair's cancer has already spread beyond the penis.
06:05Lymph nodes are important stations in our body where our white cells, our lymphocytes, tackle infections.
06:13But lymph nodes are also a station where cancer spreads to.
06:16So you've got to deal with the primary tumour, but also chasing where the cancer cells might have gone to
06:22the lymph nodes.
06:24The operation to remove Alistair's cancer will be carried out in three stages.
06:31First, CJ will dissect Alistair's right groin and take out three lymph nodes so they can be checked for cancer
06:39spread.
06:42Next, to remove the primary tumour, CJ will amputate the head and a section of the shaft, including a safe
06:50cancer-free margin.
06:53To reconstruct a functioning penis, a layer of skin will be lifted from Alistair's thigh and stitched to the end
07:01to create a new head.
07:05Finally, CJ will tackle the left groin, dissecting all the lymph nodes, because scans have confirmed cancer has already spread.
07:17But these are close to the junction of the lung saphenous and femoral veins, crucial blood vessels which return blood
07:25from the legs and feet.
07:26A mistake here could cause a major bleed with catastrophic consequences.
07:34I'm optimistic that we would be able to preserve two thirds of the length of the penis.
07:42Enough so that he would be able to stand and pass urine and have penetrative sex.
07:47But sometimes it may not end up looking to their satisfaction.
07:52There is, of course, psychological support that can be offered and we can direct them to that.
08:00Hello there. Hiya. Hiya. I'm Stephanie, I'm one of the nurses.
08:04Actually, nice to meet you. Hiya.
08:07Hiya. Are you feeling alright?
08:09As good as I can now.
08:15It's very difficult to prepare for. It's very difficult.
08:23A fair bit of my penis is getting taken off.
08:28My biggest fear is that the cancer doesn't go away. That's my biggest fear.
08:34But Dr Shackler is hopefully going to save my life.
08:38Nearly I, Rupa.
08:43It's 9am and in the Western General's 11 theatres, operations are getting underway.
08:50In Theatre B, CJ is briefing his team.
08:54We have one case for the day, a long case.
08:57He has had a penile cancer growing for a few months now.
09:02So we're going to do a right central node biopsy.
09:06Partial penectomy skin graft.
09:08And a left radical groin dissection.
09:11Imagine a few more deep breaths there.
09:13All the way in, all the way out.
09:15Good, man.
09:19The minute I walk into theatre, I switch into my clinical mode.
09:25We'll spend a bit of time positioning him.
09:28Might just take a little bit longer setting up initially.
09:30Don't worry. Take your time.
09:33I do detach myself from the emotional side of things.
09:37And just focus on the steps and the anatomy and the pathology.
09:42And that helps me focus on the operation and the end game.
09:46Are we good? Let's see.
09:53That's good.
09:58It's actually a foreskin tumour, which is invading the glands here.
10:06And also you can feel it's actually invading the right side of the shaft of the penis.
10:12But he should have an adequate reconstructive option here.
10:19Our primary goal has to be oncological control to cure his cancer.
10:23We cannot compromise on that.
10:26Any reconstruction that we do is a secondary issue.
10:30Okay, I'm going to inject his penis with the patent blue.
10:35The blue dye will travel to the lymph nodes in Alistair's groin.
10:40Hyperflex the skin.
10:42Making it easier for CJ to identify and remove the borderline ones.
10:48Look at that. It's like spidery webs.
10:51Excellent.
10:52Okay.
10:54Can I have the Geiger counter probe, please?
10:58The Geiger counter also helps to pinpoint the nodes by detecting radioactive isotopes,
11:05which were injected into Alistair yesterday during his preoperative scan.
11:10Okay, so, X.
11:13We have very little doubt that the left groin has got an involved set of lymph nodes,
11:18and that needs clearance.
11:20Okay, knife, please.
11:24On the right side, though, we have borderline nodes,
11:28nodes that are suspicious but not overtly involved.
11:31So, for that groin, biopsy is the most appropriate way forward.
11:35You can actually see some bluey areas there.
11:39The blue dye has already reached the lymph nodes.
11:44Let's try and get underneath it.
11:48Harmonic, please.
11:53Specimen.
11:54These nodes will be sent to pathology for analysis,
11:58which takes several weeks.
12:00And this will be sent to a node two.
12:03If cancer is detected, Alistair will require further surgery.
12:08And finally, lymph node three.
12:15With the first stage of the operation complete...
12:20Okay, okay.
12:22Can I have a marker pen, please?
12:24Yeah.
12:25CJ can now turn his attention to the primary tumour on Alistair's penis.
12:31So, what I'm doing is palpating where the tumour seems to be invading,
12:34which is around there.
12:36He carefully marks his incision line,
12:39with a clean margin of tissue between the tumour and the rest of the penis.
12:45Most patients relate to being a man in relation to having a penis,
12:49and a normal penis.
12:50Right, can I have a ten blade, please?
12:52Yeah.
12:53So, having an operation that affects that...
12:58...has a huge psychological impact on patients.
