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Surgeons: At the Edge of Life - Season 8 Episode 4 - Back from the Brink
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00:06In the UK some 5 million major operations are carried out every year and we'll give you some
00:13of the good stuff we're gonna be with you all the time but some patients procedures are so
00:19complex only the most skilled surgeons can perform them you prepare by starting you think
00:27you know in your mind what's gonna happen that's nice to skin when we go into the operation it's
00:32never quite the same well serving Edinburgh and the surrounding area NHS Lothian pioneers
00:41techniques to treat conditions that few others dare to take on the margin of success could be
00:50the thickness of a scalpel blade you've always got some nervousness or trepidation something
00:57is wrong that's very angry that's trying hard not to let that little voice of fear creep in the
01:06pressure is quite high jump jump the surgeons bear the ultimate responsibility I need to keep this
01:19under control cut you've got one chance this is what really happens behind the closed doors that's
01:27the specimen of their operating theaters we're almost there if you think that you're a good surgeon and
01:32nothing can challenge you something will come along to bite anyone who thinks that they've seen it all
01:38worse kidding themselves the Royal Infirmary of Edinburgh is a center of excellence for cardiac and vascular surgery
01:58consultant cardiothoracic surgeon Renzo Pesotto and consultant vascular surgeon Orwa Fala are among the infirmaries most experienced
02:10cardiac surgery is an enormous privilege I like that patients come with a problem and we have a way to
02:18solve that problem or improve that problem
02:25it's total responsibility you feel because the patients give you their body to appear on when they
02:32get complications we are humans we feel for our patients and we don't like them happening but that's
02:38the nature of the job we do they are taking on an operation that pushes the human body to its
02:47limits
02:49where their patient will be drained of blood leaving them effectively lifeless this radical surgery is
02:59necessary to save their patients life it's very complex in the sense that it involves his head and neck vessels
03:10scans show that their patient has serious defects in three of his major arteries
03:17starting at the top of his heart and extending up the right side of his neck towards the brain
03:24so tabular dissection very big the coat is dissected up to the internal high blood pressure has caused the
03:33inner wall of the arteries to tear a very rare condition known as a dissection the dissection in
03:40general is a split in the wall of the artery and the blood goes between the layers of the artery
03:46the
03:46problem with that is acutely this can expand very quickly and cause a rupture and the patient can have a
03:53sudden death
03:57the damaged arteries must be replaced but they can't be replaced while blood is flowing through them
04:04and so renzo and all were must cool the patient to protect his organs stop his heart and drain all
04:12the
04:12blood from his body you have to accept that these operations are risky if you do 10 of them then
04:22one or two
04:23people will not survive 70 year old peter moved to edinburgh to be closer to his family five years ago
04:42he's a retired photographer originally from hong kong
04:46he's a retired photographer after the hello of the
04:51he just started to have more of his heart and now he's tired of it
05:00he's tired of it
05:12he's tired of it
05:22We have anxiety of taking him anywhere we kind of just stopped everything and just leave him at home
05:31and because we're just scared something might happen to him
05:38according to the statistics and having a dissection and surviving that without a surgery
05:45it's very low if they don't do it he is taking time wrong because dissection when when it happens
05:56it doesn't just go away Peter's only chance of survival is to have this surgery it's all about
06:05him getting home seeing his garden playing with the cats I think that's that's what I hope for
06:13and that's what he he wishes I think
06:21Peter has three damaged arteries critical to his brain that are threatening to rupture
06:28the aortic arch the right carotid and the right subclavian with its vital branch
06:38to avoid a rupture or catastrophic stroke Renzo and Orwell will replace the damaged sections with a
06:46synthetic graft but doing this means first stopping Peter's heart cooling him to just 24 degrees
06:58and draining all the blood from his body
07:02it will collect in a heart lung bypass machine so blood can be pumped to protect Peter's brain
07:10while Renzo and Orwell complete all the graft connections
07:16they have just 30 minutes before blood flow must be returned to Peter's body
07:22and he can be re-warned to prevent organ or brain damage
07:29right son
07:30let's go
07:30you guys
07:35the patient needs to be part of the journey and he's actually the one making the decisions because
07:42he could say the risk is too high and i'm not happy to accept it
07:50if you don't survive the operation your life ends there
07:56so this is where you can say see you soon because we'll go into Peter from here okay
08:13okay okay let's go
08:17the doctor told me this is a very complicated procedure
08:22to do 5-6 minutes
08:30the doctor told me
08:43Peter's operation one of 28 taking place at the royal infirmary today
