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Surgeons: At The Edge Of Life - Season 8 Episode 1 - Sacrifice To Survive
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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.
00:14We can do it.
00:15We're going to be with you all the time.
00:17But some patients' procedures are so complex,
00:20only the most skilled surgeons can perform them.
00:24You prepare.
00:25I'm starting.
00:26You think you know in your mind what's going to happen.
00:29That's knife to skin.
00:30When we go into the operation,
00:32it's never quite the same.
00:34Wow.
00:36Serving Edinburgh and the surrounding area,
00:39NHS Lothian pioneers techniques to treat conditions
00:42that few others dare to take on.
00:46That's us.
00:46Stay fired away.
00:47The margin of success could be the thickness of a scalpel blade.
00:52You always got some nervousness or trepidation.
00:56Something is wrong.
00:59A bit of swearing.
01:00Angry.
01:01It's trying hard not to let that little voice of fear creep in.
01:06The pressure is quite high.
01:11Jump.
01:12Jump.
01:12The surgeons...
01:15...bear the ultimate responsibility.
01:18I need to keep this under control.
01:20Cut.
01:21You've got one chance.
01:23This is what really happens behind the closed doors.
01:26That's the specimen.
01:28Of their operating theatres.
01:29We're almost there.
01:31If you think that you're a good surgeon and nothing can challenge you,
01:33something will come along to bite.
01:35Anyone who thinks that they've seen it all is kidding themselves.
01:46The Western General Hospital in Edinburgh is one of only two centres in Scotland
01:52able to treat certain very rare male cancers.
01:57Consultant urologist C.J.
01:59Shukla takes on some of the most complex cases.
02:03I grew up in East Africa and in the 80s you were either a science or a non-science person
02:09and I was very much into sciences and I liked all the sciences.
02:12So it was either going to be something engineering related or something affiliated to healthcare.
02:17I felt healthcare has a more direct impact on people and helping people.
02:24Which 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.
02:37The next case we're going to do is a 48-year-old man who actually came to see me a
02:42few weeks ago
02:43with a newly diagnosed penile cancer.
02:47Cancer of the penis affects an average of around 700 men each year in the UK.
02:53So this is his corpus cavernosum which is his penile body.
02:57This is the head.
02:58Yeah.
02:59And that is his tumour.
03:01When it comes to penile cancer most people are taken aback that there is such a thing.
03:08This is such an unknown entity that most of my patients become completely surprised that you can get a cancer
03:14on the penis.
03:16Registrar Sabine Ugozova will be assisting CJ during the operation.
03:22The tumour has progressed in the short time that I've known him and that's the nature of penile cancer.
03:27How far do you think you'll need to dissect?
03:29What we're going to do is a partial amputation where we're going to take the glands and the very tip
03:35of the body of the penis.
03:42CJ's patient is Alistair, a construction engineer from Inverness.
03:47The first thing I noticed it was actually Boxing Day last year.
03:52I went to the toilet and I passed a lot of blood in my urine.
03:56But I never really thought anything of it because it only happened once.
04:03Then after that I noticed there was a small lump in my penis.
04:08But I ignored it for about six weeks.
04:11Just kind of kidded myself that the lump was always there.
04:17You ask yourself, why did it happen to me if there's so few people get this type of cancer? Why
04:22did it happen to me?
04:32At least someone's in the fairway. Good shot.
04:36His lifelong friend Richard has been supporting him since his diagnosis.
04:44We've grown up together. We played football in the park together.
04:48Played our local sports shinty together.
04:55It was a good shot.
04:57As a friend, I can only be there for him.
05:00I'll phone him up if he likes to talk.
05:03I just like to listen and try and be a good friend for him.
05:10No, it's obviously a very sensitive part that they're going to be.
05:15The one good thing that you did was you went to the doctor.
05:19You did the right thing.
05:20You'd have a good play and feel of your willies.
05:26Well, us men are all good at that.
05:30I'd be lying if I said it. I wasn't very anxious.
05:33No, I know.
05:35A worrying time, innit?
05:37It's been too much recently, innit?
05:38Aye.
05:39But, you know, these surgeons are very good and you will be in great hands with them.
05:43You've got to remain positive and hopefully they do a good job.
05:48Yes.
05:53So that's the lymph node on the left, which is suspicious and on the right, they're borderline.
06:00Scans show Alistair's cancer has already spread beyond the penis.
06:05Lymph nodes are important stations in our body where our white cells, our lymphocytes, tackle infections.
06:13But lymph nodes are also a station where cancer spreads to.
06:16So you've got to deal with the primary tumour, but also chasing where the cancer cells might have gone to
06:22the lymph nodes.
06:24The operation to remove Alistair's cancer will be carried out in three stages.
06:31First, CJ will dissect Alistair's right groin and take out three lymph nodes so they can be checked for cancer
06:39spread.
06:42Next, to remove the primary tumour, CJ will amputate the head and a section of the shaft, including a safe
06:50cancer-free margin.
