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00:01Okay, 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.
00:14I 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,
00:31it'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.
00:46Assas.
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.
00:58A bit of swearing.
01:00Angry.
01:01It's trying hard not to let that little voice of fear creep in.
01:05The pressure is quite high.
01:11Jump.
01:12Jump.
01:12Jump.
01:13The surgeons.
01:14Support you please.
01:15Bear the ultimate responsibility.
01:17I need to keep this under control.
01:20Cut.
01:21You've got one chance.
01:22This 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.
01:48The Royal Infirmary of Edinburgh has a 300-year history of surgical innovation.
01:55Consultant surgeon Anja Adair takes on complex cases involving the liver, bile duct and pancreas, a specialism known as hepatobiliary.
02:06My dad spent a lot of time in hospital and so I became really intrigued, really interested in the whole
02:11process.
02:12And I said to my careers teacher, actually I want to do medicine.
02:15And he said, have you thought about nursing?
02:18As soon as I went to medical school, I loved the thought that you would actually be fixing something and
02:23you could see that you had made a difference.
02:26For her next case, she's joined forces with fellow consultant surgeon and former boss, Professor Steve Widmore.
02:35I've known Steve for over 20 years.
02:37I first met him as a surgical trainee.
02:40Steve was an established consultant, Mr. Widmore to myself at that time.
02:44And he very much became my mentor.
02:46I was really inspired by how he worked.
02:49I'm probably getting towards the twilight of my career, but ultimately the objective of any really experienced good surgeon must
02:57be to make their colleagues as good as them, if not better.
03:01That's the yoda in us that needs to come out.
03:08Their patient has an aggressive tumour blocking her bile duct, the tube connecting her liver to her intestine.
03:15It has left her unable to digest food.
03:18She's had this imaging and that shows that there's a definite stricture in the bile duct just outside the liver.
03:25This is a bile duct cancer.
03:26It's very difficult to treat.
03:28Surgery is definitely the only possibility of cure for this lady.
03:32If the tumour isn't removed, it could prove fatal within two years.
03:37Wild duct cancers are very difficult to treat because the position of the tumours is often at a junction box
03:45where lots of arteries and veins come in and out of the liver.
03:49And the difference between success and disaster can really be just a few millimetres.
03:5962-year-old livestock farmer, Joyce, lives with her partner, Colin, near Huntley in Aberdeenshire.
04:06We're alarming just now and I'm not allowed to go near them for bugs and germs, so I'm kind of
04:12missing this this year.
04:14How's it been going?
04:15All right.
04:16All right.
04:16Plenty of alarms are there.
04:17How are you feeling?
04:19You know, better?
04:20Mm-hmm.
04:21I would say I had indigestion, but then again, like any older person, you think indigestion.
04:27I've had too much fatty foods, too rich foods.
04:31Liver function tests came back abnormal and a biopsy revealed it was cancer.
04:37My partner's busy enough harm.
04:40Your friends and neighbours, they become part of the family.
04:43Hiya, it's me.
04:45Come in.
04:46I think it is pretty tough for her at the moment.
04:48She's got a totally different life to six months ago.
04:51She knows we're here for her, especially now.
04:55More so now.
04:56Mm-hmm.
04:58So how do you feel about Wednesday, Joyce?
05:01A little bit apprehensive.
05:02Well, like anybody would be in the operation.
05:06Joyce's tumour is blocking her bile duct.
05:08Bile is a digestive fluid made in the liver.
05:12But to break down food, it has to reach the intestine.
05:17So I've got a bag and I've been draining.
05:20I have to recycle this.
05:22To bypass the blockage, Joyce must collect her bile with an external drain and then drink it.
05:29And I take it in iron brew.
05:31I've tried it with Coke.
05:32It's not the same effect.
05:33It doesn't smell.
05:34I say it tastes bitter.
05:36You just drink it and you get used to it.
05:39Even though it's like, I would say two years, but you know.
05:42I'll get a nice glass of Prosecco after, shall we?
05:45Not allowed.
05:47Wishful thinking.
05:49She's a tough cookie.
05:51But, yeah, she is obviously worried.
05:55Worried for her, obviously.
05:57She's got two little grandchildren now.
05:59So you just hope that she's going to be okay for them.
06:07Cheers.
06:07Cheers.
06:08Roll on next week, eh?
06:09Yeah.
06:10Get it over and done with.
06:11Like most people, I would say, you always think there's tomorrow.
06:15That won't happen to me.
06:17And you're thinking you've got tomorrow.
06:20But then again, you don't know what you've got.
06:24You know?
06:31Scans indicate Joyce's bile duct has a tumour where it enters the liver.
06:38To remove it, the surgeons will have to take the right side of her liver as well.
06:44But first, they must check the tumour hasn't spread to branches of the hepatic artery and portal vein.
06:52Because these are vital for the section of liver they intend to leave behind.
06:58Then, Anja and Steve will divide the bile duct near the pancreas.
07:03And the blood vessels going to the right side of the liver.
07:08They will cut the liver, dividing the bile duct where it branches into the left side, before finally removing it.
07:18Then they will join the remaining bile duct to the small intestine to restore Joyce's digestive function.
07:31Around 60 people in Scotland are diagnosed with Joyce's type of bile duct cancer every year.
07:38But only around five people meet the requirements for surgery.
07:42There are many reasons why only a small number can go ahead.
07:46And one of the reasons is that a patient's liver volume is not adequate.
07:51So that Joyce will survive with just the left side of her liver.
07:56She's undergone a procedure to encourage it to grow.
07:59We can harness the ability of the liver to regenerate and grow by selectively blocking the blood supply to part
08:08of the liver to stimulate growth in a bit that we want to keep.
08:14Hello.
08:15Hello.
08:16Hi, Idris.
08:17How are you doing?
08:18Fine.
08:19The good news is that your liver has regenerated fantastically well.
08:23So it's doubled in size, the bit that we're going to keep.
08:28Good news for you getting through this operation.
08:31It's a big deal.
08:33Yeah, it is.
08:35And you've gone through it.
08:36I mean, it's been months and you've done really brilliantly.
08:40You're in safe hands.
08:42Okay.
08:43That's it.
