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Surgeons: At the Edge of Life - Season 8 Episode 1 - Sacrifice to Survive
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00:06In the UK some 5 million major operations are carried out every year and we'll give you some
00:13of the good stuff we're gonna be with you all the time but some patients procedures are so
00:19complex only the most skilled surgeons can perform them you prepare by starting you think
00:27you know in your mind what's gonna happen that's nice to skin when we go into the operation it's
00:32never quite the same well serving Edinburgh and the surrounding area NHS Lothian pioneers
00:40techniques to treat conditions that few others dare to take on the margin of success could be
00:50the thickness of a scalpel blade you always got some nervousness or trepidation something
00:57is wrong that's worry agree that's trying hard not to let that little voice of fear creep in the
01:06pressure is quite high jump jump the surgeons bear the ultimate responsibility I need to keep this
01:19under control cut you've got one chance this is what really happens behind the closed doors that's
01:27the specimen of their operating theatres we're almost there if you think that you're a good surgeon and
01:32nothing can challenge you something will come along to bite anyone who thinks that they've seen it all
01:37as kidding themselves the Western General Hospital in Edinburgh is one of only two centers in Scotland
01:51able to treat certain very rare male cancers consultant urologist CJ Shukla takes on some of the most complex
02:03cases I grew up in East Africa and in the 80s you were either a science or a non-science
02:08person and I
02:09was very much into sciences and I liked all the sciences so it was either going to be something
02:14engineering related or something affiliated to healthcare I felt healthcare has a more direct
02:20impact on people and helping people which is why I decided actually medicine was for me
02:29CJ's next patient has an advanced cancer which if untreated will spread and become inoperable the
02:38next case we're going to do is a 48 year old man who actually came to see me a few
02:42weeks ago with a
02:44newly diagnosed penile cancer cancer of the penis affects an average of around 700 men each year in
02:52the UK so this is his corpus cavernosum which is his penile body this is the head yeah and that
02:59is his
03:00tumor when it comes to penile cancer most people are taken aback that there is such a thing this is
03:08such
03:09an unknown entity that most of my patients come completely surprised that you can get a cancer on
03:15the penis registrar Sabine Ugozova will be assisting CJ during the operation the tumor has progressed in
03:23the short time that I've known him and that's the nature of penile cancer how far do you think you'll
03:28need to dissect what we're going to do is a partial amputation where we're going to take the glands and
03:34the very tip of the body of the penis CJ's patient is Alistair a construction engineer from Inverness the first
03:48thing I noticed it was actually Boxing Day last year I went to the toilet and I passed a lot
03:54of blood in
03:55my urine but I never really thought anything of it because it only happened once then after that I
04:04noticed there's a small kind of lump in my penis but I ignored it for about six weeks just kind
04:11of
04:12kidded myself that the lump was always there you ask yourself why did it happen to me if there's so
04:20few
04:20people get this type of cancer why did it happen to me at least someone's in the fairway good shot
04:36his
04:36lifelong friend Richard right has been supporting him since his diagnosis we've grown up together we
04:46played football in the park together played our local sport shinty together it's a good shot as a
04:57friend I can only be there for them and a phone a map he likes to talk I just like
05:03to listen and try
05:05and be a good friend for them no I it's obviously a very sensitive part that they're going to be
05:14you
05:15know that the 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
05:25well we're all us men are all good at that
05:30I'd be lying if I said I wasn't very anxious no I know a worrying time innit it's just been
05:37too much
05:37recently you know aye but you know these surgeons are very good and you will be in great hands with
05:43them and got remain positive and hopefully they do a good job yes so that's the lymph node on the
05:54left which is suspicious and on the right they're borderline scans show Alistair's cancer has already
06:03spread beyond the penis lymph nodes are important stations in our body where our white cells our
06:10lymphocytes tackle infections but lymph nodes are also a station where cancer spreads to so you've
06:17got to deal with the primary tumor but also chasing where the cancer cells might have gone to the lymph
06:22nodes the operation to remove Alistair's cancer will be carried out in three stages first CJ will dissect
06:33Alistair's right groin and take out three lymph nodes so they can be checked for cancer spread next to
06:43remove the primary tumor CJ will amputate the head and a section of the shaft including a safe cancer free
06:51margin to reconstruct a functioning penis a layer of skin will be lifted from Alistair's thigh and stitched to
07:01the end to create a new head finally CJ will tackle the left groin dissecting all the lymph nodes because
07:12scans have confirmed cancer has already spread but these are close to the junction of the long
07:19saphenous and femoral veins crucial blood vessels which return blood from the legs and feet a mistake here
07:28could cause a major bleed with catastrophic consequences I'm optimistic that we would
07:37be able to preserve two-thirds of the length of the penis enough so that he would be able to
07:44stand in
07:44past urine and have penetrative sex but sometimes it may not end up looking to their satisfaction there is