08:49will be in theater for
08:53so our case this afternoon
08:56as there are two specialisms involved
08:59Renzo and Orwell brief a large team of 13
09:02CT scan has confirmed he has a type a chronic dissection which extends to his head and neck vessel
09:10in particular to the right subclavian will use retrograde cardioplegia and that's it from
09:16cardiac point of view yes from vascular point of view we need to make sure at any given point
09:21that he has uh well perfused supreme all right okay good one two three there we go
09:28it's perfect you're kidding comfortable
09:32just a little scratch okay nice deep slow breaths for us
09:35well done rest for me
09:46when you have a complicated case the night before the procedure you always think about it even
09:54before you go to sleep and when you wake up in the morning before you go to work
09:58even when you're driving to the hospital you still think about the steps you're going to do
10:04it's not just the operation start when you put the knife on the skin it comes many many many days
10:09before that
10:17the moment the patient accepts surgery then you feel responsible for his uh life and his
10:25outcome and so you carry a big weight on your shoulder i think
10:30okay thank you thank you thank you thank you thank you there before the surgeons can drain peter's body
10:36of blood to replace his arteries they must make sure blood will still reach his brain we'll start
10:43here exposing that okay all will makes a six centimeter incision just below peter's collarbone
10:50okay giving him access to the subclavian artery
10:59he carefully attaches a tube that will ensure blood flows to peter's brain throughout the operation
11:11this tube along with four others connected to peter's major arteries is linked to the heart-lung
11:18machine operated by senior perfusionist charlie ramsey perfusionists are solely responsible for
11:27for keeping that patient alive essentially this is a huge operation it doesn't come much bigger than
11:33this to be honest this is this is about the biggest thing that we do that's connected to you
11:38so check if you have a good strength and that's a good swing
11:45to go renzo needs to do the sternotomy then go through the neck
11:56renzo opens peter's chest
12:06and extends the incision 30 centimeters to below peter's right ear
12:14they can now begin the next crucial step
12:18stopping peter's heart and emptying his body of blood
12:24okay table down please
12:27it's a strange thing to do to somebody to be honest
12:30to stop their circulation completely and then drain all of the blood out of their body
12:36it's almost like we're taking them right to the edge of life and then bringing them back
12:42right the fun will start
12:53six miles from the royal infirmary of edinburgh is the western general hospital
12:59it's home to one of europe's largest dedicated specialist centers for colorectal surgery
13:09consultant colorectal surgeon varie collie joined the hospital in 2005 and was one of its first female surgeons
13:20it's very different to how it used to be my fondly departed mother-in-law was a cardiology doctor and
13:27as
13:27soon as you were married you couldn't be a hospital doctor that was in the 60s in glasgow in the
13:32uk
13:33i didn't have any of that lots of encouragement for which i'm very grateful
13:39varie's next patient has a complex and severe disease in his bowel
13:44he's a 29 year old man quite young and he has come in with a complicated diverticular disease
13:53diverticular disease is a condition where small pouches form in the lining of the intestine
13:59we've got what looks like quite a few diverticulae diverticulum is almost like a blowout so if you
14:06imagine a a strong tire and then the inner uh tire is kind of come through the outer muscle
14:12and it can get infected and inflamed and then it can pop and then you get a little hole in
14:19the bowel
14:19which may cause a small abscess or it may cause like a full-blown proper peritonitis where stool
14:27is coming out into the abdominal cavity and they're really ill with it the pouches in this patient have
14:33become infected and inflamed all of this is abnormal thickened inflammatory tissue this part of bowel
14:42is the sigmoid colon which should be further up and it's been pulled into this mass so this is a
14:47chronic abscess cavity and there's actually a connection between the sigmoid and the rectum
14:52here that shouldn't be there persistent infections have already led to the patient being hospitalized
14:59twice with sepsis my worry would be that he would have a really bad episode that would cause him to
15:06need emergency surgery which is much more risky the disease is also putting the patient's fertility at risk
15:13that chronic abscess is pressing into the seminal vesicles which are needed for fertility seminal
15:21vesicles are little glands near the prostate which are to do with the production of the fluid in sperm
15:29freezing his sperm is one sort of backup it's never a guarantee so i have to be very careful to
15:35preserve
15:36his reproductive function varis patient electrical engineer lewis lives with his partner in morningside
15:49in the south of edinburgh i first started experiencing symptoms sort of couple of years ago um but it came
15:58on very you know strongly with with with pain i couldn't actually stand with it my legs were turned into
16:04jelly because of where it was and how powerful it was you know the pain has meant lewis's passion for