08:44Okay.
08:45Thank you guys.
08:46You're welcome.
08:47See you.
08:48See you tomorrow.
08:49Thanks.
08:52This is a difficult operation.
08:53About one in three people will get a complication such as a leak or a liver failure or a significant
09:00infection.
09:01Her safety absolutely comes first.
09:03But we know that the aim of the operation is trying to give her the best chance of her survival.
09:11Across NHS Lothian, 55 theatres are preparing for surgery, including Theatre 15 at the Royal Infirmary of Edinburgh.
09:21Hey, are we good to port?
09:24Where Anya is briefing a 15-strong team.
09:27We are planning a right hypotectomy, bile duct excision.
09:31She is otherwise fitting well.
09:33We need the Thompson.
09:35Ultrasound.
09:37Thunderbeats, skinny one.
09:39Cusa.
09:40Have I missed anything?
09:41No.
09:42That's amazing.
09:43I think that's us from our side.
09:45Yeah.
09:47It's not very far to go.
09:49We're just around the corner here.
09:51Success would be back to normal health and being able to do the job.
09:56Playing with our grandchildren, seeing them grow up.
10:01I'm one of the lucky ones to get an operation.
10:05So they're trying hard to keep me alive and curing what they can do.
10:10You're right there.
10:11That's their special occupation.
10:17This is you connected up to the anaesthesia now.
10:19It takes a couple of minutes.
10:20It's a nice gradual experience.
10:21One good thing about this, you can get nice dreams.
10:24Okay.
10:26Got another big deep breath for us, Joyce.
10:28One more for the road.
10:31Doing this kind of surgery is very challenging.
10:35It is very stressful and not everyone can do it.
10:40Anya is technically excellent.
10:43She's also quite courageous.
10:48Are you all right for us to start?
10:50Yeah.
10:50Brilliant.
10:52Yeah.
10:57Anya makes a 30-centimetre J-shaped incision through skin and fat from Joyce's breastbone to her navel.
11:08You prepare, you've got step by step, you think you know in your mind what's going to happen, you've got
11:14the pictures.
11:15And when we go into the operation, it's never quite the same.
11:18That's us.
11:20Yeah.
11:20There's always this sense of uncertainty.
11:25The bile duct is tucked underneath the liver and surrounded by major blood vessels.
11:30First feel?
11:32Very solid.
11:34Yeah.
11:35And it's still right-sided for now, isn't it?
11:39Left side feels okay.
11:40And bile duct cancers typically spread up and down, but they can also move sideways and involve the arteries and
11:47veins that run alongside the bile duct into the liver.
11:51For Joyce's liver resection to work, the blood vessels supplying the left side of her liver must be tumour free.
11:59For now.
12:01Actually, can you feel around the back and towards the left?
12:07It is possible that we find that the disease has progressed. That means that we cannot proceed.
12:13Yeah, it's hard to touch tumour.
12:16Okay.
12:23Besides complex abdominal surgery, the Royal Infirmary of Edinburgh is also a center of excellence for cardiothoracic procedures on the
12:32heart, lungs, and other organs in the chest.
12:37Consultant thoracic surgeon Malcolm Will carries out some of the department's most technically challenging operations.
12:45The airway, the lungs, the cardiac system are the fundamental components of life.
12:52Without the air, you can't breathe. Without the breath, the heart doesn't function.
12:56It's major surgery, but patients can really get a good outcome and it can transform their lives.
13:04Malcolm's next case is a rare cancer that requires major reconstructive surgery.
13:10So he's teamed up with consultant plastic surgeon Patrick Addison.
13:15Personally, I have a mixture of excitement and fear when it comes to very complex cases.
13:21A bit of fear going into particularly the bigger surgeries is healthy.
13:25If you're too arrogant as a surgeon, you probably end up doing things you shouldn't do.
13:30The patient has a large 10-centimetre tumour growing through his chest wall.
13:36This gentleman, he's 79, has a spindle cell, soft tissue sarcoma.
13:41You know, these are quite rare and it's very painful, been growing quite rapidly.
13:45So it's really surrounding all the ribs and sort of pushing into the chest cavity.
13:49Yes, I mean essentially without the operation, the tumour is inevitably going to grow.
13:54It's going to cause him increasing pain and discomfort and disability.
13:57It may affect his lung function even more and ultimately it's going to take his life.
14:01Yeah.
14:04Until a year ago, widower Ian from Delkeith in Midlothian lived a very fit and active life.
14:11Last year, I felt great, you know, on top of the world.
14:18I was swimming two, three times a week doing 40 lengths a time.
14:23Went walking, you know, on good walks, far walks.
14:26I thought at the time, this is a pretty good place to be at my age.
14:33Too good to last those times, yeah.
14:37The symptoms for me first developed, just a nagging pain and I had a closer look.
14:44There was a bump starting to appear here, you know, and it was coming round further and further.
14:51I do worry about my dad.
14:53He lives on his own after we lost my mum nearly six years ago.
14:58Dad, soup's ready.
15:00Super.
15:03It's been difficult, you know, I miss her so much, you know.
15:07Being out walking in nature has been a great comfort for me.
15:13When I had to stop with the cancer, I would like to get back on that, but it's probably buying
15:20this guy.
15:21Jammies.
15:22Jammies.
15:25Okay.
15:26I think my dad is pretty anxious about it.
15:28Of course, it's going to be a worry, but hopefully we've got a good end goal and a successful, you
15:35know, outcome, you know, for my dad, so.
15:39Does it fit on?
15:39Does it fit on?
15:40All right.
15:41Yes.
15:41Probably feeling a bit apprehensive, yes, but with Elaine beside me, I know she's rooting for me.
15:49Knowing Elaine's there, it fills my heart, yeah.
15:54Yeah.
15:56Yeah.
16:02To remove Ian's tumour, Malcolm will cut out a section of his chest, including part of his pectoral muscle and
16:12four ribs.
16:13Then, to protect the chest cavity and lung, he'll use a special surgical mesh to patch the hole left behind.
16:22Patrick will replace the lost tissue by dissecting skin and muscle from Ian's back.
16:28Its blood supply must remain connected, so he'll pass the skin and muscle through a gap made in the armpit
16:36to complete the chest reconstruction.