13:13Six miles south-east is NHS Lothian's largest hospital,
13:18the Royal Infirmary of Edinburgh.
13:21It provides specialist care for women across the east of Scotland.
13:25Morning.
13:26Hi, hi.
13:28Taking on some of the most complicated gynaecological cases
13:32is consultant Cameron Martin.
13:35I think when people ask me what I do,
13:37I would generally tell them I'm a doctor,
13:39and, you know, a few might ask me,
13:41you're a bloke, why in a gynaecology,
13:43and what does it attract you to it?
13:45You know, to be honest with you, I think when you're a doctor or a surgeon,
13:49you just see a patient with a problem.
13:51And so, actually, I just see a patient for whom I can offer some form of surgical service,
13:57which I think I'm hopefully quite good at.
13:59Ureter comes down into the pelvis, we can follow that.
14:02His next case is so complex, he's enlisted the help of consultant urological surgeon, Alex Laird.
14:09The right ureter looks, you know, slightly more prominent.
14:14This will be the first time I've operated with Cameron.
14:16I do know from colleagues that he's a very experienced and talented surgeon.
14:21I think surgery is a real team sport, so bringing different specialties with different expertise in
14:25to get the best outcome for the patient is great.
14:29Our patient presented a few months back with symptoms of swelling, pain, abdominal girth extension.
14:38From a gynaecology point of view, we call this stage four endometriosis.
14:43Endometriosis, which affects one in ten women,
14:46is a chronic condition typically causing inflammation, pelvic pain and heavy periods.
14:53So endometriosis has a spectrum.
14:57Stage one is a superficial deposit of womb-like lining on the outside part of the womb,
15:03on the organs of the pelvis, usually the bowel, the bladder, sometimes the appendix.
15:08And stage four is usually taken to mean disease that's caused the bowel become adherent to the back of the
15:14womb,
15:15caused some scar tissue.
15:16In extreme cases, it can also produce large cysts full of old blood and tissue.
15:23This is an MRI scan just from yesterday, which demonstrates nicely this huge cystic mass in our pelvis,
15:30stretching all the way up to the umbilicus here, compressing the bowel at the back,
15:36the large left ovarian mass.
15:39The cyst, measuring nearly 20 centimetres, has already affected a major organ.
15:44We've got a normal looking right kidney here, but you compare that to the left side here,
15:50you can see that the left kidney has none of the normal kidney tissue,
15:55because it's chronically obstructed, no urine is able to drain down.
15:59Fewer than one percent of endometriosis cases involve the kidneys.
16:04It's unusual for the patient that this has completely destroyed the kidney.
16:09It would suggest it has come on relatively gradually.
16:13There is also a possibility the cyst may be cancerous.
16:18There is an anxiety that underlying this there's actually a malignant process.
16:23A small number of patients with advanced endometriosis can have a rare cancer called a clear cell cancer of the
16:28ovary.
16:33That's good isn't it?
16:35Their patient is Laura, who lives in Livingston with her son James.
16:40Do you want to build a car?
16:42And husband Stuart.
16:44Most of my life is kind of revolving around James at the moment.
16:48Shut the door.
16:50James's big passion is building things.
16:54Last door.
16:57Laura's illness came out of the blue.
16:59That's way, that's way.
17:00He's going to crash land.
17:02A couple of years ago we got lots of exploratory tests done to find out why we weren't able to
17:08conceive a second child after we had James.
17:11And found out I had quite severe endometriosis.
17:15My mum and my auntie both had endometriosis when they were younger.
17:21They both had incredibly heavy periods.
17:24Very, very painful.
17:26But I had no symptoms of anything.
17:30Then about a year ago I started getting pain on my left hand side.
17:36But it was intermittent.
17:41I eventually got an ultrasound and they found masses.
17:47I was terrified.
17:50I couldn't believe it, it was really hard to get my head around.
17:53I can run and jump.
17:59We don't know for definite that it's not cancer, so the current plan is to do a full hysterectomy.
18:06It seems the safer approach, specifically when we've decided we don't want any more children now anyway.
18:12I am not a pet.
18:15I'm quite happy with just James, we've got a nice family.
18:18It's a baby big cat, isn't it?
18:22To remove all traces of Laura's endometriosis,
18:26first Alex will use keyhole surgery to detach Laura's left kidney by cutting its blood vessels and carefully releasing it
18:37from surrounding tissue.
18:39Then Cameron will expose the cyst in Laura's abdomen.
18:44They must carefully remove it intact before sending it for biopsy to check for cancer.
18:52They will then disconnect the ureter from the bladder, avoiding injury to any nearby blood vessels supplying the lower body
19:00so the kidney can be removed.
19:03Finally, Cameron must carry out a total hysterectomy, carefully removing Laura's ovaries, fallopian tubes, uterus and cervix.
19:19It looks really quite nice though.
19:21It's nice isn't it?
19:22This is not a minor endometriosis procedure, this is a major undertaking in a young woman who's 37 years old.
