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00:05Every year, some three million major operations are carried out in the UK.
00:11Theatre doors are just here, yeah?
00:13But few of us will know what really happens once we're put to sleep.
00:17All right, all you've got to do now is think beautiful thoughts.
00:20I don't think a patient can even comprehend what you're doing in theatre to them.
00:25And that's what the plan is, that they don't know what they've been through.
00:27This series goes behind the theatre doors at the Queen Elizabeth Hospital in Birmingham.
00:33Let's get cracking then.
00:35Right, okie dokes.
00:36Where, for the first time, cameras have been allowed to join some of Britain's top surgeons
00:41during their most high-stakes operations.
00:45Should we go for it?
00:46We'll go for it.
00:46Using new technology and pioneering skills, they're treating conditions that used to kill.
00:52We continue to push the boundaries, continue to take the inoperable and make it operable.
00:57This is surgery at its most experimental.
01:00This is where I've got to get it right.
01:02People didn't attempt the surgery a few years ago,
01:04because it was just perceived as being too big, too difficult and too scary.
01:08But pushing the human body to its limits comes with great risk.
01:12Keep it together, keep it together, keep it together.
01:14For the patients and the surgeons.
01:17An operation will go wrong for a 30-second lapse of concentration.
01:22It's work, because if it doesn't, I'm going to cry.
01:24Things worry you. You get very worried.
01:26This is going completely in the right direction.
01:28The trick is to not appear to be worried.
01:31They need to be top of their game, every time.
01:34People often characterize surgeons as bombastic and arrogant.
01:38Blabcock, please. Long one to me.
01:39Slap it in, sweetheart.
01:41You've got to be dedicated to it. You've got to love it.
01:43Oh, my God!
01:45Jesus Christ!
01:46You're only as good as your last result.
01:48Oh, f***ing hell!
01:50This is what it takes to operate at the cutting edge of medicine.
01:54You have to be jolly careful that you don't bugger it up.
01:58It's do or die, really.
02:156 a.m. on Thursday.
02:17In Birmingham's Queen Elizabeth Hospital,
02:20the surgical department is preparing for 108 patients.
02:26Most operations will be straightforward textbook cases.
02:31But sometimes, surgeons take on procedures so complex and unpredictable,
02:36they'll only know the extent of the challenge they face once they begin operating.
02:42Planning for the unexpected can be difficult,
02:45although we do spend a lot of time beforehand running through the CT scans again and again.
02:50However, the CT will only give us so much information.
02:54And sometimes we do have to think on our feet.
02:58Surgeons Professor David Gurevich and consultant Sam Ford
03:02head up one of the only units in the country specialising in treating sarcomas,
03:08rare cancerous tumours that can grow to huge sizes.
03:12Sarcomas can be very difficult to remove.
03:15They tend to grow behind all the major structures in the abdomen and pelvis.
03:20There it is.
03:21There it is, going across that.
03:23Yeah, so it comes right round here, no?
03:25Yes.
03:25This is already something more aggressive.
03:27It's quite a business.
03:29It's going to be really treacherous.
03:30It's the sort of last bastion of big surgery.
03:34I think what makes it interesting is the fact that the unexpected is more common.
03:39That's what keeps us on our toes.
03:42Today's patient will be one of their most challenging surgeries to date.
03:48Five months ago, 71-year-old Jasmine Harkness noticed a swelling in her stomach.
03:54I've been to my sister's and I felt sort of bloated and I noticed I was getting thinner
04:01as well in the face and I thought, there's something not quite right.
04:06Within just a few months, the growth has filled her entire abdomen, from her ribs down to her pelvis.
04:13I've had three scans and they showed a picture of it on the screen.
04:20I mean, I thought, how could one person have something like that?
04:25You know, it's like, you've seen the alien films.
04:33The sarcoma is now so large, it's crushing her liver, kidneys and stomach, making even eating difficult.
04:40Left untreated, Jasmine will die within four weeks.
04:44You look at yourself in the mirror and you could see, you know,
04:48sort of your cheekbones and things like that.