06:53To reconstruct a functioning penis, a layer of skin will be lifted from Alistair's thigh and stitched to the end
07:01to create a new head.
07:05Finally, CJ will tackle the left groin, dissecting all the lymph nodes because scans have confirmed cancer has already spread.
07:17But these are close to the junction of the lung saphenous and femoral veins, crucial blood vessels which return blood
07:25from the legs and feet.
07:26A mistake here could cause a major bleed with catastrophic consequences.
07:34I'm optimistic that we would be able to preserve two thirds of the length of the penis.
07:42Enough so that he would be able to stand and pass urine and have penetrative sex.
07:47But sometimes it may not end up looking to their satisfaction.
07:52There is, of course, psychological support that can be offered and we can direct them to that.
08:15It's very difficult to prepare for. It's very difficult.
08:23A fair bit of my penis is getting taken off.
08:28My biggest fear is that the cancer doesn't go away. That's my biggest fear.
08:34But Dr. Shackler is hopefully going to save my life.
08:38You're in the eye group, huh?
08:43It's 9am and in the Western General's 11 theatres, operations are getting underway.
08:50In Theatre B, CJ is briefing his team.
08:54We have one case for the day, a long case.
08:57He has had a penile cancer growing for a few months now.
09:02So we're going to do a right central node biopsy.
09:06Partial connectomy skin graft and a left radical groin dissection.
09:11Imagine a few more deep breaths there.
09:13All the way in, all the way out.
09:16Good, man.
09:20The minute I walk into theatre, I switch into my clinical mode.
09:25We'll spend a bit of time positioning him.
09:28Might just take a little bit longer setting up initially.
09:30Don't worry. Take your time.
09:33I do detach myself from the emotional side of things.
09:37And just focus on the steps and the anatomy and the pathology.
09:42And that helps me focus on the operation and the end game.
09:46Are we good?
09:47Yeah.
09:48That's good.
09:57It's actually a poor skin tumour, which is invading the glands here.
10:06And also you can feel it's actually invading the right side of the shaft of the penis.
10:12But he should have an adequate reconstructive option here.
10:19Our primary goal has to be oncological control to cure his cancer.
10:23We cannot compromise on that.
10:26Any reconstruction that we do is a secondary issue.
10:29OK, I'm going to inject his penis with the patent blue.
10:35The blue dye will travel to the lymph nodes in Alistair's groin.
10:40Hyperflex the skin.
10:42Making it easier for CJ to identify and remove the borderline ones.
10:47Look at that. It's like spidery webs.
10:51Excellent.
10:52OK.
10:54Can I have the Geiger counter probe, please?
10:58The Geiger counter also helps to pinpoint the nodes by detecting radioactive isotopes,
11:05which were injected into Alistair yesterday during his preoperative scan.
11:10OK, so, X.
11:13We have very little doubt that the left groin has got an involved set of lymph nodes,
11:18and that needs clearance.
11:20OK, knife, please.
11:25On the right side, though, we have borderline nodes.
11:28Nodes that are suspicious but not overtly involved.
11:31So for that groin, biopsy is the most appropriate way forward.
11:35You can actually see some bluey areas there.
11:39The blue dye has already reached the lymph nodes.
11:44Let's try and get underneath it.
11:48Harmonic, please.
11:53Specimen.
11:55These nodes will be sent to pathology for analysis, which takes several weeks.
12:00And this will be sent to node 2.
12:03If cancer is detected, Alistair will require further surgery.
12:08And, finally, lymph node 3.
12:15With the first stage of the operation complete...
12:21Okidokid.
12:22Can I have a marker pen, please?
12:25CJ can now turn his attention to the primary tumour on Alistair's penis.
12:31So what I'm doing is palpating where the tumour seems to be invading, which is around there.
12:36He carefully marks his incision line with a clean margin of tissue between the tumour and the rest of the
12:43penis.
12:45Most patients relate to being a man in relation to having a penis and a normal penis.
12:51Right, can I have a 10 blade, please?
12:52Yep.
12:53So having an operation that affects that...
12:57Turn 4 to 6.
12:58...has a huge psychological impact on patients.
13:13Six miles south-east is NHS Lothian's largest hospital, the Royal Infirmary of Edinburgh.
13:21It provides specialist care for women across the east of Scotland.
13:26Morning.
13:27Hi, hi.
13:28Taking on some of the most complicated gynaecological cases is consultant Cameron Martin.
13:35I think when people ask me what I do, I would generally tell them I'm a doctor.
13:40And, you know, a few might ask me, you're a bloke, why in a gynaecology and what is it attracts
13:44you to it?
13:45You know, to be honest with you, I think when you're a doctor or a surgeon, you just see a
13:50patient with a problem.
13:51And so, actually, I just see a patient for whom I can offer some form of surgical service, which I
13:58think I'm hopefully quite good at.