07:53of course psychological support that can be offered and we can direct them to that
08:15it's very difficult to prepare for it's very difficult
08:43it's nine a.m. and in the western generals 11 theaters operations are getting
08:49underway in theater b CJ is briefing his team we have one case for the day a long case he
08:58has had a
08:59penile cancer growing for a few months now so we're going to do a right central node biopsy partial
09:06penectomy skin graft and the left radical groin dissection imagine a few more deep breaths there
09:13all the way in all the way out good man
09:20the minute I walk into theater I switch into my clinical mode we'll spend a bit of time positioning
09:27him might just take a little bit longer setting up initially don't worry take your time I do detach
09:34myself from the emotional side of things and just focus on the steps and the anatomy and the pathology
09:41and that helps me focus on the operation and the end game are we good
09:54it's good it's actually a foreskin tumor which is invading the glands here and also you can feel
10:08it's actually invading the right side of the shaft of the penis
10:12but he should have an adequate reconstructive option here
10:18our primary goal has to be oncological control to cure his cancer we cannot compromise on that
10:25any reconstruction that we do is a secondary issue
10:29okay 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 making it easier for CJ to identify and remove the borderline ones
10:47look at that it's like spidery webs excellent okay can 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 we 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 on the right side though we have borderline nodes nodes 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 which takes several weeks
11:59and this will be sent to node 2
12:03if cancer is detected Alistair will require further surgery
12:09and finally lymph node 3
12:15with the first stage of the operation complete
12:20okly-dokly
12:22can I have a marker pen please
12:25CJ can now turn his attention to the primary tumor on Alistair's penis
12:31so what I'm doing is palpating where the tumor seems to be invading
12:34which is around there
12:36he carefully marks his incision line
12:38with a clean margin of tissue between the tumor and the rest of the penis
12:44most patients relate to being a man in relation to having a penis and a normal penis
12:50right can I have a 10 blade please
12:52yep
12:53so having an operation that affects that
12:5710-4-6
12:58has a huge psychological impact on patients
13:13six miles southeast is NHS Lothian's largest hospital
13:17the Royal Infirmary of Edinburgh
13:20it provides specialist care for women across the east of Scotland
13:55morning
13:55morning
13:55hi
13:55hi
13:55can offer some form of surgical service which 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 I do know from colleagues that he's a very experienced
14:19and talented surgeon
14:20I think surgery is a real team sport so bringing different specialties with different expertise in to get the best
14:26outcome for the patient is great
14:29our patient presented a few months back with symptoms of swelling pain abdominal girth extension from a gynaecology point of
14:39view we call this stage 4 endometriosis
14:43endometriosis which affects 1 in 10 women is a chronic condition typically causing inflammation pelvic pain and heavy periods
14:53so endometriosis has a spectrum stage 1 is a superficial deposit of womb like lining on the outside part of
15:02the womb on the organs of the pelvis usually the bowel the bladder sometimes the appendix and stage 4 is
15:10usually taken to mean disease
15:11that's caused the bowel become adherent to the back of the womb caused some scar tissue in extreme cases it
15:19can 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 stretching all
15:31the way up to the umbilicus here compressing the bowel at the back the large left ovarian mass
15:38the cyst measuring nearly 20 centimeters has already affected a major organ
15:45we'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 because it's chronically obstructed no urine
15:57is able to drain down
15:58fewer than 1% of endometriosis cases involve the kidneys
16:04it's unusual for the patient that this has completely destroyed the kidney
16:08it would suggest it has come on relatively gradually
16:13there is also a possibility the cyst may be cancerous
16:17there 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
16:39do 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
16:53shut the door
16:57Laura's illness came out of the blue
16:59that's way, that's way
17:00he's gonna crash land
17:01a couple of years ago we got lots of exploratory tests done
17:06to find out why we weren't able to conceive 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
17:25but 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
17:58we don't know for definite that it's not cancer
18:02so the current plan is to do a full hysterectomy
18:06it seems the safer approach
18:08specifically when we've decided we don't want any more children now anyway
18:12I am not a pet
18:14I'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
18:27first Alex will use keyhole surgery
18:29to detach Laura's left kidney
18:32by cutting its blood vessels
18:35and carefully releasing it from surrounding tissue
18:39then Cameron will expose the cyst in Laura's abdomen
18:44they must carefully remove it intact
18:47before sending it for biopsy to check for cancer
18:52they will then disconnect the ureter from the bladder
18:56avoiding injury to any nearby blood vessels supplying the lower body
19:00so the kidney can be removed
19:04finally
19:05Cameron must carry out a total hysterectomy
19:08carefully removing Laura's ovaries
19:11fallopian tubes
19:12uterus
19:13and cervix
19:19it's really quite nice though
19:21it's nice isn't it?