04:51You wouldn't think over just a few months, you'd lose such a lot of weight.
05:00The surgeons won't know if it's even possible to remove until they're in theatre.
05:05What do you think? Do you think it's a goer?
05:08There's not enough about it to stop an operation.
05:16I think we're just going to have to see how it goes.
05:18I think this is going to be very difficult.
05:23Jasmine appears extremely frail.
05:25However, she's frail because she's carrying around a very large tumour that's slowly consuming her.
05:30It represents a third of her body weight.
05:34Five years ago, we probably wouldn't have taken her case on.
05:38Lovely to see you again.
05:40Lovely to see you.
05:40How are you?
05:42Not too bad.
05:43Have you got any questions about the operation?
05:45Well, how long will it last?
05:48It's difficult to say at the moment.
05:49And do you remember we were talking about this being quite a big operation?
05:53And it might just take a little bit of time for us to get the tumour out in entirety.
06:00The decision to go ahead with the operation is not straightforward at all.
06:06Jasmine understands that without surgery, she will certainly die.
06:11But there is a possibility that once the abdomen is open, we can't remove the tumour.
06:17We'll only know if it's actually possible once we're operating.
06:20It's a significant responsibility.
06:25Good morning.
06:26Morning.
06:29I'm obviously a bit apprehensive because it's a big operation.
06:36I've never had a big operation before.
06:42But it's either have it done or that's it.
06:50Right, let's go.
06:52Righto.
06:56Because it's an operation with so many unknowns, Sam has called upon David to support him during this complicated surgery.
07:04I'm just the old man of the department, really.
07:07And as such, when there are difficult patients or cases to be done, I'm often asked to come and give
07:16a hand.
07:17There has to be a captain.
07:19He's the captain.
07:20And I will be his number two's wingman.
07:24This is obviously an operation at one extreme because of the size of the tumour.
07:29So we are aware of the possibility of the unexpected.
07:35Guys, just until she's asleep, let's keep the noise down.
07:42That's you.
07:43You checked in.
07:44That's your boarding pass.
07:46Sue Sinclair, his lead anaesthetist.
07:49Are you going to start feeling a little bit lightheaded, darling, okay?
07:52Yeah.
07:53All right, all you've got to do now is think beautiful thoughts.
07:56There's a lot of sort of traditional argy-bargy between surgeons and anaesthetists.
08:01Well, the anaesthetists are very well-balanced.
08:03We've got chips on both shoulders because no-one thinks we're as important as the surgeons.
08:07Sue is the matriarch of the anaesthetic department.
08:11Without her, it would be very difficult to undertake an operation of this size.
08:15Yeah, go on, you hold my hand.
08:16That's lovely.
08:17You have any of your eyes for us, Jasmine?
08:19There's a good girl.
08:20Okay, you're in business.
08:22When you're anaesthetised, you're defenceless.
08:25You can't do anything for yourself.
08:27You can't even blink.
08:29You can't breathe.
08:30Our real job is keeping her alive.
08:34Now Jasmine is asleep, it'll take another hour to prep her for surgery.
08:39Five times longer than more straightforward procedures.
08:43Now, very, very gently, chaps.
08:47Sue and her team insert a seven-channeled catheter into Jasmine's jugular vein to monitor her vital signs.
08:55She's so fragile.
08:56Poor love.
08:59Mrs. Harkness is a very frail girl.
09:02There are surgical risks to her, and there are anaesthetic risks that she just, her circulation just will not withstand
09:07this scale of surgery.
09:09That's it.
09:11Beautiful.
09:12Some people would find that that was maybe a risk too big to take.
09:17But the alternative is that she will die.
09:21Okay, guys.
09:22I think we're good to go, aren't we?
09:24You bring her, I'll take drugs.
09:29Yeah.
09:29Yeah, I've seen it.
09:30Yeah, I think it's not.
09:31Gosh, you've made us work for it.
09:34Thirteen experienced clinicians are needed for Jasmine's operation.
09:39Sam and David lead another two surgeons.