16:44Ready to go up on the lift?
16:45Yeah, oh, definitely, yes.
16:48Another challenge for Malcolm and Patrick is that Ian has undergone intense radiotherapy to shrink the tumour.
16:55The downside to this approach, really, is that the radiation damages the tissues.
17:00If they're too scarred and thickened, it can make the surgery harder.
17:05Is it Ian?
17:05Yes, that's right.
17:06I'll take you round to your bed, it's all ready just now.
17:08Oh, that's brilliant, thank you.
17:10That's great.
17:10Yes.
17:12Look after yourself and hope it all goes well.
17:17And don't worry.
17:19Don't worry, I know that you're in safe hands.
17:21Exactly.
17:23We see patients, like, every day, day in, day out, who are, like, on the edge of health.
17:32Their life, their mortality is brought to the fore.
17:35I treat everyone like it was a family member in front of me.
17:38How would I do it if that was, sort of, my mum or my loved one or whatever?
17:43And that's how I approach every patient.
17:48Morning.
17:49How are you?
17:50Good.
17:51Good to see you.
17:52We'll get you into theatre hopefully quite soon.
17:55I'll be briefing the team.
17:57We're all, you know, here for you ultimately to get a good outcome and try and sort of cure this
18:01sarcoma.
18:02I'll have every confidence in your team.
18:05So, I'll speak to the team.
18:06Oh, you've been very thorough.
18:07We'll see you soon.
18:08Okay.
18:09You take care.
18:09Thanks again.
18:10You're welcome.
18:10See you later.
18:11Bye-bye.
18:13In theatre four.
18:15Right, morning, everybody.
18:17Malcolm is briefing an operating team of 18.
18:21So, it's going to be a circular incision around the mass.
18:23We're taking ribs two to five, probably.
18:26We're going to reconstruct the chest wall.
18:28The patient's been well informed, understanding the risks, which I've quoted a bit higher than average because of the radiation.
18:34Okay.
18:35Thank you, team.
18:36Thanks.
18:37All right.
18:39Here we go.
18:42Hello.
18:44Sweden.
18:45When I get out and build myself up, I'm really looking forward to getting back to nature.
18:52Feel the sun on your face or the rain on your back.
18:56You have some unfinished business.
18:59If you bring your shoulders up towards your ears and just roll them around and then just feel your muscles
19:06relaxing into the bed.
19:08Okay.
19:09We're going to take good care of you.
19:10We're going to be with you all the time.
19:12Okay.
19:16When I'm about to commence an operation, I have thought about it for so long in advance.
19:21I think all that preparation has kept me in a fairly relaxed state.
19:24It's a huge responsibility, but that just means that I have to steer the ship.
19:31Right, I'm starting.
19:33Okay, the knife.
19:34To assist the surgeons, a camera is inserted into Ian's chest.
19:39Let's put the camera in here, Sanjit.
19:41Registrar Sanjit Singh guides the camera into the pleural cavity, the space between the lungs and the chest wall.
19:49When we push a camera into a chest, we have a whole inspection of the pleural cavity.
19:55Okay, well, we're in.
19:57Can we see the edges of the tumour there?
19:59That can guide our incisions extremely, particularly if we think the tumour is bigger as it goes deeper to the
20:05ribs.
20:06Okay, so that, wow.
20:08This is all abnormal.
20:11There's quite a broad change in the pleural here.
20:14Yeah.
20:15The pleural, or lining of the chest wall, looks unusually thick and discoloured.
20:21I can see the edges of the pleural are quite white and thickened.
20:26And I'm not sure if this is a consequence of the radiation or the tumour.
20:31If I push on the edge of the tumour, it's there.
20:35So that's there, Patrick.
20:37Yeah.
20:38Yeah.
20:40Okay.
20:40We take the knife.
20:41I think Patrick and I will just work from either side.
20:45I'm already making a big incision for Ian.
20:47I'm planning something quite extensive.
20:49And now this pleural is sort of worrying me.
20:52I'm thinking, do I need to take, you know, a bigger resection margin?
20:56Is he going to deal with taking more away?
20:58Can Patrick, you know, close the defect with a bigger hole?
21:02I'm going to take him more just to get away from the pleural, really.
21:05Yeah, yeah.
21:06If we don't remove all the tumour, the chance of it growing back
21:10or spreading to other parts of his body are increased.
21:13He's only got one chance.
21:15We go later.
21:16Yeah.
21:16Yeah.
21:18We want a complete resection.
21:20To go back and do this again or over.
21:23I think at 79, that's not feasible.
21:27Yeah.
21:27We need to come down here a bit longer.
21:41In theatre 15...
21:42Let's open this up first.
21:44Mm-hmm.
21:45Anya and Steve are checking for any signs the cancer in Joyce's bile duct
21:49has spread to blood vessels supplying her liver.
21:53Okay.
21:55Just come across here.
21:57Take your time.
21:58Yeah.
21:58It's crucial to check the blood supply to the part of the liver that we wish to keep
22:05because the patient's survival is dependent on that blood supply.
22:10They begin by trying to safely locate the hepatic artery.
22:15What we're finding is that there's a lot of thick lymph tissue,
22:18which makes the operation technically more challenging to find the vessels and find them safely.
22:25And that's to see the artery.
22:27I agree.
22:27It's just under there.
22:28It is, yeah.
22:29It's around that area.
22:30Yeah.
22:31We have to find the artery.
22:32We have to be right on the artery.
22:34But at the same time, the artery is relatively fragile and what we don't want to do is bruise it.
22:39There's a pulse in that area.
22:41A quarter of the liver's blood comes from the hepatic artery.
22:46Damaging it could harm Joyce's recovery and increase the risk of liver failure.
22:53It would be nice to take that lymph nerve, wouldn't it?
22:55Yeah.
22:57We're clear the artery is...
22:59We are.
22:59Oh, yeah. Good point.
23:02I think the artery is behind.
23:04When we're doing these big operations, we don't think of who's the lead and who's the assistant.
23:08We're doing it together.
23:09I think so too.
23:11We're there as two minds and four hands because it can be physically and mentally quite challenging.