19:22this is not a minor endometriosis procedure
19:25this is a major undertaking in a young woman
19:28who's 37 years old
19:30thank you
19:32you've got a full hysterectomy
19:33precipitating menopause
19:36it's a major operation
19:37with potential for significant blood loss
19:43significant complication
19:46phone James on some help, won't you?
19:49tell him I'm okay
19:51probably go round and visit your lung first thing
19:53yeah, that would be good
19:54then go round and do the school round
19:56yes
20:04I am scared about the surgery
20:07it's major surgery
20:09no, the medication's just gone on just now, okay?
20:12there is a risk that this is cancerous
20:14it has already destroyed my kidney
20:17we're just gonna start drifting you off to sleep, okay?
20:20I'll be really glad when it's gone
20:23we'll see you in recovery
20:37thanks a lot
20:39thanks a lot
20:40so Laura is positioned on her side
20:42knife please
20:43for the keyhole surgery
20:4511-16
20:49Alex carefully makes a series of small incisions
20:53perfect and flip please
20:55and gas on please
20:57carbon dioxide inflates the abdomen
21:01to give the surgeons access
21:03and 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
21:21Alex must shut off its blood supply
21:23which comes from the renal artery
21:27about a quarter of your circulating blood volume
21:29is 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
21:42the kidney there
21:42so artery, I can't see at the back there
21:46in kidneys the artery is always right behind the vein
21:49which is a bit awkward for a renal surgeon
21:54we can just get you to rotate that
21:56so 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
22:03and if there's major bleeding
22:05you can't then see the artery
22:08all going as expected
22:09it's a bit sticky
22:10and the artery is elusive
22:14normally on a good day
22:15you 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
22:24it may be that that is the artery
22:27there's not much space around the vessels
22:30and the problem is they are fixed
22:31I have the right angle please
22:33you 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
22:43it's always just knowing what's around the boat
22:46so that if you...
22:46exactly
22:47what's about so you don't
22:49turn something straight forward into disasters
22:50yeah
23:04in theatre B at the Western General
23:07dab and bipolar please
23:09yeah
23:10urologist CJ
23:12is at a crucial stage of 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 or connective tissue
23:27within the penis
23:28okay, relax for a second now
23:30thank you
23:31I 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
23:44you can see the tumour there, right?
23:46it's bulging there
23:47just going to be careful that we just stay superficial
23:51when we're doing an amputation surgery
23:52I'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?
24:11yep
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
24:31and 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
24:50to check if CJ has removed all of the cancer
24:54that's the left corpus cavernosum
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
25:14containing 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
25:47but to be certain all the cancer has been removed
25:49CJ must pause the operation
25:51and wait for the results from the pathology lab
25:57we've just got to wait for the frozen section
25:58yep
26:00so back after a quick drink
26:03if 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
26:29all right, here we go
26:31all right, here we go
26:36hi Angelique
26:38how are we going with the frozen sections?