19:32He's going to have a full hysterectomy, precipitating menopause.
19:35It's a major operation with potential for significant blood loss.
19:42Significant complication.
19:46Phone James on some help, won't you?
19:49Tell him I'm ok.
19:51Probably go round and visit you alone first then.
19:53Yeah.
19:54And then go to this school room, okay.
20:04I am scared about the surgery.
20:07It's major surgery.
20:09None of medication is just going on just now, ok?
20:11There is a risk that this is cancerous.
20:15It has already destroyed my kidney.
20:18We're just going to start drifting you off to sleep, OK?
20:20I'll be really glad when it's gone.
20:23We'll see you in recovery.
20:35Alex will lead the first stage of the operation.
20:38Sir, thanks a lot.
20:40So Laura is positioned on her side...
20:42Knife, please.
20:43...for the keyhole surgery.
20:4511, 16.
20:50Alex carefully makes a series of small incisions.
20:53Perfect. And flip, please.
20:56And gas on, please.
20:58Carbon dioxide inflates the abdomen
21:01to give the surgeons access and a better view.
21:05If we can get the top lights off, thanks.
21:13This is the descending colon on the left,
21:16and this is the kidney round the back there.
21:19Before he can detach the kidney,
21:22Alex must shut off its blood supply,
21:24which comes from the renal artery.
21:27About a quarter of your circulating blood volume is going to your kidney every minute.
21:31Looks like an arterial branch may be coming in here.
21:35But first, he must identify the correct blood vessels.
21:41That's back of kidney.
21:42Is that kidney there?
21:42So artery, I can't see at the back there.
21:46In kidneys, the artery is always right behind the vein,
21:50which is a bit awkward for a renal surgeon.
21:54We just get you to rotate that so that veins up and down the way.
21:58Because if you're going behind the vein,
22:00then there's a risk that you damage the vein
22:02and have major bleeding.
22:04And if there's major bleeding, you can't then see the artery.
22:08All going, that's exciting.
22:09It's a bit sticky.
22:10And the artery is elusive.
22:14Normally, in a good day, you get a nice view of the artery at this point.
22:18The renal artery is the bit where you think,
22:20you know, it could go wrong at any second,
22:22so you need to focus and do this carefully.
22:25It may be that that is the artery.
22:27There's not much space around the vessels,
22:30and the problem is they are fixed.
22:32I have the right angle, please.
22:34You have to be really astute in looking at
22:36how much the tissue is separating,
22:38how much tension you're putting on blood vessels,
22:41how much pressure you're putting on things.
22:44It's always just no more around the boat,
22:46so that if you...
22:46Exactly, what's behind...
22:47So you don't turn something straightforward into disasters.
22:50Yeah.
23:04In Theatre B at the Western General...
23:07Dab and bipolar, please.
23:09Yeah.
23:10Urologist CJ is at a crucial stage
23:13of Alistair's partial penis amputation.
23:18Just keep this on traction here.
23:21He's painstakingly cutting through skin
23:23and the four layers of fascia,
23:26or connective tissue, within the penis.
23:28Okay, relax for a second now.
23:32I go by clinical experience,
23:34and I know that I can feel where the tumour is,
23:37and I go a couple of millimetres beyond it
23:40to make sure that I'm happy with that as a margin.
23:44See, you can see the tumour there, right?
23:46It's bulging there.
23:47Just going to be careful that we just stay superficial.
23:49Yes.
23:50When we're doing an amputation surgery,
23:53I'm not thinking about the impact of this on the patient.
23:58Mark a pen, please.
24:00I just focus on the science.
24:04This is where I'm going to make an incision.
24:10Can I have the knife, please?
24:11Yeah.
24:15That is not to say that the impact of what I do to a patient
24:19is of no consequence to me,
24:20but I just deal with the condition and the theatre setting.
24:27Now you can see the right corpus cavernosum
24:30and the left corpus cavernosum.
24:34The cavernosa are the main chambers of erectile tissue in the penis.
24:40This is going to be the right corpus cavernosum frozen section.
24:44These tissue samples will be sent for immediate microscopic analysis
24:49to check if CJ has removed all of the cancer.
24:54That's the left corporal tip.
25:00With the samples off to the pathology lab.
25:04Okay, so let's just go a little bit this way.
25:08And after nearly two hours of operating,
25:12the top of Alistair's penis,
25:15containing the visible tumour,
25:17is finally amputated.
25:19There.
25:22Can I have non-tooth forceps and a change of gloves for both of us, please?
25:26Yep.
25:34There's nothing there.
25:37So we are clear microscopically.
25:41Hopefully, microscopically as well.
25:44Superficially, it looks clear.
25:46But to be certain all the cancer has been removed,
25:50CJ must pause the operation and wait for the results from the pathology lab.
25:56We've just got to wait for the frozen section.
25:59Yeah.
25:59So back after a quick drink.
26:02Great.
26:04If we're unlucky and the frozen sections come back positive from the pathology lab,
26:09then I will have to trim back even more of the penis until we get a clear margin.