09:44Sue leads a team of two anaesthetists and two assistants, and another five specialist nurses oversee the surgical equipment.
09:53I think we're ready to start.
09:54Are you ready to start?
09:55Is everybody we need in the room?
09:58Yep.
09:58Yep.
09:58Okay.
09:59What are you doing for this lady tonight?
10:01We are going to excise this massive liposarcoma from her retroperitone on the right.
10:07Fantastic.
10:08Expected blood loss?
10:10Difficult to say.
10:11There will be some blood loss.
10:13Okay.
10:13And she's cross-matched for ten units, I think.
10:15Are there any issues of concern?
10:17There are plenty of surgical concerns, mainly due to size and access.
10:21Yeah.
10:21Expected duration of surgery?
10:23As long as it takes.
10:26That's it.
10:27Time out over.
10:28Great.
10:28Thanks very much.
10:29With the operating lights on.
10:30We have a little light handle, please.
10:36Are we ready to go?
10:37Yep.
10:37Is it okay to start?
10:38Yeah, off you go, boys.
10:39Have a good one.
10:40Geronimo.
10:44Despite weeks of planning, it's only now the team will see for themselves exactly what they're
10:51up against.
10:55So the team is just coming into view now.
10:58This large white structure that Professor Gorbic has his hand on.
11:03Can I have the scissors, please?
11:12Oh, my God.
11:13Oh, my God.
11:15It's a big bastard.
11:17When we open the admin for the first time and we get first sight of the enemy and appreciate
11:23its sheer size, we always look at each other in amazement just to say, what have we got
11:27ourselves into here how are we going to get this out. Wow. It's an alien. It's like a huge potato.
11:43All right let's have it. Let's open it up. Keep going Max. Yeah we need all the space we can
11:46get here.
11:50Tell you what this gym is bloody heavy. We just started.
11:55I don't need to go to the gym. Look at him. He's like a home athlete. I don't need to
12:01go to the bloody gym.
12:02Did you have your Weetabix this morning? I had three. Yes it seemed to have helped.
12:06There we go. Let's go wide darling. I know. Let's go into the chest nicely. This bit's going to be
12:11it's going to be an absolute pig in it. Jasmine's tumour needs to be removed completely intact
12:18if it's not to return. Difficult access here. Just a few cells left behind could cause the cancer to
12:26regrow. Bloody hell it goes miles. Right so careful we don't puncture the tumour here.
12:32You're full of confidence and bravado before you start and you open the patient and you feel that
12:38slight uncomfortable feeling on the back of your neck and your colleague looks at you and you look
12:43and you think have we made a terrible mistake. Most of the 36,000 operations performed each year at the
12:58Queen Elizabeth Hospital are straightforward. Like Sam and David, consultant urologist Rupesh Bhatt
13:05specialises in rare tumours that most surgeons wouldn't attempt to remove. I take on the things
13:13that other surgeons can't do or won't do. The unpredictability of these big cases really makes
13:21me feel quite excited how I'm going to rise to the challenge. There's also a bit of anxiety as well
13:28but you learn to control it. 67 year old grandfather of four Bob Moran has been told by his local
13:37hospital
13:37that his tumour is so advanced there's nothing more they can do for him.
13:46What do you say when a doctor just tells you that? I've got a tumour. It's a bad one. And
13:53that's when
13:54my world sort of fell out, you know, I just bombshell hit me. You think, is this real? Am I
14:01dreaming this?