13:59Ureter comes down into the pelvis, we can follow that.
14:02His next case is so complex, he's enlisted the help of consultant urological surgeon, Alex Laird.
14:09The right ureter looks, you know, slightly more prominent.
14:14This will be the first time I've operated with Cameron.
14:16I do know from colleagues that he's a very experienced and talented surgeon.
14:21I think surgery is a real team sport, so bringing different specialties with different expertise in to get the best
14:26outcome for the patient is great.
14:30Our patient presented a few months back with symptoms of swelling, pain, abdominal girth extension.
14:38From a gynaecological point of view, we call this stage four endometriosis.
14:43Endometriosis, which affects one in ten women, is a chronic condition typically causing inflammation, pelvic pain and heavy periods.
14:53So, endometriosis has a spectrum.
14:57Stage one is a superficial deposit of womb-like lining on the outside part of the womb, on the organs
15:04of the pelvis, usually the bowel, the bladder, sometimes the appendix.
15:08And stage four is usually taken to mean disease that's caused the bowel to become adherent to the back of
15:14the womb, caused some scar tissue.
15:16In extreme cases, it can also produce large cysts full of old blood and tissue.
15:23This is an MRI scan just from yesterday, which demonstrates nicely this huge cystic mass in our pelvis, stretching all
15:31the way up to the umbilicus here, compressing the bowel at the back.
15:36A large left ovarian mass.
15:38The cyst, measuring nearly 20 centimetres, 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, you can see
15:51that the left kidney has none of the normal kidney tissue because it's chronically obstructed, no urine is able to
15:58drain down.
15:59Fewer than one percent of endometriosis cases involve the kidneys.
16:04It's unusual for the patient that this has completely destroyed the kidney.
16:09It would suggest it has come on relatively gradually.
16:13There is also a possibility the cyst may be cancerous.
16:18There is an anxiety that underlying this, there's actually a malignant process.
16:23A small number of patients with advanced endometriosis can have a rare cancer called a clear cell cancer of the
16:29ovary.
16:33That's good, isn't it?
16:35Their patient is Laura, who lives in Livingston with her son James.
16:40Do you want to build a car?
16:42And husband Stuart.
16:44Most of my life is kind of revolving around James at the moment.
16:48Suck the door!
16:50James's big passion is building things.
16:54Passed off!
16:57Laura's illness came out of the blue.
16:59That's the way, that's the way!
17:00He's going to crash land!
17:02A couple of years ago, we got lots of exploratory tests done to find out why we weren't able to
17:08conceive a second child after we had James.
17:11And found out I had quite severe endometriosis.
17:15My mum and my auntie both had endometriosis when they were younger.
17:21They both had incredibly heavy periods, very, very painful.
17:26But I had no symptoms of anything.
17:30Then, about a year ago, I started getting pain on my left hand side, but it was intermittent.
17:41I eventually got an ultrasound and they found masses.
17:47I was terrified.
17:50I couldn't believe it. It was really hard to get my head around.
17:53I can run and jump.
17:59We don't know for definite that it's not cancer, so the current plan is to do a full hysterectomy.
18:06It seems the safer approach, specifically when we've decided we don't want any more children now anyway.
18:12I am not a pet.
18:14I'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 to detach Laura's left kidney
18:33by cutting its blood vessels and carefully releasing it from surrounding tissue.
18:40Then Cameron will expose the cyst in Laura's abdomen.
18:44They must carefully remove it intact before sending it for biopsy to check for cancer.
18:52They will then disconnect the ureter from the bladder,
18:56avoiding injury to any nearby blood vessels supplying the lower body so the kidney can be removed.
19:04Finally, Cameron must carry out a total hysterectomy,
19:08carefully removing Laura's ovaries, fallopian tubes, uterus and 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 who's 37 years old.
19:32You have a full hysterectomy, precipitating menopause.
19:36It's a major operation with potential for significant blood loss.
19:42What?
19:43Significant complication.
19:46Phone James on some out, won't you?
19:49Tell him I'm okay.
19:51Probably go round and visit your lung first thing.
19:53Yeah, that would be great.
19:54Then go round and do the skull round with this.
20:04I am scared about the surgery.
20:07It's major surgery.
20:09No, the medication's just going on just now, okay?
20:12There is a risk that this is cancerous.
20:15It has already destroyed my kidney.
20:18I'm just going to start drifting you off to sleep, okay?
20:20I'll be really glad when it's gone.
20:23We'll see you in recovery.
20:32I'm sorry.
20:35Alex will lead the first stage of the operation.
20:38Thanks a lot.
20:40So Laura is positioned on her side.
20:42Can I please?
20:43For the keyhole surgery.
20:45Ah, 11-16.
20:47That's perfect.
20:50Alex carefully makes a series of small incisions.
20:54Perfect.
20:54And flip, please.
20:56And gas on, please.
20:58Carbon dioxide inflates the abdomen
21:01to give the surgeons access and a better view.