26:28All right, here we go.
26:36Hi, Angelique.
26:38How are we going with the frozen sections?
26:45Great.
26:46Excellent news.
26:49Excellent.
26:50So it's all negative?
26:51I feel delighted that it's negative and that we have removed the primary tumour in its entirety.
26:59CJ can now begin the process of reconstructing the penis.
27:04We're hoping to preserve erectile function and a length that allows penetrative sex.
27:10These factors are important in giving patients the best outcome.
27:16That's the muretha there.
27:18Just hold that there for me.
27:20The first stage is to preserve Alistair's ability to urinate and ejaculate as before.
27:27So what I'm trying to do is evert the urethra like that, okay?
27:33Everting the urethra means turning the end of it inside out and securing it to the new head of the
27:39penis.
27:40We'll come out now.
27:42One of the complications of urethra reconstruction is that 7 to 10% of patients can get stenosis or narrowing.
27:51To prevent that from happening, you've got to try and evert the edges.
27:55A bit like when the rose opens up, you want the urethra mouth to open up in that fashion as
28:00well.
28:01So if you turn the penis to me that way.
28:04Perfect.
28:06Great.
28:07Every stitch, every cut that you make makes a difference.
28:10Ready?
28:11Yep.
28:12Okay, come up.
28:13Yes.
28:14That's nice.
28:15That's the fella.
28:17Okay, come up.
28:20Brilliant.
28:21Now we're ready to prepare the donor bed.
28:26CJ carefully reattaches the skin to the shaft.
28:32So I'm securing the skin to the deep focal tissue so it doesn't slide.
28:37And prevents the graft from sliding off as well.
28:43Okay, let's just see how it is on that side, next side.
28:48Yep.
28:49I'm happy with that.
28:50The next stage is to cover the new head of the penis.
28:54Right, can I have a ruler please, next?
28:56By harvesting a skin graft from Alistair's thigh.
29:01See, it's five centimetres, that's two inches.
29:04And that way it's six centimetres.
29:08Reconstruction is quite complex because you have to know the patient.
29:12You have to know what their expectations are.
29:14Six by five, right?
29:16Yep.
29:17And there are two aspects of it.
29:18There are the cosmetic aspects that he has to accept how it looks.
29:22We'll just make it a bit bigger.
29:24In addition to the cosmetic aspects, it's the functionality.
29:28Will he be able to stand to pass urine and to be able to have sex in the future?
29:34A special surgical instrument, called a dermatome,
29:39is used to harvest the strip of skin...
29:43..one thousandth of an inch thick.
29:51OK.
29:53So, safety on.
29:55OK.
29:57That's the graft.
30:00This wafer-thin piece of skin must be carefully stitched to the new head of the penis.
30:08So, let's just anchor it dorsally first.
30:14The difficulty isn't securing it.
30:16The difficulty is tailoring it so it looks like a good fit.
30:20Skin.
30:22Opus cavernosum.
30:25And skin.
30:28Scissors, please.
30:29The sharp ones.
30:33You have to work in a systematic way all the way around
30:36so that it covers it without any crinkles, wrinkles or creases.
30:41It's beginning to take shape.
30:43Hmm.
30:46You want it to be a smooth covering all the way around.
30:50OK.
30:51I'm happy with how that has anchored.
30:53Yeah.
30:54It's looking really nice.
30:55Now we quilt.
31:02Quilting involves securely attaching the skin graft with dozens of individual stitches.
31:10Quilting allows us to secure the graft to the underlying tissue, allowing it to absorb nutrients from it.
31:19If you've quilted it nicely, the graft should survive.
31:25So that's this side of the hemisphere done.
31:28I think it looks beautiful.
31:30Yeah.
31:35I think I'm happy with that.
31:38Got this open? Yep.
31:39The reconstruction is complete.
31:42But after five hours, the operation is far from over.
31:47So what I'm going to do is just cover this up like so.
31:51CJ still has to remove all of the lymph nodes from the left side of Alistair's groin.
31:57A procedure that is fraught with risk because of their proximity to a junction of critical blood vessels.
32:04It's an important landmark in the operation.
32:06You cannot avoid it.
32:09OK.
32:09Right.
32:10Have the knife, please.
32:13That's the point that it gets my heart racing because the biggest worry I have is damaging these important blood
32:18vessels.
32:19One of the tributaries of the thefino-femoral junction.
32:23That would be the ultimate nightmare.
32:39In theatre one at the Royal Infirmary of Edinburgh.
32:42We have a look around the top here.
32:45Consultant urological surgeon Alex.
32:47That is actually the artery on the other side.
32:51Has finally identified the elusive renal artery.
32:55But it's hard to reach.
32:57I'll try and get a couple of purple haemolox on that, please.
33:01The haemolox are great because they're permanent clips.
33:05They're actually easier than trying to stitch blood vessels.
33:09But what you need to do is make sure they're in the right position.
33:13I'll maybe leave that at the moment.
33:15Just because it's tight, I don't want to nick that.