23:17And so for me, for Steve, it's someone who I trust his opinion and I can bounce ideas off.
23:21So, there's a bit of tissue here.
23:25Okay.
23:26Clean up a bit.
23:28That's our artery.
23:30Yeah, exactly.
23:31That's nice, isn't it?
23:32The hepatic artery is located and marked.
23:37That's very much a sense of, okay, that is one tick box.
23:41The artery is clear and so we can confirm that we are able to proceed.
23:47Now they need to find the second critical vessel, the portal vein.
23:52You take some of this tissue because that will get us to the portal vein.
23:54It will.
23:56Finding the portal vein with the artery still running and the bile duct still attached is slightly more tricky because
24:02it's sitting just behind it.
24:04Right.
24:06That portal vein?
24:07I think it is.
24:08Oh, that's great.
24:09Yes.
24:09Okay.
24:10That feels better.
24:12Yeah, it's nice to see the portal vein then.
24:14Feel some lymph.
24:16The portal vein delivers blood from the major digestive organs for processing in the liver.
24:22That feels clear up there.
24:24Mm-hmm.
24:26That's good.
24:27Yeah.
24:28That's got it up.
24:29Okay.
24:31Finding that the vessels are clear is a big relief and makes the likelihood of success in the operation much
24:38higher.
24:39To proceed with the operation to remove the bile duct tumour and right side of Joyce's liver, they must cut
24:46the bile duct.
24:47I think that's the duct there.
24:50Yeah.
24:51But first, they need to isolate it.
24:54The imaging suggested that her tumour was high up in the bile duct just as the bile duct entered the
25:01liver.
25:03It feels very firm.
25:05It does.
25:06I can feel that there's thick tissue extending from the tumour at the base of the liver all the way
25:14down the bile duct.
25:16We looked at each other and both thought, oh no, this looks like it could be a real problem.
25:23Let's have another feel.
25:25Yeah.
25:26It's very solid.
25:29What we're finding is that the bile duct is thick and abnormal all the way down its length to the
25:36top of the pancreas and this is not what we're expecting.
25:39I just wonder whether we can dig down into the pancreas.
25:44Can you get down below it? That's the question.
25:46Right.
25:47We're starting to think, is the cancer more extensive than we had anticipated?
25:52Is this cancer that is now in the lower end of the bile duct? Does this mean that we cannot
25:57proceed to the operation because it would mean that we will not be able to clear the cancer?
26:03I don't know that I can dig much further down there.
26:06No.
26:10Okay.
26:11And I'll take a sloop.
26:13Oh, yeah.
26:13Yellow.
26:14Yellow.
26:15Thanks.
26:15They reach the bottom end of the bile duct where it enters the pancreas and isolate it.
26:21Let's just have a pause a moment.
26:25So, um, the bottom end of the bile duct...
26:29Is thick.
26:29Is thick.
26:30And, um, that's worrying.
26:32Agree.
26:33But that must have changed quite recently because, you know, it looked like there was a good bit of normal
26:41bile duct.
26:42I never lose the ability to be suppressed in cancer cases.
26:46I think anyone who thinks that they've seen it all is kidding themselves.
26:49It feels like it's hollowed all the way down.
26:51Yeah, I think so.
26:53You can't feel or you can't get below it?
26:55No.
26:57We've already taken it down, sort of, almost into the pancreas.
27:02The pancreas is a vital organ, producing digestive enzymes and insulin.
27:07Removing it would have life-changing consequences for Joyce, like diabetes.
27:13We may not be able to remove all of the cancer by doing the operation that we've planned.
27:19And that leaves us with difficult choices.
27:23The question is whether we say that this can only be cancer, in which case she is not curative.
27:31So are we going to then do a disservice then to put her through?
27:36If we carry on then?
27:37Yeah.
27:40Yeah.
27:44Yeah, possibly.
27:46I don't know.
27:50If we went ahead, operated, and it was of no benefit whatsoever, and she had significant complications,
27:57then we would have given her the worst of both worlds.
28:00Do we just bail out at this point?
28:02Do we say, actually, that the risks of the operation outweigh the benefits?
28:07Oh, it's difficult, huh?
28:09Yeah.
28:19Yeah.
28:20In operating theater four...
28:22There.
28:24Yeah.
28:25Yeah.
28:28Malcolm and Patrick are working together to remove Ian's sarcoma.
28:32But identifying the tumor edges in the lining of the chest wall is proving a challenge.
28:38I can't say with any confidence where the tumor from the pleural surface starts and finishes, to be honest.
28:47When we take out any tumor, we need a margin of clear tissue, normal tissue that's not involved with the
28:54tumor cells.
28:55We're sense-checking each other as we go along.
28:58Do we feel the margins are clear?
29:00So, are you happy this is down far enough?
29:03Yeah, let's do a quick check again.
29:04We can undermine it further if you need to, but...
29:06Yeah, I think it looked okay.
29:09We generally tell ourselves we want at least maybe a thumbs width, about two centimeters.
29:15Ideally, maybe two thumbs, like four centimeters clearance.
29:19We might just have to bite the bullet and say, look, try and achieve the four-centimeter margin if we
29:25can.
29:25We've circled the tumor here, and really we've been right up into the armpit.
29:31We've taken off the pectoral, sort of minor muscle.
29:34We're just taking the pec major down towards the sternum.
29:38It's going to have a bigger hole than they thought.
29:40So, I think the tumor's there.
29:43I'm just thinking this operation's getting bigger and bigger.
29:46And Ian at 79, I need to keep this, in a sense, under control.
29:50A bigger hole will be harder on Ian's body, and harder to reconstruct later.
29:57So, maybe we should start cutting the ribs, I think, yeah?
30:01Malcolm begins to remove a section of Ian's ribs.
30:05See that inside?
30:07He makes an incision through the gap, or intercostal space, between the ribs, millimeters away from Ian's lung.
30:15So, I've just dissected around one of the ribs here.
30:17We'll just cut it, maybe the rib shear.
30:20We use what we call a shear, and it just cuts a nice, clean slice, like a clean break through
30:26the rib.
30:28It's brutal. It's a big insult to the chest.
30:31It's like almost having a car crash.