21:05If we can get the top lights off, thanks.
21:13This is the descending colon on the left,
21:16and this is the kidney round the back there.
21:19Before he can detach the kidney,
21:22Alex must shut off its blood supply,
21:24which comes from the renal artery.
21:27About a quarter of your circulating blood volume
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.
21:42So artery, I can't see at the back there.
21:46In kidneys, the artery is always right behind the vein,
21:50which is a bit awkward for a renal surgeon.
21:54We just get you to rotate that,
21:56so that veins up and down the way.
21:58Because if you're going behind the vein,
22:01then 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.
22:25It may be that that is the artery.
22:27There's not much space around the vessels,
22:30and the problem is they are fixed.
22:32Have 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.
22:44It's always just no more around the boat,
22:46so that if you...
22:46Exactly.
22:47So you don't turn something straight forward into disasters.
22:51Yeah.
23:04In Theatre B at the Western General...
23:07Dab and bipolar, please.
23:10Urologist CJ is at a crucial stage
23:13of Alistair's partial penis amputation.
23:18Just keep this on traction here.
23:22He's painstakingly cutting through skin
23:24and the four layers of fascia,
23:26or connective tissue, within the penis.
23:28Okay, just relax for a second now.
23:32I go by clinical experience,
23:34and I know that I can feel where the tumour is,
23:37and I go a couple of millimetres beyond it
23:40to make sure that I'm happy with that as a margin.
23:44See, you can see the tumour there, right?
23:46It's bulging there.
23:47Just going to be careful that we just stay superficial.
23:50When we're doing an amputation surgery,
23:53I'm not thinking about the impact of this on the patient.
23:58Mark a pen, please.
24:00I just focus on the science.
24:04This is where I'm going to make an incision.
24:10Can I have the knife, please?
24:11Yep.
24:15That is not to say that the impact of what I do to a patient
24:19is of no consequence to me,
24:21but I just deal with the condition and the theatre setting.
24:27Now you can see the right corpus cavernosum and 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 corporal tip.
25:00With the samples off to the pathology lab.
25:04Okay, so let's just go a little bit this way.
25:08And after nearly two hours of operating,
25:12the top of Alistair's penis,
25:15containing the visible tumour,
25:17is finally amputated.
25:19There.
25:22Can I have non-tooth forceps and a change of gloves for both of us, please?
25:26Yep.
25:34There's nothing there.
25:37So we are clear macroscopically.
25:41Hopefully, microscopically as well.
25:44Superficially, it looks clear.
25:46But to be certain all the cancer has been removed,
25:50CJ must pause the operation
25:52and wait for the results from the pathology lab.
25:57We've just got to wait for the frozen section.
25:59Yep.
26:00So, back after a quick drink.
26:02Great.
26:04If we're unlucky and the frozen sections come back positive from the pathology lab,
26:09then I will have to trim back even more of the penis until we get a clear margin.
26:28All right, here we go.
26:36Hi, Angelique.
26:38How are we going with the frozen sections?
26:45Great.
26:46Excellent news.
26:49Excellent.
26:50So it's all negative?
26:51I feel delighted that it's negative and that we have removed the primary tumour in its entirety.
26:59CJ can now begin the process of reconstructing the penis.
27:05We're hoping to preserve erectile function and a length that allows penetrative sex.
27:10These factors are important in giving patients the best outcome.
27:16That's the urethra there.
27:18Just hold that there for me.
27:20The first stage is to preserve Alistair's ability to urinate and ejaculate as before.
27:27So what I'm trying to do is evert the urethra like that, okay?
27:33Everting the urethra means turning the end of it inside out and securing it to the new head of the
27:39penis.
27:40Can you come out now?
27:42One of the complications of urethra reconstruction is that 7 to 10% of patients can get stenosis or narrowing.
27:51To prevent that from happening, you've got to try and evert the edges.
27:55A bit like when the rose opens up, you want the urethra mouth to open up in that fashion as
28:00well.
28:02So if you turn the penis to me that way.
28:05Perfect.
28:06Great.
28:07Every stitch, every cut that you make makes a difference.
28:11Ready?
28:11Yep.
28:12Okay, come on.
28:13Yes.
28:14That's nice.
28:15That's the fella.
28:17Okay, come on.
28:20Brilliant.
28:21Now we're ready to prepare the donor bed.
28:27CJ carefully reattaches the skin to the shaft.
28:32So I'm securing the skin to the deep focal tissue so it doesn't slide.
28:37And prevents the graft from sliding off as well.
28:43Okay, let's just see how it is on that side, that side.
28:48Yep.
28:49I'm happy with that.
28:50The next stage is to cover the new head of the penis.
28:54Right, can I have a ruler please next?
28:56By harvesting a skin graft from Alistair's thigh.
29:01See, it's five centimetres, that's two inches.
29:04And that way it's six centimetres.
29:08The reconstruction is quite complex because you have to know the patient.