33:17Yeah, yeah.
33:20With a clip on the artery, Alex can tackle the vein.
33:25Great. And another one, thanks.
33:27You've got to be really careful and really precise when you're doing this part of the operation.
33:33And another one, thank you.
33:36Two on the bottom side, yeah.
33:38That will stay, and then the one on the top just stopping his back bleeding.
33:42Scissors, thanks.
33:43With the vein dissected.
33:46Purple haemolox 6.
33:48Alex can now fully access the renal artery to clip and cut it.
34:00We've definitely dealt with the main vein and artery.
34:05With the blood supply shut off, Alex must mobilise the kidney.
34:14Yeah, completely disconnect.
34:16Now free from surrounding tissue, the kidney is still connected to the bladder by the ureter.
34:23Well, that's what it's done in the phrectomy bit.
34:26And won't be fully removed until phase two of the operation.
34:31Yeah, perfect. Okay.
34:33That's us, top lights on, please.
34:35Yes, scope can come out.
34:36Gas can go off.
34:39Once Alex has finished his part of the operation, the focus then turns round.
34:46Wonderful.
34:46I know this woman has endometriosis, which is stage four. It's going to be difficult.
34:52Okay, sir.
34:54Cameron makes a 20 centimeter incision, cutting through layers of skin, fat and fascia to reach the abdominal cavity.
35:03That's the large mass there.
35:05And they get their first glimpse of the cyst.
35:08When we open up the abdomen, you get a real feeling for, one, the size of this cyst, and also
35:14where it's connected.
35:17So I think they can get a bit more space in the bottom here.
35:19This cyst is a balloon with dense fluid inside it, so you can compress it, but not squash it down
35:26flat.
35:28The cyst is so large.
35:29You'll weave it further down here.
35:31They need to make the incision bigger.
35:35Really, really stuck in the back as well.
35:37I'm going to take the round ligament first of all.
35:39Yep.
35:40By feeling round at the back of the cyst, we're trying to identify that point of attachment.
35:46But it's really difficult because we can't see under it, we can't see over it, we can't see through it.
35:51And we have to work on the assumption it's stuck to something important.
35:57There isn't much space, but you can see the colon coming, reflecting at the top there.
36:02It's definitely under tension and pressure when we're mobilizing that.
36:07Okay.
36:08I think the Mets are those two things.
36:10Deflating it would give us a bit more space, but I think we should try and get out without deflating
36:14it if we can.
36:15I want to remove this cyst without bursting it, because at this point in surgery, we don't know if this
36:20is endometriosis or it's an ovarian malignancy.
36:23So by containing it, keeping it complete, we are avoiding spillage in the abdominal cavity.
36:30I think we'll just keep going down here. I'm nibbling down.
36:34Yeah.
36:34In my mind, I have a 3D idea of how everything connects together.
36:38With endometriosis, everything becomes quite distorted.
36:42So when you're operating, you have to work around that.
36:45But you're always trying to be meticulous with what you do.
36:48It is actually coming up now.
36:50Yeah.
36:50Yeah.
36:51It's definitely more mobile than it was.
36:51More mobile.
36:53Carefully, the surgeons work together to separate the cyst from surrounding tissue.
36:59It seems like a sort of window.
37:00I think there is a window there.
37:01There, isn't there?
37:02Yeah, there is.
37:03It's extraordinary.
37:04Come on, bro.
37:05Sizzles, please.
37:13Okay, happy with that.
37:14So what I want to do is get this mass out now, Alex.
37:16Yeah.
37:16If you do that, then we'll have loads of space.
37:19Cameron cuts the last adhesion, the left ovary and fallopian tube where the cyst originated.
37:26And this huge mass can be removed.
37:30And specimen.
37:31It's amazing that someone can have such a massive cyst.
37:36That's the left ovarian mass.
37:39Taking it out intact is a really important moment because I knew that if it was malignant,
37:45we've removed it without bursting it, which is better for Laura, which is great.
37:49So I think what we might do now is take an Alexis retractor, please.
37:53The retractor gives the surgeons a better view of Laura's abdomen.
37:57I can now see right into the pelvis and I can see the extent of the endometriosis.
38:04Endometriosis triggers inflammation in the pelvis, which the body tries to heal by producing adhesions and scar tissue.
38:16Causing the abdominal organs to stick to each other.
38:20This is a biopsy from right pelvic sidewall.
38:23What has now become clear is the degree of scarring.
38:28So step one has been difficult.
38:30Step two is likely to be as challenging.
38:37The next task is to remove the damaged left kidney, which is still attached to the bladder.
38:45Deleted kidney.
38:48To fully disconnect the kidney.
38:51I know you keep it beside me.
38:52They must identify and then stay clear of the major blood vessels in the abdomen.
38:59The kidney's there.
39:01Find the common iliac.
39:04There's the vein there.
39:05I think that's vein, there's artery.
39:08The ureter is very stuck to the pelvic sidewall on the left.
39:12And that's from endometriosis.