16:10riding his motorcycle has been put on hold if i was to go out on it for anything sort of
16:16over half an
16:16hour then that'd be me not able to to stand able to sit down not able to do anything with
16:21any sort of
16:21comfort you know a ct scan and other tests revealed the diverticular disease i didn't really know what
16:31it was the only reason i'd i'd heard of it was because my grandmother had it you know she was
16:36in
16:36her 70s even then i didn't really understand what it was it's only when they explained the extent of
16:43the damage it caused i started realizing right okay this is actually quite serious you know
16:50the abscess is very near my seminal vesicles i believe they're called which is something i need
16:56if i want to have kids there's a risk they'll be damaged now as a result of this surgery with
17:02taking precautions i've been able to um you know freeze some sperm but i've been very upset yeah
17:09it was very hard to hear that i might not be able to have kids naturally
17:17lewis's sigmoid colon has been badly damaged by disease
17:22and a fistula or abnormal join is leaking waste and causing serious infections
17:32but before the colon can be taken out
17:36vari must deal with an abscess which is growing dangerously close to the seminal vesicles
17:43which produce seminal fluid she has to take care removing the abscess
17:49as damage to the vesicles could jeopardize lewis's fertility
17:56next vari must cut the upper part of the rectum below the disease
18:02and the sigmoid colon above the disease
18:08with the sigmoid colon removed vari will connect healthy colon with the rectum
18:14restoring lewis's digestive function
18:22lewis that's me my name is crushley i'll be doing your getting your organ excellent
18:26if you're talking about any patient that's going to need a four or five hour operation to get them
18:32clear that's pretty big pretty big surgery
18:38morning morning how are you i'm fine thank you how are you i'm fine you can't be living like this
18:45all the time no absolutely no and i also think there's a bit of a ticking time bomb there that
18:48bit
18:48bar we just need to get rid of it get it gone exactly
18:54across the western general's 11 operating theaters teams prepare for surgery
19:01in theater b vari briefs a team of six
19:06so lewis is quite fit and young we're going to do the pelvic dissection open because he's got a complex
19:13fistula and an abscess you ready yeah there's no one i think i'd rather do my surgeries she's got my
19:19absolute trust and faith otherwise i wouldn't be doing it frankly let's go hello good morning
19:29are you warm enough can you open your eyes happy yeah
19:36vari will be assisted by clinical fellow mariam baig
19:42so she's not far off finishing completing the surgical training so i'll kind of be in control
19:47of how the operation proceeds but there'll be quite a lot of parts of it that she'll be
19:52doing as well if i can have the cables please thank you vari begins with keyhole surgery
20:02it will mean a smaller incision when they open lewis up later aiding his recovery time can you grab
20:09that bit there sure that's it and then pull it sort of laterally enough yeah
20:17they need to free up or mobilize a healthy section of lewis's upper colon which will be used to
20:25reconstruct his bowel
20:29now can you get that bit yeah okay it's quite a long learning curve for lapiscoping every movement
20:36that you make outside of the patient is opposite to the movement that will be produced by the tip
20:43of your instrument everything's backwards so that makes it a bit more challenging okay good and if you
20:50pull a medial and a little bit down you do one little bit that's it great well done and your
20:58view
20:58it's 2d rather than 3d so that slightly limits your depth perception it's very much a two-person job
21:08continuously sometimes i will provide her with the vision so that she can cut something or burn
21:14something other times she'll do it for me that's fine so let's have a look how much bowel have we
21:20kind
21:20got to bring down i think we've got quite a lot we've got nice mobility yeah we do with enough
21:27healthy bowel freed up let's just look down here get into the pelvis a little bit varie can now focus
21:34on the diseased lower end of lewis's bowel the sigmoid colon so this is us getting it all it's all
21:40getting stuck now it's all jammed in the pelvis yeah you see there yeah and there's another loop of
21:48sigmoid there we can't really get into the pelvis because the loop of sigmoid colon is jammed down
21:55and stuck onto the rectum stuck onto the abscess stuck into where the seminal vesicles are but i
22:01don't know if i want to do any more locks properly yeah okay there's no way i'm going to be
22:07able to
22:07undertake a safe and effective uh operation and without opening him up am i when you're ready thank you
22:19mariam makes a 15 centimeter incision in lewis's abdomen i've probably come all the way okay we're
22:27going to need as much as we can down there sure
22:32thank you yes
22:37only now will they discover how bad the disease is
22:41yep let's have a look and see what we can do there sure yeah that's it
22:52in theater four at the royal infirmary
22:55so do this okay scissor 16 please renzo and orwa are preparing to drain all the blood from peter's body
23:05so they can replace his damaged arteries have been cold please yeah and cooling to 24. yep as it passes
23:14through the heart lung machine peter's blood is cooled from 37 degrees to just 24.