29:12You have to know what their expectations are.
29:14Six by five, right?
29:16Yep.
29:17And there are two aspects of it.
29:18There are the cosmetic aspects that he has to accept how it looks.
29:23We'll just make it a bit bigger.
29:24In addition to the cosmetic aspects, it's the functionality.
29:28Will he be able to stand to pass urine and to be able to have sex in the future?
29:34A special surgical instrument called a dermatome
29:39is used to harvest the strip of skin
29:421,000th of an inch thick.
29:51Okay.
29:53Safety on.
29:56Okay.
29:57That's the graft.
30:00This wafer-thin piece of skin must be carefully stitched to the new head of the penis.
30:08So, let's just anchor it dorsally first.
30:14The difficulty isn't securing it.
30:16The difficulty is tailoring it so it looks like a good fit.
30:20Skin.
30:22Opus cavernosum.
30:25And skin.
30:28Scissors, please.
30:29The sharp ones.
30:33You have to work in a systematic way all the way around
30:37so 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.
30:50Okay.
30:51I'm happy with how that has anchored.
30:53Yes.
30:54I think 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, the graft should survive.
31:25So that's this side of the hemisphere done.
31:28I think it looks beautiful.
31:30Yeah.
31:35I think I'm happy with that.
31:38Got this open? Yep.
31:40The reconstruction is complete.
31:42But after five hours, the operation is far from over.
31:47So what I'm going to do is just cover this up like so.
31:51CJ still has to remove all of the lymph nodes from the left side of Alistair's groin.
31:57A procedure that is fraught with risk because of their proximity to a junction of critical blood vessels.
32:04It's an important landmark in the operation.
32:06You cannot avoid it.
32:09Okay.
32:09Right.
32:10Have the knife, please.
32:13That's the point that it gets my heart racing because the biggest worry I have is damaging these important blood
32:18vessels.
32:19It's one of the tributaries of the thephino-femoral junction.
32:23That would be the ultimate nightmare.
32:39In theatre one at the Royal Infirmary of Edinburgh.
32:42You have a lean look around the top here.
32:45Consultant urological surgeon Alex.
32:48That is actually the artery on the other side.
32:51Has finally identified the elusive renal artery.
32:55But it's hard to reach.
32:57I'll try and get a couple of purple haemolox on that, please.
33:01The haemolox are great because they're permanent clips.
33:05They're actually easier than trying to stitch blood vessels.
33:09But what you need to do is make sure they're in the right position.
33:13I'll maybe leave that at the moment.
33:15Just because it's tight and I don't want to nick that by accident.
33:20With a clip on the artery, Alex can tackle the vein.
33:25Great. And another one, thanks.
33:27You've got to be really careful and really precise when you're doing this part of the operation.
33:33And another one, thank you.
33:36Two on the bottom side, Jim.
33:38That will stay and then the one at the top just stopping his back bleeding.
33:42Scissors, thanks.
33:44With the vein dissected.
33:46Purple haemolox 6.
33:49Alex can now fully access the renal artery to clip and cut it.
34:00We've definitely dealt with the main vein and artery.
34:05With the blood supply shut off, Alex must mobilise the kidney.
34:14Yeah, completely disconnect.
34:17Now free from surrounding tissue, the kidney is still connected to the bladder by the ureter.
34:23Well, that's what it's done in a phrectomy bit.
34:26And won't be fully removed until phase two of the operation.
34:31Yeah, perfect. Okay.
34:33That's us, top lights on, please.
34:35Yeah, scope can come out.
34:36Gas can go off.
34:39Once Alex has finished his part of the operation, the focus then turns round.
34:46Wonderful.
34:47I know this woman has endometriosis, which is stage four, it's going to be difficult.
34:52Okay, sir.
34:54Cameron makes a 20-centimetre incision, cutting through layers of skin, fat and fascia to reach the abdominal cavity.
35:03That's the large mass there.
35:05And they get their first glimpse of the cyst.
35:08When we open up the abdomen, you get a real feeling for, one, the size of the cyst, and also
35:14where it's connected.
35:17So I think they can get a bit more space in the bottom here.
35:19This cyst is a balloon with dense fluid inside it, so you can compress it, but not squash it down
35:26flat.
35:28The cyst is so large.
35:29You'll weed it for the right to you.
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 at the back of the cyst, we're trying to identify that point of attachment.
35:46But it's really difficult because we can't see under it, we can't see over it, we can't see through it.
35:51And we have to work on the assumption it's stuck to something important.
35:57There isn't much space, but you can see colon coming, reflecting at the top there.
36:02It's definitely under tension and pressure when we're mobilising that.
36:07I think the METs are those two things.
36:10Deflating it would give us a bit more space, but I think we should try and get out without deflating
36:14it if we can.
36:14I want to remove this cyst without bursting it, because at this point in surgery,
36:19we don't know if this is endometriosis or it's an ovarian malignancy.