14:03Bob has a very rare form of cancer. His tumour has grown from his left kidney into the surrounding
14:10blood vessels and is making its way up a major vein called the inferior vena cava or IVC. A piece
14:19could
14:19break off at any time and travel into Bob's heart, killing him in minutes. I'm happy for you to ask
14:25any questions, you know, as I go along. Okay. So recapping. Only a handful of surgeons in the UK are
14:31willing or skilled enough to carry out this operation. I think you know everyone here. Yes. I'm Rupesh Bhatt,
14:37the surgeon. Surgery to remove a kidney cancer is already a challenge. But in Bob's case, that's a whole
14:44different ball game. The tumour is untreatable by chemo or radiotherapy. Two surgical teams will need
14:53to remove Bob's left kidney and the rest of the tumour that has grown within his IVC. The only way
15:00they
15:00can do this is to stop Bob's heart, then drain his blood, slice open the vein, remove the tumour and
15:09restart
15:10his heart. I would do about six of these cases a year. That's very rare. By the time the patient's
15:19coming to see me, they really are at the last chance saloon. Okay, let's go. Everyone's ready for
15:29you downstairs. Right then. So we'll crack on with things. Thank you. Okay. That's all I want. Good.
15:33Good. I'll see you down there. Urologically, I'm at the edge of what I can do. The anaesthetists
15:42are doing the same. What makes this procedure unique is that we are really at the edge of what
15:50we can do as surgeons. There is no alternative. That's the end of it for me. The end of everything.
16:02We can't start without you. No. So this is the only chance that I've got.
16:10You put your hand out, you take it.
16:15One, two, three.
16:22Okay. Okay, let's go. Thank you.
16:26It's estimated the operation will take seven hours. Rupesh will work with urologist
16:33colleague, Richard Viney. I'm going to use a little twirl. Thank you very much. Cheers.
16:39Right, let the magic begin. I always enjoy working with Rupesh, particularly when it comes to the big
16:45cases. Because they're few and far between, and because they're complex, we tend to try and do them
16:50together. I think it gives the best expertise for the patient, and it's also very easy to make fun of,
16:56which is great. Table up a bit, please. Ah, I love these. These are like a treat. Thank you.
17:05Most surgeons undertaking this kind of surgery are slight adrenaline junkies. There is an immense
17:11sense of build-up when you're undertaking this kind of work, and you'll often see a lot of dark humour.
17:16This is like what I have to do to my wife, which is having a fake tan, sort of, Clyde.
17:23See, look. I mean, that looks like a week in Saint-Tropez, doesn't it?
17:28But inside, everyone's heart's pumping away. There you go. Done.
17:32And everyone's sort of very much at the edge. Cheers. Okay. Let's get cracking then, yeah?
17:40The challenge for Rupesh is the sheer unpredictability of the tumour's growth.
17:45Okay. Knife then, please. Until he stops Bob's heart and opens the IVC vein,
17:51he won't know whether the tumour is loose. Watch your fingers, mate. A worst-case scenario stuck to its
17:58lining and much more complicated to remove. A surgeon has to have strong self-belief.
18:06Bit of length on that, please. You're operating on somebody who's got a beating heart,
18:12and you're opening up their biggest vein. It's a very complicated, very stressful operation.
18:26By 11.30 a.m., 28 patients are already out of theatre.
18:34Oh, my God. Nice.
18:36Oh, jeez. Need a big one.
18:39They've had surgery to repair damaged nerves and stop nosebleeds.
18:45In theatre 15, surgeons are only beginning to remove Jasmine's tumour.
18:52What's this down here? What's that peritoneum or tumour?
18:55It's grown so large, it's displaced much of her anatomy.
18:59There.
19:00We think the other ureter is going to be in here somewhere.
19:04Sam and David won't be able to remove it until they establish exactly which organs and vessels are where.
19:11Yeah, it's probably there, isn't it? Let's just work out where we are.
19:15Because everything is on its side, isn't it? Just take this gallbladder out of the way.
19:19Where's your kidney?
19:20Kidney's going to be in your hand somewhere.
19:24Oh, fuck. Okay. Are you serious?
19:26Well, it's in the tumour, isn't it? We would have seen it by now.
19:30The tumour has grown so much, it now extends all the way from Jasmine's diaphragm to her pelvis.
19:37Her liver, intestines and stomach have all been pushed aside.
19:41And the tumour has swallowed up one of her kidneys.
19:45How are you going? How are you getting on, boys?
19:47Just as you said that, we found something.
19:50It's really sort of spot the organ, isn't it?
19:53Jeez, this thing's heavy.