30:33Chump. Chump.
30:34Okay, that's up.
30:37It's crazy to think that when I do surgery, I'm doing quite a violent thing to a patient in that
30:44moment.
30:48Okay, just lift that slightly.
30:51I thought about this a few times, because when I was growing up in Hong Kong,
30:55it was quite a traumatic event in my life.
31:00I had a very violent sort of robbery when I was 14, like a family, like a gang robbery.
31:06But I literally awoke at three in the morning to a machete on my neck, and I was like hogtied
31:12and restrained.
31:14But I've like turned the violence in the opposite direction.
31:17It's like I'm helping somebody in a sort of controlled assault.
31:21I do think life sends you some experiences and you navigate it and you hear.
31:28Yeah.
31:32Malcolm's efforts to take wide margins with the tumour brings him very close to the right mammary artery.
31:39How's that inside sound, Ethan?
31:42Tell me where the mammary is. The mammary artery.
31:45A major vessel supplying blood to the chest.
31:48We've got about a centimeter and a half maybe.
31:52Okay, you haven't got cautious here then.
31:55It's a good going vessel. It's a good size.
31:57And if you injure that one, you'll get quite brisk bleeding.
32:01And because it's really fixed quite tightly to the back of the sternum,
32:04it can be quite difficult to stop the bleeding in that area.
32:08You see the mammary on the inside there?
32:10You're very close there.
32:12Malcolm can't necessarily see the vessel as well as myself and Sanjit can see it.
32:16Where's the mammary there? Okay.
32:19You're just above it.
32:20Above it?
32:20You're pretty close, but you're above it.
32:22Just above it.
32:23It's a little bit like your co-driver or your front seat passenger in the car
32:26is advising you that the road is clear.
32:28You have to have a trust in their judgement.
32:31The stakes go up a little bit.
32:33About there.
32:34Yeah, see?
32:35See?
32:36Yeah.
32:36Yeah, see there.
32:38Here, there.
32:39Yeah, you could come and just...
32:41You could just trip the third.
32:43Just here.
32:44Yeah.
32:44Okay.
32:44What's up?
32:45Yes.
32:46Key principles are complete resection and resection on block.
32:51And that simply means in one piece.
32:55You're not wanting to breach sort of into the tumour itself.
32:59We don't want to fragment the tumour and potentially seed it,
33:03you know, into the wound.
33:04We're trying to avoid that at all costs.
33:07Just lift up on the specimen slightly.
33:09Slowly, slowly, slowly.
33:15Okay.
33:16Okay.
33:17Okay.
33:17Right.
33:19The tumour is finally removed, but taking the extra cancer-free margins
33:24has almost doubled the specimen size.
33:29It's got a hole.
33:31This is about a scratch.
33:33There's no doubting that the hole is a considerable size.
33:37It is at the upper end of what I was anticipating.
33:41Obviously, the bigger the resection, the bigger the reconstruction is going to be.
33:45To reconstruct Ian's chest, Malcolm must first patch the hole in his ribcage with surgical mesh.
33:52Line it up somewhere about here.
33:54Okay.
33:55I think we should start somewhere on this first rib.
33:58Okay.
33:58So I'll take the drill.
33:59Thanks.
34:00The mesh needs to be stitched directly onto Ian's ribs to provide structural support.
34:06Okay.
34:08We're just making lots of little holes in the ribs.
34:11Yep.
34:12Okay.
34:13Okay.
34:14Yes.
34:14Without the reconstruction, the lung would, in essence, not function.
34:19When he took a breath in, in fact, the lung would collapse down rather than expand.
34:23It's important that there is some rigidity to ensure that you restore the mechanics of breathing.
34:30Okay.
34:31The mesh is folded into a pocket and stitched to one side of Ian's ribs.
34:37Okay.
34:37Let me see.
34:38One.
34:39Eight.
34:40I just want to see if it'll reach.
34:41The principle is to not have too much tension, but enough.
34:45Why don't we just see if we can reach to there?
34:48Because that'd be good to know that it will actually reach now rather than later.
34:54I'm definitely a bit worried.
34:55It's looking tight.
34:57It's on the cusp.
34:58Mm-hmm.
35:02We're trying to get this done quite swiftly, particularly when you're 79,
35:05to get them awake and breathing as quick as we can.
35:09It's tight.
35:12Am I having to take the whole thing out and just start over?
35:21In every major operation, up to 100 surgical instruments can be required.
35:28Across NHS Lothian, responsibility for making sure surgeons are handed the correct instruments
35:34lies with around 400 scrub practitioners.
35:38This is the tray we're going to be using today.
35:40I got a job in the department 12 years ago.
35:44I wanted to give back after losing somebody in my family and a friend.
35:48I was like, what can I do?
35:49And then I got into working in hospital and I've not looked back since.
35:53Katie is putting new recruits through their paces today with Peter, who's nearing the end of his two-year-long
36:00training.
36:01Treat your hands from now on like they're sterile.
36:04I got interested in being a scrub practitioner through my role as a clinical support worker.
36:09So I pull it back and there we go.
36:11When you watch a surgery and you see the scrub trays are out and all this equipment's getting used, I
36:17was just like, that's amazing, how do I do that?
36:20This high-pressured role means every item must be identified, prepped and passed with precision.
36:27You are the one who is handing up the instruments to the surgeon.
36:31You are checking that the instruments are correct in working order.
36:34It's something you need to learn to anticipate what could happen on worst-case scenario.
36:40What's this for?
36:41It's a backhouse towel case.
36:43Yep.
36:44It's very important that you understand the surgeon's needs and wants.
36:48It builds that trust and it makes the overall case work smoother.
36:52What do you call that?
36:54It's a cup rub.
36:55Yep, that's what they are. These are rub shears.
36:58I try and test myself sometimes, so if I open up a tray I'll look and say to myself, all
37:02right, what's that, what's this?
37:04How many scissors is on that tray?
37:06One, two, three, four, five.
37:08And then try and memorise.
37:11So we're just going to practise loading up some sutures.
37:15Nice.
37:16I enjoy working as part of this team and doing what I'm doing.
37:18I think it's a brilliant place to work.
37:20This is actually harder than parents are.