26:46great, excellent news, thank you
26:49excellent, so it's all negative
26:52I feel delighted that it's negative
26:54and that we have removed the primary tumour in its entirety
26:58CJ can now begin the process of reconstructing the penis
27:04we're hoping to preserve erectile function
27:07and a length that allows penetrative sex
27:10these factors are important in giving patients the best outcome
27:15that's the urethra there, just hold that there for me
27:19the first stage is to preserve Alistair's ability to urinate and ejaculate as before
27:27so what I'm trying to do
27:28is evert urethra like that, okay
27:33everting the urethra means turning the end of it inside out
27:37and securing it to the new head of the penis
27:40will come out now
27:42one of the complications of urethra reconstruction
27:46is that seven to ten percent of patients can get stenosis or narrowing
27:51to prevent that from happening
27:52you've got to try and evert the edges
27:55a bit like when the rose opens up
27:57you want the urethra mouth to open up in that fashion as well
28:02so if you turn the penis to me that way
28:05perfect
28:06great
28:08every stitch, every cut that you make makes a difference
28:11ready?
28:11yes
28:14that's nice
28:15that's the fella
28:17okay
28:18come off
28:20brilliant
28:21now we're ready to prepare the donor bed
28:26CJ carefully reattaches the skin to the shaft
28:31so 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
28:44okay let's just see how it is on
28:46left side, next side
28:47yep
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 centimeters, that's two inches
29:04and that way it's six centimeters
29:08reconstruction is quite complex because you have to know the patient
29:11you have to know what their expectations are
29:14six by five right?
29:16yep
29:16and there are two aspects of it, there 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
29:33yeah
29:35a special surgical instrument called a dermatome
29:39is used to harvest the strip of skin
29:42hold hard
29:43one thousandth of an inch thick
29:51okay
29:53so safety on
29:55okay
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
30:08let's just anchor it dorsally first
30:14the difficulty isn't securing it, the 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
30:37so that it covers it without any crinkles, wrinkles or creases
30:41it's beginning to take shape
30:46you want it to be a smooth covering all the way around
30:49okay
30:51I'm happy with how that has anchored
30:53yeah, it'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
31:21if 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
31:37got this open?
31:38yep
31:40the reconstruction is complete
31:42but after five hours
31:44the operation is far from over
31:46so 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
31:59because of their proximity to a junction of critical blood vessels
32:04it's an important landmark in the operation, you cannot avoid it
32:08okay, right
32:09have the knife please
32:13that's the point that it gets my heart racing
32:15because the biggest worry I have is damaging these important blood vessels
32:20one of the tributaries of the thefino femoral junction
32:22that would be the ultimate nightmare
32:39in theatre one of 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 at 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
33:04they'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 and I don't want to nick that by accident
33:20with a clip on the artery
33:22Alex can tackle the vein
33:25great, and another one, thanks
33:27you've got to be really careful and really precise
33:29when 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
33:40just stopping his back bleeding
33:41scissors, thanks
33:43with the vein dissected
33:46purple haemolox 6
33:48Alex can now fully access the renal artery
33:52to clip
33:54and cut it
34:00we've definitely dealt with the main vein and artery
34:05with the blood supply shut off
34:08Alex must mobilise the kidney
34:14yeah, completely disconnect
34:17now free from surrounding tissue
34:19the kidney is still connected to the bladder by the ureter
34:23well that's what's done in the phrectomy bit
34:26and won't be fully removed
34:28until phase two of the operation
34:31yeah, perfect, okay
34:32that's us, top lights on please
34:34yeah, scope can come out
34:36gas can go off
34:39once Alex has finished his part of the operation
34:42the focus then turns round
34:46wonderful
34:46I know this woman has got endometriosis
34:49which is stage four, it's going to be difficult
34:51we can start
34:52thank you
34:54Cameron makes a 20cm incision
34:57cutting through layers of skin
34:59fat and fascia
35:01to 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
35:10you get a real feeling for
35:11one, the size of the cyst
35:13and also where 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
35:24so you can compress it
35:25but not squash it down flat
35:27the cyst is so large
35:29you'll weave it further down here
35:31they need to make the incision bigger
35:35really, really stuck at the back as well
35:37I'm going to take the round ligament first of all
35:39yep
35:40by feeling round the back of the cyst
35:42we're trying to identify that point of attachment
35:46but it's really difficult
35:47because we can't see under it
35:48we can't see over it, can't see through it
35:50and we have to work on the assumption
35:53it's stuck to something important
35:57there isn't much space
35:58but you can see the colon coming
36:00reflecting at the top there
36:02it's definitely under tension and pressure
36:04when we're mobilising that
36:07I think the mitts are those two things
36:10deflating it would give us a bit more space
36:11but I think we should try that out
36:13deflating it if we can
36:14I want to remove this cyst without bursting it
36:17because at this point in surgery
36:19we don't know if this is endometriosis
36:21or it's an ovarian malignancy
36:23so by containing it, keeping it complete
36:26we are avoiding spillage in the abdominal cavity
36:31I think we'll just keep going down here
36:32I'm nibbling down
36:34in my mind I have a 3D idea of how everything connects together
36:38with endometriosis everything becomes quite distorted
36:41so 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 a little bit
36:50yeah, it's definitely more mobile than it was
36:53I don't know
36:54carefully, the surgeons work together to separate the cyst
36:57from surrounding tissue
36:59it seems like a sort of wind
37:00I think there is a window there, isn't there?