19:54I know, it's just a short way to do this.
19:58As Sam and David navigate through Jasmine's radically altered anatomy,
20:03Sue is constantly monitoring her vital signs.
20:06From blood pressure and heart rate, to kidney function and oxygen levels.
20:11Sue's imperative. During the operation, there's potential for massive blood loss.
20:17There's potential for big swings in the blood pressure from us moving the tumour around.
20:21So she knows what we're going to do so that she can be a step ahead of us.
20:26There's a small vessel coming up.
20:29Simon, can you come in, please?
20:31See, if you want us to back off, just let us know.
20:35I've got no return at the moment, guys.
20:37OK, do what you need to do, we'll just back off.
20:38Just 20 minutes into the operation, Jasmine's blood pressure suddenly drops.
20:43It's the same, 120.
20:46It's not like something just took a tumble, like a big tumble.
20:48Very little blood is pumping around her body, restricting oxygen to her organs.
20:53We're not losing any blood. We've got no blood down here.
20:56Are we tensioning the chest, maybe?
20:57You can just take it this way.
21:00Are you OK on the bend?
21:03No problem with the chest.
21:05Sue suspects it's the weight of the tumour that's the problem.
21:12As they roll it around in the abdomen, it will press on the major blood vessels going to and from
21:18the heart,
21:19which means that we will have instability with the circulation, quite significant instability.
21:25You've got it there?
21:26See you.
21:27I've got it.
21:29It's coming up now. Hold on.
21:30As they move the tumour again, the blood pressure returns.
21:35Hmm, very strange.
21:37It doesn't, I don't think it takes a lot of obstruction.
21:41It must have been compressing a major blood vessel.
21:45The trouble is, those blood vessels aren't where they should be.
21:49Sam and David must now find them.
21:52We're heading up into tiger country here, aren't we?
21:55We sometimes use the phrase tiger country, and that really refers to the frighteningly large and
22:02thin-walled blood vessels.
22:03I just want to know where this effing IVC is.
22:06A particular tiger country is around the IVC, the inferior vena cava, which is a very large
22:12vein that takes blood back from the legs back up to the heart.
22:16Normally, it looks blue.
22:19Should have seen the busted by now, shouldn't I?
22:23Yeah, I think it's going to be in here.
22:24I think it's that, is it?
22:29Is that it?
22:30No, no, no. I'm not convinced yet.
22:31No, I'm not convinced either.
22:34There's the cava. Look, there. There, got you.
22:37Just there.
22:38Yeah, it's blue all right, isn't it?
22:43I'm happy now we've got a glimpse of the big blue.
22:46I'm not so happy that it's going to be absolute devil.
22:50The full length of the IVC vein is stuck to the tumour.
22:55To save Jasmine, they'll need to detach it meticulously without penetrating either the tumour
23:00or the vein.
23:02You can actually see the blood flow streaming through it. It's transparent. It's so thin.
23:06So it just tears like tissue paper.
23:11That's the perfect thing, get on top of the caver, isn't it?
23:13They bleed out very rapidly and much more scarily, probably, than any other blood vessel in the body.
23:20Put the light over here, please. Put the light out for it.
23:24Wait for it to come in. I can't see. Shit.
23:26It needs to come round a bit more.
23:27Come out and come out.
23:28You're absolutely dead still now, James. I know you're not moving, but it's just a couple of millimetres and the
23:32tip of the diaphragm is into the caver.
23:35I'll just cut one as well.
23:37James, keep still, for Christ's sake.
23:45You have to be jolly careful that you don't bugger it up, really.
23:50And that's why you need to operate with a colleague on the other side of the table.
23:54So when I get a bit nervous and uncertain, Sam takes over and vice versa.
24:00Yeah, it's not very nice up here.
24:03The diatomy, please.
24:04If you can't do it, I don't know who else can.
24:07Professor Gurevich can be a bit of a handful.
24:09He's very forthright, quite noisy and opinionated at times.
24:13But one of the biggest things that he's taught me is that you just have to get on with it
24:19and believe that things will work out.