23:23the cold will protect peter by slowing the function of the cells in his brain and organs
23:29so they need less oxygen to survive in cooling the patient and using profound hypothermia buys you a
23:37window of time to be able to to do that operation safely so you can put the ice on the
23:45head if it's
23:45not there already shall we do the graft while we're cooling now yeah let's do now we need the graft
23:55give us those two no no let's do
24:02renzo and orwa need to tailor the graft a synthetic tube that will be used to replace the damaged arteries
24:12how's it cooling going charlie uh good yeah 30 degrees nasopharyngeal these operations are quite
24:20intense so in the crucial times you're not thinking about anything else but the technical aspect
24:28finishing what you're doing what is the next thing they're 25 please so we're almost there
24:39as his blood cools and a special solution called cardioplegia is infused peter's heart stops so his heart
24:48stopped we'll just do a final test with peter's body nearly at 24 degrees renzo and orwa need to make
24:59sure his brain will receive blood when the rest of his body is drained so start trickling through the
25:07cerebral cannula please okay that's running
25:16okay off it's all over places a tube into peter's right carotid artery which along with the tube in
25:25subclavian he placed earlier will supply his brain with blood okay so the right side of the brain now
25:32is secured with giving blood through the cannula on the right so we're 24 degrees okay okay stop the
25:45circulation there please okay that's down on flow and that's clamped peter has just been put into circulatory
25:58arrest his heart has been stopped and there is no blood flowing around his body it's draining into the heart
26:08lung machine we know it is possible that you can keep a live patient without having blood flowing through
26:20the patient as surgeons we are prepared for it but it still is an amazing part of the surgery that
26:28we do
26:30at this point at this point is fascinating to see a patient whose heart has stopped completely there's
26:39no blood going to any part of the body apart from the brain so essentially the patient is dead on
26:44the table
26:49that's the fascinating thing about doing surgery in people if you believe somebody has a soul
26:56okay okay and what keeps the human alive is it his heart or his soul
27:03i'm a muslim and i believe in what make you alive is your soul it's not your heart depends what
27:11you believe
27:20my dad as a person he's very caring
27:28deep in his heart he is a family man
27:34i think success will be him walking out the hospital himself
27:42uh just that's it i mean there's nothing more i can ask for
28:02in theater b at the western general
28:04you get the light any better there yes colorectal surgeon varie and clinical fellow mariam
28:13have just opened up lewis's abdomen in order to remove a diseased section of bowel
28:19there's something very intimate and interesting about the actual physicality of open surgery
28:26i suppose it's like anybody playing a musical instrument you know their fingers will be attuned to
28:31that instrument that's the same thing for a surgeon okay we've got lots of bowel
28:37diverticular disease has badly damaged lewis's sigmoid colon
28:42to remove it they must first carefully free it from surrounding tissue and organs
28:48and this loop of sigmoid is stuck do you want to have a feel yeah so there's we can actually
28:55feel
28:56underneath your face yeah so this is probably where the fistula is
29:02one of the diverticular pouches has become infected and burst creating a fistula
29:09so fistula is a connection between two things that shouldn't be connected like um your bowel and your
29:17skin or your bowel and your bladder so in the case of lewis it's actually bowel to bowel
29:25going between the sigmoid and the lower rectum so there's the fistula yeah
29:32into the bowel that's so that's probably the diverticulum that's caused all the trouble oh
29:37that's amazing the fistula has not only caused lewis's sepsis it's also leaking puss and fecal
29:45matter into the abscess and that abscess is threatening his fertility
29:53right so let's pack this small violet away the seminal vesicles are small glands they're quite
30:01soft and delicate and easy to damage and the abscess is kind of almost pushed into them
30:06and there's a persistent little collection of pus pushing them
30:11so this is really right into the seminal vesicles where the abscesses
30:19what i don't want to happen is that i end up cutting into his seminal vesicles that are
30:25difficult to see because the abscess is plastered on the top of them
30:34how does it feel is it coming it's all a bit attached on this side
30:40just haven't quite got it off that seminal vesicles yet okay it's all stuck isn't it
30:47if fari cuts the seminal vesicles lewis will lose his fertility he's so young you know he's not