37:24I don't think people realise how many people it takes for the team to actually be able to do all
37:30of this and how many people are in the background.
37:38In theatre 15.
37:40That's pretty soon, isn't it?
37:42Yeah.
37:43The operation to remove Joyce's bile duct cancer is on hold.
37:48The surprise discovery of what may be tumour further down her bile duct has left the surgeons facing a difficult
37:55decision.
37:57To continue high-risk surgery knowing they may not clear all her cancer or abandon the operation.
38:09What do you think?
38:11What do you think?
38:11Difficult to call.
38:12I know that I was thinking, I don't know what the right thing to do.
38:16And, you know, looking at Steve as well, you can see his brain, you know, what is the right thing?
38:22There isn't a right answer.
38:27So, I don't know. I mean, it's difficult to say, isn't it? If it was me, I think I would
38:32rather go ahead and have it taken out.
38:36I think that would be probably better than being told that we bailed out.
38:42I think she's frightened of being inoperable.
38:47That's why I kind of picked up from talking to her yesterday.
38:50Through every step of Joyce's treatment up until now, it's been a joint decision between her and us as to
38:57what we do.
38:58And we're now in a dilemma that we cannot share with her.
39:00That is both a privilege and a responsibility to make the decision thinking what would Joyce want and what is
39:07in her best interest.
39:09Every surgeon aims to leave behind clear margins, tissue that is tumour free.
39:15Sometimes positive margins are unavoidable.
39:20If we do leave cancer behind, is it likely to impact badly on her long-term survival?
39:29I think the thing that sways me is that generally our pathology often does have positives somewhere.
39:36And we didn't know it and we accept it.
39:38Yeah.
39:39And actually they do okay. Our patients have done all right.
39:42They have some chemotherapy and they do all right.
39:44So actually having a positive margin may not be the end of the world?
39:48Yeah.
39:52We don't know that this is cancer. We're suspicious, but we don't have definite evidence.
40:00I think it is reasonable to proceed.
40:03Okay.
40:03So we decide to proceed with the operation that we planned to do, but divide the bile ducts as low
40:10down as we possibly can to make sure that we can clear as much as the abnormal tissue as we
40:15possibly can.
40:16Okay, so are we, as a team, do we feel comfortable?
40:20Yeah.
40:20Yeah.
40:21Okay.
40:22Uh, Lehi.
40:25Anya makes the critical first cut at the lower end of the bile duct, close to the pancreas.
40:35Okay.
40:36I'll just, I'll teach you.
40:38Now that we've made the decision, we can't have the what if, is this right, is this wrong?
40:43We need to put that to one side and now we focus on doing the operation safely and as effectively
40:49as we can.
40:51To remove the right side of Joyce's liver, they begin by marking out a path for dissection.
40:58So here, I just wonder whether we need to sort of-
41:01Slip down this way.
41:01Let's go, go.
41:02Yeah, agree.
41:03Go in there.
41:04Because our bile duct is here.
41:06That's all coming.
41:07Yeah.
41:08Come down here.
41:10Right, I'll take the accuser home.
41:12Yep.
41:15Accuser is a precise cutting tool, well suited to working on the liver.
41:19Right, let me just open this thing.
41:21It uses ultrasonic waves to break up tissue, while leaving blood vessels intact to minimise bleeding.
41:30Maybe put a clamp on the focal vein.
41:35So as you divide the liver, there can still be quite a significant amount of blood loss.
41:40What you can do is clamp the blood flow into the liver.
41:45We're going to put a, kind of a Pringle on, but just from the vein.
41:49Clumping the portal vein will cut off three quarters of the blood flowing to the liver.
41:55That's Martha Pringle coming on.
41:56But it's a risky procedure.
41:58Yep.
41:59That's it.
42:00Clock on.
42:00Ten minutes.
42:01Back.
42:04Maybe just got a bit more.
42:07What we are doing is clamping the portal vein for ten minutes, allowing us to work in a relatively bloodless
42:13field,
42:14and then letting the liver recover for five minutes, and then repeating.
42:20Oh, there's somebody.
42:21There's a big vein there.
42:23There it is.
42:25If you clamp it too much and the blood flow is not going in, it's going to affect the function
42:30of the liver.
42:34There's nine minutes.
42:36We're going to use every minute.
42:37Yeah.
42:39So sometimes you're just in a really good place, and, or you may have identified a vessel that you need
42:45to be careful with,
42:46and you need to secure safely, so it's okay to push it out a little bit.
42:50Wow.
42:51Yeah.
42:53Yeah, just give us a sec.
42:55Just tie this vein.
42:59Scissors.
43:05Pringle off?
43:06Yes, we're going to take the Pringle off.
43:08And we'll take some squish there, just to clean up.
43:14There, that feels better.
43:16There, now we're on the right side.
43:18This is all duct.
43:19They've divided the liver.
43:21Now, Anja must divide the top end of the bile duct, making sure to leave enough healthy duct behind for
43:28the reconstruction.
43:30Should we do it?
43:31Do you like the other field ducts?
43:32It needs a pair of sharp scissors for any.
43:35Yep.
43:36Oh.
43:37Okay, we're going to go here.
43:39So, let's just double check.
43:40So, arteries with you, left portal vein is there.
43:44Okay, you're going to go?
43:45Yeah.
43:50With the bile duct severed, there's one final vessel to cut before the liver can be removed.
43:56So, specimen's just about to come through, yeah?
44:00Just got to divide the right hepatic vein.
44:03Yeah, yeah.
44:03A bit of a good view.
44:04I've got a good view.
44:06Everyone can see?
44:07Yeah.
44:07Yep.
44:11Got a sucker there.
44:14Yeah.
44:14Okay.
44:15That's the specimen.
44:16Yeah.
44:17Let's just have a, yeah.
44:19That's good.
44:20Duct.
44:21The bile duct tumour is removed, along with the right side of Joyce's liver.
44:26Okay, thank you very much.
44:29Removing the specimen is always quite a tipping point in the operation.
44:33It does feel like a moment of relief.
44:36I'm going to look down here.
44:38There are times when actually you don't realise that you're not breathing properly
44:42and you're like, inside you've actually held your breath, but you're not aware of it.