24:24This is clearly monumental scale surgery.
24:28She is one of the few patients that you would counsel may die on the table.
24:42Underneath the operating theatres, in the basement, lies the molecular pathology department.
24:49All tumours removed from surgery end up down here for investigation.
24:55The team are expert in analysing cancer cells in unprecedented detail.
25:02Molecular pathology has really been a game changer in certain cancers.
25:07It means that now we're able to transform what were otherwise potentially untreatable cancers
25:12into ones that we can control and essentially treat like chronic diseases.
25:17One of the latest innovations in molecular pathology is the use of robots.
25:23So in the past, pathology was very, very labour intensive.
25:27And with labour intensive procedures done by humans, you're increasingly adding in the risk of, say,
25:33for example, contamination, which can have really severe effects for patient samples.
25:39More accurate diagnosis makes for more effective treatment.
25:44So the team have also started to use fluorescent dyes to detect specific genes in the DNA of tumour samples.
25:52Each of these blue dots is a cell and within those cells, you've got green dots and you've got red
25:59dots.
26:00Now, normally, you should expect to have two copies of the green and two copies of the red.
26:05But what you can see here is that we've got huge numbers of these red dots and that supports diagnosis
26:11of liposarcoma.
26:14In the past, a lot of these cases would just have been diagnosed as being undifferentiated sarcomas.
26:20And those patients would generally just have received quite aggressive chemotherapy,
26:24which brings with it lots and lots of side effects.
26:27Now we can pick and choose which patients need to have that aggressive chemotherapy
26:32and which patients could potentially have lighter, more tolerable chemotherapy with the same effect.
26:40Overall, that means that for patients, they have a good expectation of how likely they are to do well
26:46or poorly, which means that on a very human level, they can plan their lives.
27:00Clean swabs like that, please.
27:02Are you happy with the place?
27:04Can you go there?
27:05Mate, you can go wherever you want, if you're the boss.
27:07Perfect, thank you.
27:08In Bob's operation, Rupesh has made a start on the tumour.
27:13The only way to remove it from the main vein will be to stop Bob's heart.
27:17But first, they must remove his kidney, where the cancer started.
27:22Cut along the dotted line.
27:26Rupesh and Richard must carefully disconnect the many veins and arteries supplying the kidney.
27:32Take a clip, please.
27:34There you go, my friend.
27:35Thank you, sir.
27:37This is, so far, quite nice.
27:40Shh, I don't know exactly.
27:41You had to jinx it.
27:42You had to jinx it.
27:44I'm always worried about bleeding.
27:46It's a real threat.
27:48You need to make sure that every single little blood vessel is completely tied off.
27:54Anger ligger, please.
27:55Anger ligger, please.
27:58Because the next step is that Bob is going to be given medications to completely thin his blood.
28:06So, his clotting will not work.
28:09So, if there's a little tiny hole, even if it's a millimetre, it'll keep bleeding until all the blood is
28:15gone.
28:19Hold on, hold on, hold on, hold on.
28:21So, I think I've just caused some bleeding there.
28:23Suck it, suck it, suck it, suck it.
28:24Where's the suck it?
28:29There it is.
28:31Naughty little artery.
28:34It takes Rupesh and Richard two and a half hours of painstaking work to seal the blood vessels before they
28:41can free the tumour.
28:43It's coming, it's coming, it's coming.
28:46There we go, it's come.
28:47It's there.
28:49Ta-da!
28:51OK.
28:51Done.
28:52The only remaining part of the tumour is inside the IVC, the vein leading straight into Bob's heart.
28:59Good.
29:00OK.
29:01To remove the tumour within it, they need the IVC vein to be completely empty of blood.
29:08This means that all the blood in Bob's body needs to be drained.
29:15So, now would be a good time to get Mr. Rooney to start opening the chest.
29:22Consultant cardiothoracic surgeon Stephen Rooney and his team will join Rupesh and Richard with this,
29:28the riskiest stage of the operation.
29:31So, have you got any more dissection to do?
29:33No, no, we're done.