36:23So by containing it, keeping it complete, we are avoiding spillage in the abdominal cavity.
36:31I think we'll just keep going down here. I'm nibbling down.
36:34Yeah.
36:34In my mind, I have a 3D idea of how everything connects together.
36:39With endometriosis, everything becomes quite distorted.
36:42So when you're operating, you have to work around that.
36:45But you're always trying to be meticulous with what you do.
36:48It is actually coming up now, a wee bit.
36:50Yeah, it's definitely more mobile than it was.
36:53Carefully, the surgeons work together to separate the cyst from surrounding tissue.
36:59It seems like a sort of window.
37:01I think there is a window there.
37:01There, isn't there?
37:03There is.
37:03It's extraordinary.
37:05Scissors, please.
37:13Okay, happy with that.
37:14So what I want to do is get this mass out now, Alex.
37:16Yeah.
37:16If you do that, then we'll have loads of space.
37:20Cameron cuts the last adhesion, the left ovary and fallopian tube, where the cyst originated.
37:26And this huge mass can be removed.
37:30And specimen.
37:32It's amazing that someone can have such a massive cyst.
37:36That's the left ovarian mass.
37:39Taking it out intact is a really important moment, because I knew that if it was malignant,
37:45we've removed it without bursting it, which is better for Laura, which is great.
37:49So I think what we might do now is take an Alexis retractor, please.
37:53The retractor gives the surgeons a better view of Laura's abdomen.
37:57I can now see right into the pelvis, and I can see the extent of the endometriosis.
38:04Endometriosis triggers inflammation in the pelvis, which the body tries to heal by producing adhesions and scar tissue.
38:12My endometriosis, now.
38:14So that's pretty classical endometriosis.
38:17Causing the abdominal organs to stick to each other.
38:20This is a biopsy from right pelvic sidewall.
38:23What has now become clear is the degree of scarring.
38:29So 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.
38:37Yes.
38:37The next task is to remove the damaged left kidney, which is still attached to the bladder.
38:45A big deleted kidney.
38:49To fully disconnect the kidney.
38:51I know you keep it the same here.
38:52They must identify and then stay clear of the major blood vessels in the abdomen.
38:59These signals there, find the common hyliac.
39:03There's the vein there, I think that's vein, there's artery.
39:08The ureter is very stuck to the pelvic sidewall on the left.
39:12And that's from endometriosis.
39:15The problem here is it's quite dense scar tissue.
39:19I think I'd like to open this up here.
39:22It's definitely through a lot more than you expect.
39:26I think it's just all peeled in.
39:27All fucked into the centre of the way.
39:31What's feel down there?
39:32I like to feel down that little space at the front of the belly.
39:35Yeah.
39:37I'm confirming to the front of the belly.
39:42Bobby.
39:44Finally, Laura's damaged kidney is disconnected from her bladder.
39:48Kidney and ureter.
39:50And removed.
39:53There's a sense of relief when you've removed the damaged kidney.
39:58Fantastic.
39:59So, I've 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, the cervix,
40:09and the remaining fallopian tube and ovary on the right-hand side.
40:13I think we'll do the back here.
40:15I'll take the pair of scissors, please.
40:16I'll just take the next specimen.
40:19Right ovary and tube.
40:23The thing about endometriosis surgery that distinguishes it
40:26from general gynecological surgery is 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 to just keep sort of slowly going down here.
40:42To remove the uterus.
40:44I've got a 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.
40:55Yeah.
40:55Yeah, yeah.
40:56But there is a lot of bleeding.
40:59I'm going to check this other side out, so that we can get some control of healing and stasis to
41:02the back.
41:03They're just getting in their way.
41:05The bleeding from the uterine artery on the left side is a problem,
41:08but 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, not rushing and cascading the problem out of control.
41:30To control bleeding in operations like Laura's,
41:33surgeons rely on a range of highly technical surgical tools.
41:38At the Western General, a dedicated team of 11 technicians are responsible for servicing over 7,000 pieces of equipment
41:48every year.
41:50Across most hospitals, you'll find medical physics equipment management is always in the basement,
41:56and a lot of people don't know that we exist.
42:00One of the most specialized pieces of kit is an electrosurgical unit,
42:05which only the most skilled technicians can service.
42:09This device came in for repair.
42:13This machine provides the energy for surgical instruments that use heat to cut through and cauterize human tissue.
42:22Electrosurgery has been around for nearly 100 years.
42:25It's effectively an electrical scalpel.
42:31The only reason you can use electricity and not be electrocuted is because of the frequency that it's at.
42:38Operating at over 300,000 hertz, the high-frequency electricity vaporizes tissue by fractions of a millimeter,
42:46but doesn't penetrate deeply to cause an electric shock.
42:50A phenomenon known as the skin effect.
42:54Part of what we do is to ensure not just the safety of the patients, but the safety of the
42:59people actually using them as well.