44:46But it's almost like a sports person, you've got to keep going.
44:48It's kind of mobile litter.
44:51That's very nice.
44:51The final stage of the operation is to reconstruct Joyce's digestive system.
45:00Anya dissects a loop of small intestine and brings one end up to sit snugly against the
45:07remaining end of the bile duct.
45:09That's really nice.
45:10It's going to sit there quite nicely.
45:12Just there.
45:12Yeah.
45:14The bile duct and intestine are stitched together, which should now allow Joyce to digest food without having to drink
45:21her own bile.
45:24Technically, it's a fantastic operation.
45:27Every skill that I've learnt over all the years has come together.
45:31And so you're there with your team and you're working together and it's a wonderful place to be.
45:3610, 20, 30.
45:40The remaining end of Joyce's intestine is reattached, far enough downstream of the bile duct join,
45:47to allow good drainage and prevent reflux.
45:51It's good to share the responsibility and also share the technical skills.
45:57Thanks.
45:57I think Anya is technically easily as good as me, if not better.
46:02It's really slick and that's exactly the way that you want to do these complicated procedures.
46:08With the reconstruction complete,
46:14Anya and Steve make one final check of the blood supply to Joyce's liver.
46:19Oh, that's nice.
46:22The sound is very reassuring and you can see the pulse of the flow within the ultrasound.
46:28And yes, it's incredibly reassuring.
46:31It's all good.
46:31Thanks.
46:32Okay.
46:35I think we did do everything we could for Joyce from the very beginning all the way through.
46:40Steve and I have been completely invested in this.
46:43You know, we've been looking after Joyce since the beginning of the year now.
46:46So for months we've known Joyce.
46:49She's actually got quite a lot of muscle, hasn't she?
46:51She has.
46:52You know, she's farming women.
46:54Strong.
46:58Knowing the uncertainty with Joyce does leave a little bit of a cloud.
47:02There is this question mark.
47:04Have we left cancer cells?
47:06They won't know if it is cancer in the lower bile duct until the results come back from pathology.
47:25In theatre four, Malcolm has reached a critical point in Ian's chest wall reconstruction.
47:33Let's just see where this is going to get to.
47:35Let's pull towards us.
47:39The mesh pocket has been stitched to one side of Ian's ribs.
47:42The worry is, it's too small.
47:45We'll have to coax it.
47:46Okay.
47:47Surgeons are naturally perfectionists.
47:48And they want everything to look, you know, as good as it could possibly be.
47:52But the key thing as a surgeon is to make your decisions fairly quickly.
47:56But to also not allow that slight, you know, anxiety or perfectionism to sometimes frustrate you or to tell you
48:04to actually do it again, do it again.
48:07I think it will, but it needs to be snug, but it is snug.
48:11It is?
48:11Yeah, okay.
48:12Okay, one more stitch.
48:14Yeah, sometimes you've got to weigh up and go, actually, that looks just a little tight, but it's acceptable.
48:19And the quicker you do that, then the quicker the patient gets through the operation.
48:23Take it quickly here.
48:25To give Ian's chest wall extra support, the mesh pocket is filled with quick-drying acrylic bone cement.
48:32I think that's just done now.
48:34As the cement is setting, you know, there's a period of maybe three or four minutes where it's sort of
48:39malleable.
48:40We can still manoeuvre it.
48:41We can compress it.
48:42I think just give me a little elevation, just gently.
48:46Sanjit pulls on the threads to shape the cement into a dome, allowing space for the lung to expand.
48:52As long as it's not too tight.
48:54It's more painful when it's too tight.
48:55Yeah.
48:56The height's all right.
48:57It looks pretty good.
48:58Let's take these out.
49:00At that moment, I'm certainly feeling a bit more relief and, ah, I can step back a little bit.
49:08More light, Patrick, or no?
49:10For the final stage of Ian's reconstruction, Patrick will cover the defect using skin and muscle from Ian's back.
49:18He begins by dissecting the latissimus dorsi, the largest muscle on the back, which helps control arm and shoulder movement.
49:27Most patients are not overly bothered by losing the latissimus dorsi muscle.
49:33I think if you're a competitive athlete, you might notice it in older or middle-aged patients.
49:39Most of them are not that affected by the loss of that muscle.
49:43Just come up underneath the muscle.
49:48When I'm harvesting the muscle, I'm thinking, hoping that it's going to be the right size and that the skin
49:54paddle is big enough to close the skin on the front so that I don't need to use additional measures
50:01like skin grafts, which will delay the healing process and increase the risk of complications such as infection.
50:08Patrick works up towards Ian's armpit, separating most of the latissimus muscle to leave a connecting bridge of tissue or
50:17pedicle containing the muscle's vital blood supply.
50:21I'm getting closer and closer to where the blood supply to that muscle comes in.
50:26And so I'm taking greater care to try and make sure that I'm not damaging either the artery or vein
50:32that are keeping that muscle alive.
50:35Let me just kind of free it up a little bit more here.
50:40I'm not going to tempt fate by dissecting any closer to it because there's no need.
50:45Now Patrick must transfer the skin flap, still attached by its blood supply, to Ian's chest.
50:52We can come up a little bit higher maybe and take it through there.
50:55To do that, he creates a tunnel through Ian's armpit.
50:59Can you see it on your side? There it is there.
51:02We need to make the tunnel through the armpit big enough to pass the muscle and the skin paddle through.
51:08And that's a big enough hole to, Ian, it's nice.
51:11We also need to make sure that when we pass the muscle through that we don't twist it or kink
51:16or in any way compromise the blood supply to the muscle itself
51:19because the muscle would very quickly die and the reconstruction would fail.
51:35What's going through in my mind is whether the muscle flap will be big enough to cover the mesh, preferably
51:41in its entirety.
51:44OK. Yeah, I think it's good for the muscle.
51:47Actually, yeah.
51:48Yeah.
51:49Looks good.
51:50It's actually pretty much perfect size, isn't it?
51:52Yeah.
51:52It's going to cover the whole area.
51:54And the skin paddle should hopefully be a relatively nice fit in there.
51:58I think what we'll do is just cut the...
52:00The nerve.
52:01The nerve.