39:15The problem here is it's quite dense scar tissue.
39:19I think I'd like to open this up here.
39:22It's definitely through a lot more than you expect.
39:26I think it's just all peeled in.
39:27Oh, stuck into the centre there.
39:31What's peeled in there?
39:32It's just peeled in that little space at the front and belly.
39:34Yeah.
39:37Be careful.
39:42Bobby.
39:43Finally, Laura's damaged kidney is disconnected from her bladder.
39:48Kidney and ureter.
39:50And removed.
39:53There's a sense of relief when you've removed the damaged kidney.
39:57Fantastic.
39:59So, you've just got this to do now.
40:02We're then left with the gynecological part of the procedure, which is a hysterectomy.
40:06And that involves removing the womb, the cervix, and the remaining fallopian tube and ovary on the right-hand side.
40:13I think we'll do the back here.
40:15I'll take the pair of scissors, please. I'll just take the next specimen.
40:19Right ovary and tube.
40:22The thing about endometriosis surgery that distinguishes it from general gynecological surgery is that structures tend to be pulled in
40:30an unusual position often.
40:32So, this is the point of which the rectum is firmly adherent to the back of the uterus.
40:37There's another option but to just keep sort of slowly going down here.
40:42To remove the uterus.
40:44I'm going to watch here. I don't go too low.
40:47Cameron must find a way to safely separate it from the rectum.
40:52That's the raggedy uterine artery.
40:55But there is a lot of bleeding.
40:59I'm going to check this other side out, so that we can get some control of pulmonary stasis to the
41:02back.
41:03They're just going in their way.
41:05The bleeding from the uterine artery on the left side is a problem.
41:07But I can't afford to blindly suture or clip or cauterize, because near that there are other major blood vessels.
41:16So I have to just be really careful, not rushing and cascading the problem out of control.
41:29To control bleeding in operations like Laura's,
41:33surgeons rely on a range of highly technical surgical tools.
41:38At the Western General,
41:41a dedicated team of 11 technicians
41:44are responsible for servicing over 7,000 pieces of equipment every year.
41:50Across most hospitals, you'll find medical physics equipment management is always in the basement.
41:56And a lot of people don't know that we exist.
42:00One of the most specialised pieces of kit is an electrosurgical unit,
42:05which only the most skilled technicians can service.
42:09This device came in for repair.
42:13This machine provides the energy for surgical instruments that use heat
42:18to cut through and cauterize human tissue.
42:22Electrosurgery has been around for nearly 100 years.
42:25It's effectively an electrical scalpel.
42:31The only reason you can use electricity and not be electrocuted is because of the frequency that it's at.
42:38Operating at over 300,000 hertz, the high-frequency electricity vaporises tissue by fractions of a millimetre,
42:47but doesn't penetrate deeply to cause an electric shock.
42:51A phenomenon known as the skin effect.
42:54Part of what we do is to ensure not just the safety of the patients, but the safety of the
42:59people actually using them as well.
43:04Particularly with a high-risk device like this, it's very important that it's doing what you're expecting it to do.
43:11It's one of the most tested devices that we have to make sure that it's very, very safe because it's
43:18using electricity to cut.
43:20Start a test.
43:24I moved 300-odd miles to come here, but I've not regretted it for a minute.
43:30So that's a pass then, that's within the spec.
43:33If you can see something that you've done which positively affects patients, it's very satisfying.
43:39Be good.
43:48In Theatre B at the Western General, urology surgeon C.J.
43:53Has successfully excised the tumour and a section of Alistair's penis.
44:00Okay.
44:02Preoperative scans show the cancer has already spread.
44:05That's the node. Can you feel the node now? It's a decent size.
44:10It's huge.
44:12So every lymph node in his left groin must be removed.
44:17Right.
44:19Embedded in layers of fat and fascia, the packet of lymph nodes also lie next to the lung saphenous and
44:26femoral veins,
44:27which return blood from the legs and feet.
44:30There's the lung saphenous, I think, underneath there.
44:35You have to be able to take the lymph node packet out without injuring the sapheno-femoral junction.
44:43You've got to anticipate trouble.
44:45Have you got a two ovicle ready in case I prang the lung saphenous?
44:51That's the one bit where I could get myself into trouble.
44:55Worse still, potentially bring harm to the patient.
45:00Oh, careful.
45:01Just careful. Just hold on a second. Let's just find where we are.
45:05Hmm.
45:06We have to be just extra, extra gentle and take our time here.
45:12That's where we need to be.
45:17Gingerly, gingerly.
45:18You just take your time and take your time and take your time.
45:24I can actually see the sap junction right there.
45:28The nightmare scenario that I would never want to be in is that you can inadvertently damage that junction and
45:37can lead to catastrophic hemorrhage.
45:39Stay right here.
45:44Okay. Pleasure, please.
45:53As CJ tries to free up the packet of nodes from the sapheno-femoral junction.
45:59This needs to all come with us, doesn't it?
46:02Yeah.
46:06It starts to bleed.
46:12Give me a sword.