43:04Particularly with a high-risk device like this, it's very important that it's doing what you're expecting it to do.
43:11It's one of the most tested devices that we have to make sure that it's very, very safe, because it's
43:18using electricity to cut.
43:20Start a test.
43:24I moved 300-odd miles to come here, but I've not regretted it for a minute.
43:30So that's a passing, that's within the spec.
43:34If you can see something that you've done which positively affects patients, it's very satisfying.
43:39Be good.
43:49In Theatre B at the Western General, urology surgeon CJ...
43:53It's pretty cool, slowly and slowly, yes.
43:55...has successfully excised the tumor and a section of Alistair's penis.
44:00Okay.
44:02Preoperative scans show the cancer has already spread.
44:06That's the node. Can you feel the node now? It's a decent size.
44:10It's huge.
44:11Yep.
44:13So every lymph node in his left groin must be removed.
44:17Right.
44:19Embedded in layers of fat and fascia, the packet of lymph nodes also lie next to the lung saphenous and
44:26femoral veins,
44:28which return blood from the legs and feet.
44:30There's the lung saphenous, I think, underneath there.
44:35You have to be able to take the lymph node packet out without injuring the sapheno-femoral junction.
44:43You've got to anticipate trouble.
44:45Have you got a two ovicle ready in case I prang the lung saphenous?
44:51That's the one bit where I could get myself into trouble.
44:55Worse still, potentially bring harm to the patient.
45:00Oh, careful. 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 time here.
45:12That's where we need to be.
45:17Gingerly, gingerly.
45:19Just take your time and take your time and take your time.
45:24I can actually see the sapheno-fem junction right there.
45:28The nightmare scenario that I would never want to be in is that you can inadvertently damage that junction
45:36and can lead to catastrophic hemorrhage.
45:39There we go.
45:44Okay. Pleasure, please.
45:54As CJ tries to free up the packet of nodes from the sapheno-femoral junction.
46:00This needs to all come with us, doesn't it?
46:03Yeah.
46:06It starts to bleed.
46:12Give me a saw.
46:15Give me a two ovicle.
46:17Mm-hmm.
46:21Pull that towards you.
46:23Okay, hold on. Let me get down.
46:28Touch in there.
46:32This bleed isn't a single vein that I can actually clip and tie.
46:36It's flush against the sapheno-femoral junction.
46:40Give me the right angle.
46:47Just suck in there.
46:54Okay.
46:57Where are we bleeding from?
46:58It's the edge of that vein, still.
47:01I have to say to myself, just take a deep breath.
47:04It's just a vein.
47:05You're the surgeon.
47:06Control it.
47:07A foroproline, please.
47:09It's about talking to yourself and keeping yourself calm.
47:13I'm just going to put a few scrolling stitches.
47:18CJ uses stitches and his years of experience.
47:23You often have to resort to the three Ps, which are perseverance, pressure and patience.
47:31Let me just control.
47:38The bleed finally stops.
47:41He can now safely remove the cancerous lymph nodes.
47:46Okay.
47:47Now, this is the lymph node packet here.
47:50Chunky packet, this.
47:52Yeah.
47:57Specimen.
47:59Okay.
48:00So, stop for a second.
48:01Can I have a swab?
48:03The main group of nodes is successfully detached.
48:06But to stop the cancer spreading further, CJ must remove them all.
48:13Okay.
48:14That's your natural packet.
48:16Okay.
48:17Excellent.
48:18Okay.
48:21With all the lymph nodes cleared from Alistair's left groin, the six and a half hour operation is almost complete.
48:29Fantastic.
48:34Great.
48:35That's closed it.
48:36Yep.
48:36Perfect.
48:39Every time I finish the operation, I look at how much of the phallus is left behind and think, will
48:46he be happy with this or not?
48:50We'll have the tegudum with pads for the groin.
48:56Good.
48:57It's an honor 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.
49:14I think that's us now.
49:16Hey.
49:18Lovely.
49:19Excellent.
49:20Thank you, everyone.
49:22Thanks.
49:29Alistair is moved to the recovery room.
49:32Just try and stay down before it's just snow.
49:36Take it easy.
49:37Just relax.
49:43How you doing?
49:46Good.
49:47Good.
49:47Operation went very well.
49:49Very, very well.
49:50Okay?
49:51When he's awake and I'm telling him how things have gone, I'm seeing the much more human side
49:58where I'm focusing on his emotions and I stop focusing on the science and the anatomy.
50:05Couldn't have asked for it to go any better.
50:07Good.
50:07Good.
50:08All right?
50:09Rest well.
50:10Look after yourself, all right?
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 and what the next steps are.
50:22Met tutaj to one of the Royal Infirmary of Edinburgh gynecologist Cameron and urologist Alex are trying to remove Laura's
50:43uterus.
50:45But she's losing more blood then expected.
50:48Right.
50:49And there's new앙te is with me in here before-screen.