37:03it's extraordinary height
37:05scissors please
37:13okay, happy with that
37:14so what I want to do is get this mass out now Alex
37:16if you do that, then we'll have loads of space
37:19Cameron cuts the last adhesion, the left ovary and fallopian tube
37:24where the cyst originated
37:26and this huge mass can be removed
37:29and 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
37:43because I knew that if it was malignant
37:45we've removed it without bursting it
37:46which is better for Laura, which is great
37:48so 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
37:59and I can see the extent of the endometriosis
38:04Endometriosis triggers inflammation in the pelvis
38:06which the body tries to heal by producing adhesions
38:10and scar tissue
38:12the endometriosis is there
38:14it is pretty classical endometriosis
38:16causing the abdominal organs to stick to each other
38:19this 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
38:34I think there's a section to do just here actually
38:36yes
38:37the next task is to remove the damaged left kidney
38:40which is still attached to the bladder
38:45a big deleted kidney
38:48to fully disconnect the kidney
38:50and how you keep it the same here
38:52they must identify and then stay clear
38:55of the major blood vessels in the abdomen
38:59the general's there
39:00find the common hyliac
39:03there's the vein there I think
39:05that's vein, there's artery
39:08the ureter is very stuck to the pelvic sidewall on the left
39:12and that's from endometriosis
39:14the problem here is it's quite dense scar tissue
39:19so I think I'd like to open this up here
39:22it's definitely through a lot more than I expect
39:26I think it's just all peeled in
39:27oh, fucked into the centre of the area
39:31what's peeled in there?
39:32it's just peeled in that of the space at the front of the valley
39:35yeah
39:37I have to go right to try this
39:38be careful
39:42lovely
39:43finally
39:45Laura'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
39:58so, you just got this to do now
40:02we're then left with the gynecological part of the procedure
40:05which is a hysterectomy
40:06and that involves removing the womb
40:07the cervix
40:09and the remaining fallopian tube and ovary on the right-hand side
40:12I think we'll do the back here
40:15I'll take the pair of scissors please
40:16I'll just take the next specimen
40:18right ovary and tube
40:23the thing about endometriosis surgery that distinguishes it from general gynecological surgery
40:28is that structures tend to be pulled in an unusual position often
40:32so, this is the point at which the rectum is firmly adherent to the back of the uterus
40:37there's another option but it just keeps 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
40:54yeah, yeah
40:56but there is a lot of bleeding
40:59I'm going to check this other side I like
41:00so that we can get some control of pulmonary stasis to the back
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
41:12because near that there are other major blood vessels
41:16so I have to just be really careful
41:19not 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
41:37at the Western General
41:41a dedicated team of 11 technicians
41:44are responsible for servicing over 7,000 pieces of equipment
41:48every year
41:50Across most hospitals you'll find medical physics equipment management
41:54is 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
42:02is an electrosurgical unit
42:05which only the most skilled technicians can service
42:08This 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
42:35is because of the frequency that it's at
42:38Operating at over 300,000 Hertz
42:41the high frequency electricity vaporises tissue
42:44by fractions of a millimetre
42:47but doesn't penetrate deeply to cause an electric shock
42:50a phenomenon known as the skin effect
42:53Part of what we do is to ensure
42:56not just the safety of the patients
42:58but the safety of the people actually using them as well
43:04particularly with a high risk device like this
43:07it'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
43:17because it's using electricity to cut
43:20Start a test
43:24I moved 300 odd miles to come here
43:27but 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
43:38it's very satisfying
43:39Be good
43:48In theatre B at the Western General, urology surgeon CJ
43:52This plate was slowly and slowly, yes
43:55has 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
44:22the packet of lymph nodes also lie next to the lung saphenous and femoral veins
44:27which return blood from the legs and feet
44:30There's the lung saphenous, I think
44:32underneath there
44:35You have to be able to take the lymph node packet out
44:38without 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
44:54Worse still, potentially bring harm to the patient
45:00Oh, careful, just 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 tongue here
45:12That's where we need to be
45:17Gingerly, gingerly
45:18Just take your time, and take your time, and take your time
45:24I can actually see the sapheno-junction right there
45:28The nightmare scenario that I would never want to be in
45:32is that you can inadvertently damage that junction
45:36and can 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
46:02Doesn't it?