29:34We've got the kidneys through the mesoteric window, ready to lift out, basically.
29:38It's sweet.
29:39Have you enjoyed yourself so far?
29:40It's been awesome.
29:42It's just a pity you have to put up with Rupesh, but, you know, what can you do?
29:45Yeah.
29:45All right, then.
29:46Yeah.
29:47Starting with the chest.
29:49The first step is cutting open Bob's ribcage to access his heart.
29:54Here we go.
30:03Lunge back on, the sore can go.
30:06When you're looking over their shoulder when they've got the chest open, you just see the heart sat there
30:10quite an extraordinary thing.
30:13It is life right there.
30:17Can I have 15 blade, a pair of forceps and the altered cannula.
30:25There we go.
30:27With the chest now open, Stephen starts by inserting two cannulas directly into the heart.
30:34The process involves making an incision in a beating heart, which to an onlooker is kind
30:38of a very, very weird thing to watch.
30:40You see someone actually stabbing someone's heart with a knife, but that's what the cardiothoracic
30:44surgeons do.
30:45Yeah.
30:47You want to go onto the pump, please?
30:49Going on bypass.
30:55That's on bypass.
30:56So, and start to cool, please.
30:58I have started to cool, thanks.
30:59Excellent.
31:00For Bob to survive having his heart stopped and his body entirely drained of blood,
31:05they first need to gradually cool his temperature from 37 degrees down to just 18.
31:13Cooling to 18 degrees.
31:16At normal body temperature, without blood flow, Bob's organs would fail in minutes.
31:22But the cold will protect him by putting him into a kind of hibernation,
31:27offering a few precious minutes for Rupesh to open the IVC vein.
31:33It's mainly for his brain. When it's cooler, the cells aren't requiring as much oxygen.
31:38They go to sleep, essentially.
31:40So we've just got to cool now.
31:43Very cool.
31:44To bring his temperature down, Bob's blood leaves his heart via the cannula into the bypass machine,
31:50where it's gradually cooled and then returned to his body.
31:54This cooling was discovered accidentally. There's a famous medic who fell through into a frozen river,
32:01and they fished her out a long time afterwards.
32:05Even though she was technically dead as far as the heart was concerned,
32:10they still carried on and on and on.
32:12And what they found was as she re-warmed, she came back to life again.
32:20As the cooled blood returns to Bob's body,
32:23it shuts down his organs and slowly stops his heart.
32:30To see it stop, it's very odd.
32:34It's an incredible notion. It's a bit like suspended animation.
32:43I'm a scientist, and yet there is something special about the state that patients are in.
33:01I'm not going to get sort of religious about it, but it's quite awe-inspiring.
33:09It is literally on the edge of life and death.
33:16In theatres around the unit, surgeons make progress through their daily lists.
33:21Ligaments are tightened, heart valves replaced, a pancreas transplanted.
33:27Lab cock, please. Long one to me, please.
33:30Slap it in, sweetheart.
33:31In theatre 15, the sarcoma team are slowly removing Jasmine's tumour,
33:36along with a margin of healthy tissue around it.
33:39OK, that's it.
33:40Good. Ooh, that's good.
33:42OK, that's enough. Well done.
33:44Are we going to the plough after this?
33:49They're trying to contain the operation. You're thinking about alcohol?
33:51Well, yeah.
33:52You're thinking of the future, haven't you?
33:56Do you think you're nearly there, then?
33:57No.
34:00James, are you OK? Do you want to rest?
34:02I think it's a little bit numb.
34:04OK, change the rest.
34:10Can you make it any more difficult?
34:12An operation to remove a sarcoma can be prolonged,
34:17and we need points in the operation where we can release the tension.
34:20We quite often poke fun at each other and have a bit of banter.
34:23Stop slacking. Get on with it.
34:25No, we're just having a breather.
34:27Sue, can you put the table up a little bit?
34:29Again? What, more?
34:30Hit your own time, darling, don't worry.
34:32God's sake, man.
34:33We saw you sneaking off.