46:15Give me a two ovicle.
46:17Mm-hmm.
46:21Pull that towards you.
46:23Okay, hold on. Let me get down.
46:28Touch in there.
46:29Okay.
46:31This bleed isn't a single vein that I can actually clip and tie.
46:36It's flush against the sapheno-femoral junction.
46:40It's nothing to glue.
46:42Give me the right angle.
46:47Just up in there.
46:54Okay.
46:57Where are we bleeding from?
46:58It's the edge of that vein still.
47:01I have to say to myself, just take a deep breath.
47:04It's just a vein.
47:05You're the surgeon.
47:06Control it.
47:07A foroproline, please.
47:09It's about talking to yourself and keeping yourself calm.
47:13I'm just going to put a few strolling stitches.
47:18CJ uses stitches and his years of experience.
47:23You often have to resort to the three Ps, which are perseverance, pressure and patience.
47:31Let me just control.
47:38The bleed finally stops.
47:41He can now safely remove the cancerous lymph nodes.
47:45Okay.
47:47Now, this is the lymph node packet here.
47:50Chunky packet, this.
47:52Yeah.
47:57Specimen.
47:59Okay.
48:00So, stop for a second.
48:01Can I have a swab?
48:02The main group of nodes is successfully detached.
48:06But to stop the cancer spreading further, CJ must remove them all.
48:13Okay.
48:14That's your natural packet?
48:15Yes.
48:16Okay.
48:17Excellent.
48:21Fantastic.
48:21With all the lymph nodes cleared from Alistair's left groin, the six-and-a-half-hour operation is almost complete.
48:29Fantastic.
48:34Great. That's closed it. Yep. Perfect.
48:39Every time I finish the operation, I look at how much of the phallus is left behind and think, will
48:46he be happy with this or not?
48:50We'll have the tegudum with pads for the groin.
48:56It's an honor to be able to do what I do.
48:59So, this is basically like a cushion.
49:03It's a big responsibility when patients put their care and their long-term outlook in your hands.
49:13Good. I think that's us now.
49:15Hey.
49:18Lovely.
49:19Excellent.
49:20Thank you, everyone.
49:22Thanks.
49:29Alistair is moved to the recovery room.
49:32Just try and stay down for us to snow.
49:36Take it easy. Just relax.
49:43How are you doing?
49:45How are you doing?
49:46Good.
49:47Operation went very well.
49:49Very, very well. Okay?
49:51When he's awake and I'm telling him how things have gone, I'm seeing the much more human side where I'm
49:59focusing on his emotions and I stop focusing on the science and the anatomy.
50:05Couldn't have asked for it to go any better.
50:07Sure.
50:08Good.
50:08All right?
50:09Rest well.
50:10Look after yourself, all right?
50:12Okay.
50:16I'm delighted how it's gone.
50:18I'm delighted how it's gone.
50:18It's just a matter of time now to see what the results show and what the next steps are.
50:34In theater one at the Royal Infirmary of Edinburgh, gynecologist Cameron and urologist Alex are trying to remove Laura's uterus.
50:46But she's losing more blood than expected.
50:49Yes.
50:49And there's even an archery that's leading in here, of course.
50:52I have to fight and then clamp the season archery.
50:56You have to be cautious.
50:58You can't just put a big leg issue around because the danger is you cause collateral damage to another vessel
51:04and the whole thing can cascade.
51:10I got it.
51:12I got it.
51:13I think that.
51:16Pretty good, that.
51:17I think that's got it.
51:19I'll take the scissors, thanks.
51:23See?
51:24That's uterine artery there.
51:25That just gives a bit more breathing space.
51:30Much better, isn't it?
51:31Much better.
51:33With the uterine artery tied off, the bleeding is under control.
51:38Okay.
51:39Can I have the knife, please?
51:40And the uterus can be removed.
51:43Can I express some of the uterus?
51:49Yeah.
51:50That's the uterus.
51:53The next challenge is to detach the cervix from the top of the vagina.
51:58So, this is the cervix here.
52:01But because of the endometriosis, it's also stuck to the rectum.
52:06Not the rectum, the rectum.
52:07The danger is going into the wrong plane here.
52:12I'm nervous at this point.
52:15Cameron and I are communicating about the difficulties.
52:17But as a surgeon, you can appreciate when dissection's difficult, planes are stuck.
52:23And you're also aware of the potential complications or risks in that area too.
52:30I think that that's gone on there.
52:32And I think the danger is going...
52:33Just that bit up.
52:33Too close.
52:34Yeah.
52:36This is the way of the rectum down here, you see, but I think...
52:38Are you not sure what this is?
52:39Yeah, sir.
52:41We have to be really careful with the dissection of the cervix.
52:44There's a big risk of a damage to the bowel.
52:49I don't even want to use that any here.
52:51It's just a bit close.
52:55I know that if I make a hole in the rectum at this point, I know what that means for
53:01Laura.
53:02It could mean potentially further surgery, possibly even a stoma, a bag on her abdominal wall.