30:55had his family yet and he wants to have a family freezing his sperm is the best we can do
31:03in terms
31:03of a fail safe but nothing is a hundred percent in medicine you're always hoping for the best preparing
31:09for the worst and then there's no guarantees i think the safest thing is to pinch it off yeah rather
31:14than try and cut because we don't want to cut any seminal vesicles sure yeah yes if i sort of
31:21pinch it
31:22off then i may leave a little bit of the wall of the abscess behind on the seminal vesicles but
31:27i
31:27think that would be safer than actually going into it yeah we could just take a little bit more here
31:34i
31:45think it's fine to leave a small amount of scar tissue it's the least dangerous thing to do in terms
31:51of
31:52not damaging things underneath all right let's get started here
32:04right when you push that back there
32:22i feel definitely relief that we've got past that rather tricky part um where i was worrying that
32:30i was going to potentially damage something that would have a lifelong repercussion for him
32:35so normally we'd be like oh done and dusted but in this case we've still got to get
32:41the direction the rectum sorted out we're not very good at taking our joy
32:48because we're on to the next problem immediately to prepare to cut out the damaged colon
32:54vari must now work her way down towards the rectum to find the end of the disease it is a
33:00bit stuck
33:00more stuck than i felt and more low feels much thicker and harder than normal bowel so when
33:11we're trying to join the bowel together it needs to be soft and pliable and well vascularized and likely
33:17to heal this don't seem to have a nice bit of rectum yet yeah we might need to go a
33:24little bit further down
33:27fari and mariam have to tunnel down deep into lewis's pelvis
33:32there's still a horrible bit there isn't there but yeah certainly quite horribly struck
33:39there's a period of time where i'm thinking i'm not going to find enough bowel and that would be
33:44healthy yeah maybe if you hold okay that bit for me there i think i might come and come through
34:08so that's nice bowel yeah that's good that's really good definite release and suddenly we're in soft tissue
34:17like you know sunshine after rain you know suddenly it's all all right again and we've found a nice
34:24bit of bowel it's worse than i thought it was going to be to be honest but we've got below
34:28it which is
34:29good now they've reached healthy tissue they can divide and take out the diseased colon
34:39first vari has to cut below the disease at the top of the rectum
34:46then she must cut at the other end above the disease
34:52enabling her to remove the sigmoid colon finally to restore lewis's digestive function
34:59she will join healthy bowel to the remaining rectum
35:04okay take a knife on a long blade you can let go i think yeah i think so yeah yeah
35:11you're very sorry
35:22so let's just have a look at it yeah well that's the worst place actually yeah it was all kind
35:28of
35:28stuck in like that wasn't it yeah like that so that's the fistula here to here and then the abscess
35:36here yeah yeah all right vari has to find a place to cut at the other end above the diseased
35:44section of
35:45colon my worry would be once we take out that bit of bowel how much have we got left between
35:51the anus
35:51and the bit that we're going to join up and the answer is not very much uh right let's decide
35:57what's
35:57coming down so nice nice and pink i think so yeah that's it
36:11very good okay i'll give you the specimen
36:18it certainly feels very satisfying to have it out of lewis not able to harm him anymore and also to
36:27visualize exactly why he's been unwell you know it's a nasty horrible bit of bowel which has been
36:32making him sick and it's out now they've cut out a third over half a meter of lewis's large bowel
36:42but for him to have a functioning digestive system they must reconnect the two ends where we're going
36:51to staple is about four or five centimeters from the anus yeah there it is but you might not be
37:00able
37:00to staple that so i think we're our limit here in lewis of how low i can do a join
37:07from above
37:08if fari can't make the join lewis would have to have a permanent stoma where waste is collected on
37:16the outside of the body in a bag this is the tricky bit isn't it
37:31in the days following their operation patients like lewis may not be able to absorb nutrients when
37:38eating you could have a patient that has had a complex colorectal surgery and sometimes when
37:44they've had the bowel played with it goes to sleep if nutrients can't be absorbed by the bowel
37:50they must be given intravenously total parenteral nutrition or tpn is a vital mixture that must be
38:00tailored for each patient so we were looking at a few things on this chart nutrition is so important