50:56You have to be cautious. You can't just put a big leg issue around because the danger
51:01is you cause collateral damage to another vessel and the whole thing can cascade.
51:10I got it. I think that's pretty good that's it I think that's got it. I think the scissors
51:20things. That's uterine artery yeah. That just gives a bit more breathing space.
51:30Much better isn't it? Much better.
51:33With the uterine artery tied off, the bleeding is under control.
51:38Okay, can I have the knife please? And the uterus can be removed.
51:43Can I express some of the uterus?
51:49Yeah, that'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.
52:08The danger is going into the wrong plane here.
52:12I'm nervous at this point. Cameron and I are communicating about the difficulties,
52:18but as a surgeon you can appreciate when dissection is difficult, planes are stuck,
52:23and you're also aware of the potential complications and risks in that area too.
52:30I think that that's gone on there.
52:32I think the danger is going to be too close.
52:34Yeah.
52:36This is the weird rectum down here you see, but I think,
52:38I'm just not sure what this is.
52:39Yeah, sir.
52:41We have to be really careful with the dissection of the cervix.
52:44There's a big risk of a damage to the bowel.
52:49I don't want to use the AFME here. It's just about close.
52:56I know that if I make a hole in the rectum at this point, I know what that means for
53:01Laura.
53:02It could mean potentially further surgery, possibly even a stoma, a bag on her abdominal wall.
53:09So that single part of the operation, that release of the rectum for me as a gynaecologist,
53:14is the most complex part of the operation.
53:20The rectum's going down.
53:27When we've reached beyond the scar tissue on the back of the cervix and the rectum,
53:33we reach the softer point where we know we've gone beyond endometriosis.
53:38It's a fantastic feeling.
53:39The next special with the cervix.
53:43It's a really tricky section of that.
53:47The cervix.
53:48Yeah, I think so.
53:49Perfect.
53:50Perfect.
53:51Full end suture, I think.
53:53After six hours, the operation is nearly finished.
53:57Full end suture, please.
53:59I need some warm water.
54:01The final task is to suture the vagina where the cervix was removed.
54:06What I'm doing is a continuous mattress locker and that means that you reduce the risk of pain afterwards.
54:13Yeah.
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 major health implications for Laura in the future.
54:26The rectum.
54:27Top of the vagina.
54:29Bladder.
54:30The rectum's fine.
54:31Yeah.
54:31The ulcer's done.
54:33Nice and dry.
54:34Fine.
54:35So the tractor out.
54:37Okay, can I have the local anesthetic, please?
54:42Can I have some half-inch therese as well, please?
54:44I think that was a great outcome.
54:49One, two, three.
54:53As Laura is moved to recovery, Cameron calls her husband.
54:59Hi, Stuart.
54:59It's Cameron speaking.
55:01Hello there.
55:01Well, that's just finished and it took a long time actually.
55:05Laura, can you give my hand a squeeze there?
55:07Can you hear me?
55:08Hi.
55:08Kidney's removed.
55:09The hysterectomy undertaken.
55:11The big mass is removed.
55:13And there was no injury to the bowel, so I was delighted.
55:15Yeah, no, really good news.
55:17I think she'll feel a great deal better after this.
55:19I really do.
55:20Okay.
55:21Great.
55:22Bye-bye, Stuart.
55:23Bye-bye.
55:23Bye.
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 found cancer.
55:42So I had to go back for another operation.
55:46Since then, I've been given the all clear, which is fantastic news.
55:50Hang on up.
55:52His friend Richard continues to support him.
55:55Hi, Cameron.
55:56How are you?
55:56As he deals with lymphedema, a known complication of lymph node clearance.
56:02I'm suffering from a lot of lymphedema, which is massive swelling in my testicles.
56:07So it's very uncomfortable.
56:10It's been difficult, but take that as long as it means surviving.
56:16I would definitely say he's getting stronger as the weeks go on.
56:20Getting there.
56:21Good days and bad days, but I can't thank Dr. Shockley enough for what he's done.
56:28I'd like to thank the nurses at the Western General for all their support,
56:30and also the district nurses in Brunesse.
56:34Here's us sitting there with a couple of fruit juices in front of us.
56:38That's not normal.
56:40I'm very optimistic for Alistair.
56:43Once things have settled from the cancer point of view,
56:45we can reduce that lymphedema, preserve sexual function,
56:49and hopefully allow him to live a more fulfilling life.
56:57Come on, get a wiggle on.
57:01Laura'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.
57:23Show 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.
57:33I've only got one left.
57:34I haven't got any more spares to take.
57:37I'm really impressed with your monkey bars, buddy.
57:39That was really, really energetic.
57:41It's great to be home with the boys.
57:44The last six months have been so stressful.
57:48It's brought us all closer.
57:50We've got our little team.
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.
58:07It's a complex condition.
58:10I'm not a woman.
58:11I 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.
58:26I agree.
58:27Where 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.
58:39I'm not by noods.
59:08I'm not by noods.
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