53:08So that single part of the operation, that release of the rectum, for me as a gynaecologist, is the most
53:15complex part of the operation.
53:20The rectum's going down.
53:25There we go.
53:27When we've reached beyond the scar tissue on the back of the cervix and the rectum,
53:32we reach the softer point where we know we've gone beyond endometriosis.
53:37It's a fantastic feeling.
53:39The next special one with the cervix.
53:43It's a really tricky section of that.
53:47The cervix.
53:49Perfect.
53:51Full in suture, I think.
53:53After six hours, the operation is nearly finished.
53:57Full in suture, please.
53:59I need some warm water.
54:00The final task is to suture the vagina where the cervix was removed.
54:06What I'm doing is a continuous mattress locker and that means that you reduce the risk of pain afterwards.
54:12Yeah.
54:14I think Laura will do really well.
54:17The endometriosis is fully resected.
54:19It's unlikely to come back and I don't think there are any major health implications for Laura in the future.
54:25The rectum.
54:27Top of the vagina.
54:29The rectum's fine.
54:31Yeah.
54:31Neil, that's all done.
54:33Nice and dry.
54:34Fine.
54:35So the tractor out.
54:37OK, can I have the local anesthetic, please?
54:42Can I have some half-inch stereosis as well, please?
54:44I think that was a great outcome.
54:52As Laura is moved to recovery, Cameron calls her husband.
54:58Hi Stuart, it's Cameron speaking.
55:00Hello there.
55:01That's just finished.
55:03It took a long time actually.
55:05Laura, if you give my hand a squeeze there, you can hear me. Hi.
55:08Kidneys removed.
55:09The hysterectomy undertaken.
55:11The big mass is removed.
55:12And there was no injury to the bowel, so I was delighted.
55:15Yeah, no, really good news.
55:17I think she'll feel a great deal better after this.
55:19I really do.
55:20OK.
55:21Great.
55:22Bye-bye Stuart.
55:23Bye-bye.
55:23Bye.
55:30It's been 12 weeks since Alistair's operation.
55:33The recovery's been a lot more difficult than I thought it would be.
55:37The biopsy of nodes in his right groin found cancer.
55:42So I had to go back for another operation.
55:46Since then, I've been given the all clear, which is fantastic news.
55:50Hang on up.
55:51His friend Richard continues to support him.
55:55Hi Cameron.
55:56As he deals with lymphedema, a known complication of lymph node clearance.
56:03I'm suffering from a lot of lymphedema, which is massive swelling in my testicles.
56:07So it's very uncomfortable.
56:10It's been difficult, but take that as long as it means surviving.
56:14Cheers.
56:15Cheers.
56:15Cheers.
56:16I would definitely say he's getting stronger as the weeks go on.
56:20Getting there.
56:21Good days and bad days, but...
56:22Aye.
56:24I can't thank Dr Shockley enough for what he's done.
56:27I'd like to thank the nurses at the Western General for all their support and also the district nurses in
56:33the Burness.
56:34Here's us sitting there with a cup of fruit juices in front of us.
56:38That's not normal.
56:40I'm very optimistic for Alistair.
56:43Once things have settled from the cancer point of view, we can reduce that lymphedema, preserve sexual function, and hopefully
56:50allow him to live a more fulfilling life.
56:56Come on, get a wiggle on.
57:00Laura's operation to remove a huge cyst caused by extreme endometriosis was just seven weeks ago.
57:09The surgery went really well.
57:11The big thing is the pathology came back clear.
57:16Probably my biggest fear was that that mass may have been something more sinister and we would have needed more
57:21treatment.
57:22Come on then. Show us the monkey bars.
57:25If we hadn't done the full hysterectomy, this could have come back and possibly attack my right kidney.
57:33I've only got one left. I haven't got any more spares to take.
57:37I'm really impressed with your monkey bars, buddy. That was really, really energetic.
57:41It's great to be home with the boys.
57:44The last six months have been so stressful.
57:48It's brought us all closer. We've got our little team.
57:51Wow, that was amazing! High five!
57:54Yeah!
57:56I'm so grateful to everyone that looked after me.
58:00James, he now wants to be a medical scientist.
58:04It's inspired him.
58:07I need to be dressed as a complex condition.
58:10I'm not a woman. I can't imagine what it's like with pain every day.
58:13I'm always amazed by how people handle things.
58:16She's come through it, which is just fantastic.
58:20Next time...
58:21There's a pulse in that area.
58:23Life-saving surgery...
58:25That's worrying.
58:26Agree.
58:27...where surgeons must prepare for the unexpected.
58:31Do we just bail out at this point?
58:33What do you think?
58:35I think anyone who thinks that they've seen it all is kidding themselves.
58:41You Jamesak refused to leave my power then.
59:00All he attended...
59:01Again, we canationですね...
59:01Tells her all about theャ tribe Huh?
59:08What's the secret rooms?
59:08I think they can't tell people who invest themselves in their own company,
59:08I think, for a long time i do not pay them per se,
Comments