38:06for patients recovery and throughout their whole journey right so yeah we should probably be able to
38:12give her just the regular potassium in the bag great the dietitian is the specialist in working
38:18out what calories and nutrients the patient needs we then look at the patient's blood results and work
38:24out what they need on an electrolyte basis so i'll order one day from aseptic and then we can review
38:30her
38:31again tomorrow across nhs lothian around 8 000 tpn bags are made each year
38:39in the western general hospital's aseptic unit lead pharmacist david houll oversees the preparation
38:45of these life-saving infusions parenteral nutrition itself is a complex mixture of ingredients so you've
38:54really got a full dietary meal in one bag the first part of the process is combining the ingredients
39:02within the bag the majority of bags come as prepared mixtures of amino acids glucose and lipids
39:11once the seals are broken the bag is transferred into an isolator cabinet where more ingredients are
39:18added parental nutrition contains all your fat your protein your carbohydrate all your electrolytes
39:25like potassium magnesium things like calcium the ingredients themselves have got to be added in a
39:32specific order as well as in the correct volumes once prepared all tpn bags go for their final checks
39:42before heading up to the ward the aseptic team are a little bit behind the scenes
39:48but it's hugely important in the patient's journey everyone has those pieces of the jigsaw to help
39:56get that patient fit for discharge at the end of the day
40:05at the royal infirmary of edinburgh renzo and orwa are over two hours into the operation to save peter's life
40:15his blood has been drained into the heart lung machine and his heart stopped so are you loving
40:21bleed again they have just 30 minutes to replace peter's damaged arteries with sections of synthetic graft
40:31or he'll be at risk of organ damage
40:37if you don't do it in that certain time there's major problem can happen to the patient so that's an
40:42add-on pressure on you to execute it in a manner that it should be perfect and does work
40:49up on the suckers please suckers are up
40:55before they can refill peter's body with blood renzo and orwa must cut out the damaged section of peter's aorta
41:06and attach the synthetic graft
41:10when it's clamped blood can slowly be returned to peter's body
41:17the surgeons will attach the graft to the carotid artery in peter's neck
41:22and above his heart which can then be restarted
41:28finally the graft will be connected to the subclavian artery completing the reconstruction
41:38okay
41:38okay 11 blade renzo cuts open peter's damaged aorta
41:47carly remind us once in a while how long we have had the circulator arrest for okay
41:56so and all we need to attach the graft to the aorta's inner wall
42:01yeah graft please
42:03graft please
42:07there's a lot of adrenaline in your body you feel that you are just super concentrated and you know
42:16what is coming next
42:26okay now charlie come up on this line gently once the graft is secured to the remaining part of the
42:34aortic arch yeah it can be clumped meaning peter's blood can be returned to his body from the heart lung
42:42machine
42:44okay now you go back to full flow so you've got perfusion on the body coming up on flow
42:52when renzo asks me to come up on flow i can restart the systemic circulation and the clock will stop
43:00so to speak and then it's a bit of a sigh of relief okay you happy here yeah
43:10the heart lung machine is once more circulating blood around peter's body
43:16but his heart has been stopped for two hours and there are three more graft connections to complete
43:23so we'll now do the right carotid
43:34the first join or anastomosis must connect the graft to the right carotid artery in peter's neck
43:44where the artery walls are extremely fragile you have to do the anastomosis in a way that does not
43:52cause a further dissection because by definition when a patient have a dissection all over their
43:57arteries in the body they are vulnerable
44:01which is very important now
44:06it requires intricate work to stitch on the graft
44:11if you don't execute anastomosis in a perfect way you can make things more complicated
44:16so you have to do it perfect yes
44:26so there's six in the carotid sorted now i've got new grafts
44:30okay the graft to the carotid artery is complete
44:35so you can rewarm okay we warm it
44:38okay with just two more graft joins left charlie uses the heart lung machine to slowly bring peter's
44:47body back to a normal temperature you can never relax completely i've been doing this for so long that
44:54i know that there's there's a multitude of things that can go wrong and they can go wrong at any
45:00time
45:00and the head up
45:02the blood flowing through peter's body once again has created pressure the pressure is quite high charlie