52:01To the muscle.
52:02So it doesn't twitch when he's moving his arm.
52:05To stop the muscle functioning in its new location, Patrick must sever its nerve.
52:12That's the nerve there, isn't it?
52:14Yeah.
52:16Is that a mushroom?
52:20I think all surgeons do doubt themselves from time to time.
52:25Just as you feel that you're getting good at something,
52:29if you're getting complacent or cocky or think that you're a good surgeon
52:33and nothing can challenge you, something will come along to bite.
52:36I want to check that it's the nerve and not the artery I'm about to cut.
52:40I mean, I'm surprised it's that close, but it's not normally right next to it.
52:45It's normally a little bit separated from it.
52:48What is that?
52:49The nerve can look quite similar to an artery.
52:52All the structures are thin, tube-like structures,
52:56and sometimes it can be a little bit tricky to tell them apart.
53:02The artery is the muscle's main blood supply.
53:05Severing it now would damage the tissue,
53:08risking complete failure of the flap reconstruction.
53:13It would just be a bit of a disaster to cut the artery at the moment.
53:16Yeah, yeah.
53:17A mistake you don't want to make, no, is it?
53:19No.
53:23Patrick works along the close-packed structures
53:26to find a point where they are further apart.
53:30The pulsation is behind it here, then.
53:32Yeah.
53:33You can see a pulsation in an artery.
53:36That's obviously a giveaway.
53:37Yeah.
53:37Just transmitted pulse.
53:38The pulse is behind it here, yeah.
53:40Yeah.
53:41Nerves have a more solid feel to them.
53:43They're slightly less compressible.
53:45It's too solid.
53:47It's not good enough.
53:50Okay, I'm just going to divide that.
53:51Happy?
53:52Yeah.
53:53We use our colleague as a sense check.
53:55Are you comfortable not doing something silly?
53:57We need to be 100% sure.
54:00Crunchy.
54:01Yeah?
54:02Yeah.
54:02Okay.
54:04Perfect.
54:04So they're divided?
54:05Okay.
54:06At some level, it's also a shared risk.
54:10With the nerve cut, Patrick and Malcolm work together to stitch the muscle in place.
54:17The muscle is a nice size.
54:19You know, it's almost a perfect match.
54:21We're feeling really quite pleased with ourselves, because it looks actually perfect, you know?
54:26Take the staple, please.
54:28It often astounds me how robust the body is, and how much you can free up a muscle or a
54:35chunk of skin and move it to another part, and how little blood supply it needs to stay alive.
54:44It's a thing of beauty.
54:45Yes.
54:46Not too shabby, is it?
54:48It's taken five hours for a team of 18 to remove Ian's tumour and reconstruct the hole in his chest.
54:56Thanks, Patrick.
54:58You've done very well.
54:59You're good.
54:59Thanks, Sanjit.
55:01At the end of most of my operations, I can 100% say I've given it my all.
55:05Are you able to stick out your tongue for me?
55:07Yes.
55:08Thank you very much.
55:09But I get relief if I can tell Ian, actually, yes, we've got it all out.
55:15Then at that point, I feel like I can rest.
55:24It's been four months since Joyce had her operation to remove her bile duct tumour.
55:30Due to a series of infections, she's still in hospital.
55:35I wasn't expecting to be this length of time in the hospital. Neither was my relations or friends.
55:41But there is good news. The pathology report came back negative, and she is cancer-free.
55:48I was told they've got everything, so I'm chuffed about that.
55:53Hello.
55:54Jen and her husband, Chris, have been visiting regularly.
55:59The first time we came down to see her, we just weren't sure if and when she was going to
56:04get home, in all honesty.
56:07She was just so poorly and so weak.
56:10The change since I saw her last is just dramatic.
56:14She looks like she's ready for home.
56:16So what are they saying regarding getting back?
56:18I'm hoping the end of the month.
56:19So you've got a couple of weeks, then, to keep at it.
56:22Yeah.
56:23Fingers crossed.
56:24Yeah, I know.
56:24Everything crossed.
56:25I'm feeling good and better, because I can see the light at the end of the tunnel.
56:29I've been well looked after.
56:31They've done everything for me, that they could do.
56:34I can't thank them enough.
56:37Joyce, the resilience that she's shown and what she's gone through is really commendable.
56:42And I don't know if I personally could be able to go through what she has and continues to go
56:47through.
56:47It really is something.
56:53So nice to be here now.
56:55This is one of the places you were going to come back to?
56:58Yeah.
56:58Yeah.
56:59Pain's nearly gone.
57:00Good.
57:01Oh, that's great.
57:02Yeah.
57:03I just saw a swallow there.
57:04Oh, wow.
57:06Right, so have a wee walk?
57:08Okay.
57:08Since leaving hospital 12 weeks ago, Ian has received the good news.
57:14He's cancer free.
57:16Very grateful.
57:17They really done their bit.
57:19I never had any doubts that they weren't going to see me through.
57:25I'm so pleased that he's come through it all and, you know, he's doing great.
57:30He's able to get back out walking.
57:32He's doing stuff in the garden.
57:34He's determined to live a good life again, which is great.
57:38You know, he's going to be 80 this year.
57:40And I think that there'll certainly be a good few more years to come, which, you know,
57:45we're just really, really pleased about.
57:47Bees seem to quite like it.
57:49Sort of bee friendly.
57:50Yeah.
57:51Always bee friendly.
57:54It's a real tonic for me.
57:56Onward and upwards.
57:57You know, there's...
57:58Keep exercising.
58:00You know, there is room for improvement.
58:03Still similar petrol in the tank, yeah.
58:06Ian, he's doing extremely well.
58:09I'm hoping of bottom time and that he goes back to his gardening,
58:14that he spends time with his daughter.
58:16We want him to go back to almost where he was before all this.
58:20And if that's achievable, then we're happy.
58:39Next time...
58:41I really didn't expect it to be cancer.
58:43Resection, right tongue.
58:46An operation to remove tongue cancer.
58:48There's a big no.
58:50With no guarantee of success.
58:53I'm still stuck.
58:54The margin of success could be the thickness of a scalpel blade.
59:26And you'll be it.
59:29That has
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