46:03Yeah
46:06It starts to bleed
46:12Give me a sword
46:15Give me a two ovicle
46:17Mm-hmm
46:21Pull that towards you
46:22Okay, hold on, let me get down
46:28Touch in there
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 bleed
46:41Give me the right angle
46:44So...
46:47Just stuck 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, you're the surgeon, control it
47:07A four o'er proline, please
47:08It's about talking to yourself
47:11And keeping yourself calm
47:13I'm just going to put a few proline stitches
47:18CJ uses stitches
47:20And his years of experience
47:23You often have to resort to the three P's
47:26Which are perseverance, pressure and patience
47:31Let me just control
47:32Oh
47:38The bleed finally stops
47:41He can now safely remove the cancerous lymph nodes
47:46Okay, now
47:47This is the lymph node packet here
47:50Chunky packetless
47:51Yeah
47:57Specimen
47:59Okay
47:59Okay, so stop for a second
48:01Can I have a swab?
48:03The main group of nodes is successfully detached
48:05But to stop the cancer spreading further
48:08CJ must remove them all
48:13Okay, that's your natural packet
48:16Okay, excellent
48:18With all the lymph nodes cleared from Alistair's left groin
48:24The six and a half hour operation is almost complete
48:28Fantastic
48:34Great, that's closed it
48:36Yep, perfect
48:39Every time I finish the operation
48:41I look at how much of the phallus is left behind
48:44And think, will he be happy with this or not?
48:50We'll have the tegidum with pads for the groin
48:56It's an honour to be able to do what I do
48:59So this is basically like a cushion
49:01Hmm
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, excellent
49:20Thank you everyone
49:21Thanks
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?
49:46How are you doing?
49:47Operation went very well
49:49Very, very well, okay?
49:51When he's awake and I'm telling him how things have gone
49:55I'm seeing the much more human side
49:58Where I'm focusing on his emotions
50:01And I stopped focusing on the science and the anatomy
50:05Couldn't have asked for it to go any better
50:06Sure
50:08Alright?
50:09Rest well
50:10Look after yourself, alright?
50:12Okay
50:16I'm delighted how it's gone
50:18It's just a matter of time now to see what the results show
50:21And what the next steps are
50:35In theatre one at the Royal Infirmary of Edinburgh
50:38Gynecologist Cameron and urologist Alex
50:41Are trying to remove Laura's uterus
50:45But she is losing more blood than expected
50:48Yes
50:49And there's he's an archery that's with me in here, unfortunately
50:53I have to fight
50:53And then clamp the he's an archery
50:56You have to be cautious
50:58You can't just put a big leg issue around
51:00Because the danger is you cause collateral damage to another vessel
51:04And the whole thing can cascade
51:10I got it
51:12I think that
51:16Pretty good, that
51:17I think that's got it
51:19I'll take the scissors, thanks
51:23See your teeth?
51:24That's uterine artery, yeah
51:25That just gives it a bit more breathing space
51:30Much better, isn't it?
51:32Much better
51:33With the uterine artery tied off
51:35The bleeding is under control
51:38Okay, can I have the knife, please?
51:40And the uterus can be removed
51:43Can I express some of the uterus?
51:49Yep
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
52:06The 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
52:22Planes are stuck
52:23And you're also aware of the potential complications or risks in that area too
52:29I think that's gone on there
52:32I think the danger is going...
52:33Just that bit up here
52:33Too close?
52:34Yeah
52:35This is the rectum down here, you see
52:37But I think...