45:13and there's a bleed from where the graft has been joined to the aortic arch
45:18is there any reason for that i'm not sure why no no it's very high i can feel it
45:24it's just too high i'm not quite i'm not quite even at full flow okay reduce the flow because it's
45:29too
45:30too yeah i can feel the pressure it's too high for the stick you know all right okay it's like
45:35when
45:36you're chased by a lion you've got to run you're not thinking whether i'm enjoying it or or not you're
45:42just doing it then doing it properly how is the what's the pressure on the arms 90 years i mean
45:56okay slow down please okay slow down charlie reduces the volume of blood going through the aorta
46:02can i have a big needle four-o please with a fly jet enabling renzo to try to fix the
46:09bleed with a stitch
46:10reinforced with a teflon coated pad
46:15you have to have confidence in your experience and expertise you need to be able to rely on a team
46:25that is focused
46:29the bleed has stopped back up for a moment okay back up
46:35can we have the table head up about this three and a half hours after they started the operation
46:43renzo and always secure the graft above the heart just uh deep plumbing and as his body warms and
46:55charlie withdraws the cardioplegia peter's heart restarts when you see that the blood has been pumped
47:04perfectly by the heart and the anastomosis is under control then you feel relieved
47:10the last join is to the right subclavian artery where the operation began quite a lot of uh
47:22don't think you can do one every day yep huh no um
47:29all right looks much better than it did i think okay everything is perfused now looks nice
47:44i hope he does well because we've not had any you can't do you couldn't have done any more yeah
47:50it's nothing else you can do
47:55okay wires please
48:07you won't know if the brain defects has been adequate till the patient wakes up from the general
48:13anesthesia that's going to happen later so the key point is that the heart is working well and peter's
48:21alive okay thank you very much hi dominic hello hello the operation went as planned we didn't really have
48:34any difficulties or unexpected findings so that's good news and then the key element will be when we
48:42wake him up and hopefully we will find out that we've been able to protect the brain and he hasn't
48:47had
48:48any strokes yeah see you you've got the number for itu you can call anytime okay okay all right thank
48:54you
48:54very much bye-bye peter will spend the next two days in intensive care
49:19and the western general colorectal surgeon varie and clinical fellow mariam have removed lewis's
49:27diseased colon now they must reconnect his bowel to restore his digestive function yep the only thing
49:35that's going to worry me is getting the rectum in enough here just to get the join you know yeah
49:42sure
49:42but there may not be enough healthy tissue left for a successful join
49:48if there isn't lewis would have to have a permanent stoma or colostomy bag
49:55it's just finding something that we could safely um yeah join join to not really
50:03worst case now is that i don't manage to find a decent bit of bowel and i have to just
50:08um staple it off
50:11sometimes even stapling it over it doesn't hold very well and it bursts and you end up with another
50:17abscess then there and you're kind of a bit back to square one
50:26there's a speaker just to get the join you know yeah sure
50:30all right we'll take the top of the gun and we'll see
50:34varie plans to use a tool called a circular stapler to make the join
50:39so do you hold it or not yeah let's fold it but it will only work if there's enough healthy
50:45tissue
50:48the stapler has two parts the first the anvil is inserted into one end of the divided bowl
50:59does that look tight yeah i think so
51:02so are you happy to put the gun in absolutely the second part the staple gun must be inserted into
51:10lewis's rectum it's a bit one chance really it's lewis that will deal with that long term if we don't
51:19get that right we're quite aware of that so just be careful when you put that in you've not got
51:25far
51:25yeah exactly we have to trust each other i have to trust her particularly at the beginning because
51:31when she starts off you can quite easily ram the stapler through the whole thing because it will
51:38suddenly give through the sphincters okay i am in okay so just gently follow it yeah and come in a
51:48wee bit
51:48more okay perfect right i'm just gonna click on okay gently slowly close okay they're about to
51:59find out if there is enough rectum left for the join okay fire away
52:06now done it's worked the gun has successfully stapled the two ends of the bowl together
52:14and removed the anvil it's a big relief you know you really do have a feeling of satisfaction yep
52:24but there was a while there we were thinking there's nothing to join to here yeah i mean i thought
52:28it
52:28was challenging it was not straightforward one but with the join so low down in his bowel
52:36lewis is at greater risk of complications if it doesn't heal and it breaks down if there's infection
52:42it's definitely lifelong stoma for him it's so low yeah that he could end up with a permanent
52:48uh philostomy if he gets a bad leak so i think i'm quite risk averse especially when he's so young
52:57he's got years he's got to live i don't want him to have years coping with a permanent stoma because
53:03i took a risk we'll cut we'll close yeah and that feels fine
53:07so we decide to give him a temporary stoma and using a small bowel so that all the pickle matter
53:13will come into the bag nothing will go on through the remaining colon and through that precious
53:19joint so that while it's healing it'll hopefully not get infected
53:25uh right can i have the stoma bag thank you very much
53:32we just like to feel that there's a nice hole
53:37thank you very much everyone
53:40i made the right decision with lewis that he needed to have that done
53:44went as well as i could have imagined and we've done the best we can
54:05eight weeks on lewis is adjusting to his new life day to day it's going well very glad to be
54:11back
54:11at work i'm not feeling any pain or discomfort anymore the actual after effects of the surgery
54:17itself have gone yeah couldn't really be much happier could i compare myself to an old old car
54:21i used to have and getting rust cut out of it you know i'm just dealing with my new normal
54:28living with
54:28a stoma it's working well for me i've never really had any significant issues with it what's helped me
54:34with that is having a very supportive partner whenever i'm feeling down or low about any of it or
54:38anything indeed um she can she can always find the right way to um to feel better about it lewis
54:45has
54:45been given good news his temporary stoma will be reversed in four months time and the operation
54:52hasn't affected his fertility i'm 30 years old i want to have a family and i want to have my
54:58own kids
54:59and to have that peace of mind that i should be able to have kids biologically and without without
55:03complication it's um yeah it's a hell of a relief it's a very freeing feeling being back on my bike
55:11just being back out and about and being just by myself i'm now free once more we're able to plan
55:17things live our life and not worry about it you know future's really good it's looking really good
55:24miss collie came to see me on a day off just to make sure i was okay post-surgery
55:27which is only a testament to her character and how good of a person she is i hope that he'll
55:34be
55:34well that he'll not have any more episodes of infection and that he'll just you know have a full
55:40life back to normal it's 12 weeks since peter underwent life-saving surgery after the operation he was
55:56really skinny and he can barely walk thank you
56:13it took like a month to actually have him like walk around without him being tired
56:22but now i can see him like walking and unimaginable distance i'm happy that he's recovering well
56:32so i have to remember when i was in a hospital hospital
56:35so i saw my home home to a hospital
56:37so i see the ones that you see the old
56:46and that there are too many days
56:49that it's great to be able to be able to work
56:51that's the final thing that's the way she came to mind
56:51i think that i was very lucky
56:52i could add to that
56:53it was very lucky that i'd have to help me
57:02The only thing I have to say to everyone that has taken care of my dad is that you have
57:10saved his life and will forever be grateful.
57:20I'm feeling good.
57:22I'm really happy.
57:27I'm very pleased.
57:28We have been able to complete the best operation for Peter and that has been a success and he
57:36has recovered well from it.
57:38When you do your major complicated surgery and it goes as planned, you feel proud that
57:44you have done something for that patient and you feel proud of yourself as well.
57:51Cardiac surgery is a very fulfilling profession.
57:54He keeps teaching me that life is very precarious, so we all spend our life trying to control
58:01or predict the future or worry about the past.
58:04But actually, things can change very quickly.
58:08Every moment of life is precious and sometimes in the routine we forget about that.
58:15I feel positive and strong.
58:18A 13-hour operation for throat cancer.
58:21Happy for us to start?
58:24With no room for error.
58:26Ashley, can you stop?
58:27Ashley.
58:28A bit of pressure on the neck.
58:29This sort of surgery is constant problem solving.
58:32No case is ever the same.
58:34No case is ever the same.
59:00No case is ever the same.
59:01You've to only be the same like that.
59:03You just disappear for the lack of trouble!
59:04No case is ever the same.
59:04True.
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