52:38I'm not sure what this is
52:40We 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
52:50Just a bit close
52:55I know that if I make a hole in the rectum at this point
52:59I know what that means for Laura
53:01It could mean potentially further surgery
53:05Possibly even a stoma
53:06A bag on her abdominal wall
53:08So that single part of the operation
53:11That release of the rectum
53:12For me as a gynecologist
53:14Is the most complex part of the operation
53:20The rectum's going down
53:25There he is
53:27When we've reached beyond the scar tissue
53:30On the back of the cervix and the rectum
53:32We reach the softer point
53:35Where we know we've gone beyond endometriosis
53:37It's a fantastic feeling
53:39The next session will be the cervix
53:43It's a really tricky section of that
53:47The cervix
53:49Perfect, perfect
53:51Full end suture, I think
53:53After six hours
53:54The operation is nearly finished
53:57Full end suture, please
53:59I need some warm water
54:00The final task
54:02Is to suture the vagina
54:04Where the cervix was removed
54:05What I'm doing is a continuous
54:08Mattress locking
54:09And that means that
54:10You'll 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
54:21And I don't think there are any
54:23Major health implications for Laura in the future
54:25The rectum
54:27Top of the vagina
54:29The rectum's fine
54:30Yeah
54:31Neil, that's that's done
54:33Nice and dry
54:34So the tractor out, thank you
54:37Okay, can I have the local anesthetic please?
54:42Can I have some half-inch terraces as well please?
54:45I think that was a great outcome
54:48Yes
54:49One, two, three
54:52As Laura is moved to recovery
54:55Cameron calls her husband
54:58Hi Stuart, it's Cameron speaking
55:00Hello there, that's just finished
55:03It took a long time actually
55:05Laura, can you get my hand a squeeze there?
55:07Can you hear me? Hi?
55:08Kidneys removed, the hysterectomy undertaken
55:11The big mass is removed
55:12And there was no injury to the bowel
55:14So I was delighted
55:15You know, really good news
55:16I think she'll feel a great deal better after this
55:19I really do
55:21Okay, great
55:21Bye-bye Stuart
55:22Bye-bye, bye
55:30It's been 12 weeks since Alistair's operation
55:34The recovery's been a lot more difficult than I thought it would be
55:38The biopsy of nodes in his right groin
55:40Found cancer
55:42So I had to go back for another operation
55:45Since then, I've been given the all clear
55:48Which is fantastic news
55:50Hang on up
55:52His friend Richard continues to support him
55:54Hi Cameron
55:55As he deals with lymphedema
55:58A known complication of lymph node clearance
56:02I've suffered from a lot of lymphedema
56:05Which has massive swelling in my testicles
56:07So it's very uncomfortable
56:10It's been difficult
56:11But take that as long as it means surviving
56:14Cheers
56:15Cheers
56:16I would definitely say he's getting stronger
56:19As the weeks go on
56:20Getting there, good days and bad days
56:22Aye
56:23I can't thank Dr Shockley enough
56:26For what he's done
56:27I'd like to thank the nurses at the Western General
56:29For all their support
56:30And also the district nurses in Inverness
56:34Here's us sitting there with a couple of fruit juices in front of us
56:37That's not normal
56:40I'm very optimistic for Alistair
56:43Once things have settled from the cancer point of view
56:45We can reduce that lymphedema and preserve sexual function
56:49And hopefully allow him to live a more fulfilling life
56:57Come on, get a wiggle on
57:00Laura's operation to remove a huge cyst caused by extreme endometriosis
57:06Was 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
57:20And we would have needed more treatment
57:22Come on then, show us the monkey bars
57:26If we hadn't done the full hysterectomy
57:29This could have come back and possibly attack my right kidney
57:32I've only got one left, I haven't got any more spares to take
57:37I'm really impressed with your monkey bars buddy
57:38That was really, really energetic
57:41It's great to be home with the boys
57:44The last six months have been so stressful
57:47It's brought us all closer
57:49We've got our little team
57:51Wow, that was amazing
57:53High five!
57:54Yeah!
57:56I'm so grateful to everyone that looked after me
57:59James, he now wants to be a medical scientist
58:04It's inspired him
58:07Endometriosis is a complex condition
58:09I'm not a woman
58:10I 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
58:22There's a pulse in that area
58:23Life-saving surgery
58:25That's worrying
58:26Where 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
58:39F
58:40You
58:40You
59:08Transcription by CastingWords
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