34:34Well, you're certainly making it look tricky, aren't you?
34:37Up in the air.
34:38Thank you, Steve.
34:38Sorry to disturb your chit-chats over there.
34:40Yeah.
34:41All right.
34:42We've got to get this bloody kidney, haven't we?
34:45We've got a bit of cowboy action.
34:47All right.
34:47The cancer is thought to have originated in the fat around Jasmine's right kidney,
34:52which is now buried so deep in the tumour, it can't be saved.
34:57Are you going to take the kidney?
34:58Yeah, the kidney is out.
35:00The kidney is definitely out, yeah.
35:01It's got to come out, because the kidney is right.
35:02Yeah, no, that's fine.
35:05In order for Jasmine to survive this disease, the tumour has to be taken out intact.
35:11The tumour contains a kidney, so that kidney's going.
35:15It's an important consideration, though, because on a healthy person with two kidneys,
35:20there is still a risk of them going into renal failure.
35:24It is very possible that Jasmine's remaining kidney can't cope.
35:28So she's between a rock and a hard place.
35:31Ready?
35:32Yeah.
35:33Is that full?
35:33Yeah.
35:36Normally, to remove a kidney, the surgeons would simply cut the main artery leading directly to it.
35:42I'm just worried that the anatomy is so distorted here.
35:46The trouble is, Jasmine's kidney is so deep inside the tumour, they can't see which artery leads to it.
35:53OK, and what have we got here? Behind here, there's the renal veins, isn't it?
35:57The surgeons have in their mind a road map of how the anatomy should look,
36:02and when anatomy is so distorted by the sheer size of the tumour,
36:06you have to be very careful not to make assumptions.
36:10Are you happy?
36:11I don't mind. It's your operation.
36:12Well, no, you just bloody well picked it up.
36:13So we just need to think about it a little bit, because it's big, isn't it?
36:17We've taken one vessel already, and we are upside down with our anatomy.
36:20Let's have a look. Let's have a look.
36:22Stop, stop, stop.
36:24They need to decide between two very similar-looking blood vessels.
36:29One supplies the kidney, the other is called the superior mesenteric artery,
36:34or SMA, and supplies blood to the whole of Jasmine's bowel.
36:39James, suck this stuff out here.
36:42I'm here, I'm here.
36:44The superior mesenteric artery comes off the aorta,
36:46almost at the same point as the right renal artery.
36:50It'll literally come off within a millimetre of each other.
36:52Yeah.
36:52This is a very, very dangerous part of anatomy.
36:55Is that the vein?
36:56It must be the vein.
36:57Shall we just be brain?
36:59No.
36:59Don't be done with brain.
37:01If we were to divide the SMA, mistaking it for the renal artery,
37:06then Mrs Harkness would lose all the blood supply to a small bowel,
37:10and that would be a fatal mistake.
37:13Yeah.
37:14SMA.
37:14Yeah, SMA's in my hand.
37:16Shall we stop it for a moment, please, Shep?
37:18Who's got to be certain?
37:20SMA is here.
37:21You got it?
37:21Put your hand around.
37:25Yeah, SMA's in my hand.
37:27Sure?
37:27Yeah. Are you sure?
37:28Well, I think so, because this is going completely the wrong direction,
37:31and it's going into the tumour.
37:32But if we do take it, we are up shit creek.
37:34Yeah. Put a bulldog on it.
37:36OK, so the vaccine bulldog, please.
37:41Long one, so thank you.
37:43They clamp one of the arteries.
37:46If the small bowel drains of blood, they'll know they've got the wrong one.
37:51What's the blood pressure?
37:53Enough.
37:55Let's just talk our way through this again.
37:56You can see I've got my finger around what I think is the SMA.
37:59It's pumping.
38:00It is pumping nicely.
38:00At some points in a sarcoma operation, we have to be absolutely certain
38:06that we know which artery it is we're about to divide,
38:09a little bit like bomb disposal.
38:11If we were to divide the wrong artery,
38:13then it can have catastrophic consequences for the patient.
38:17We are absolutely committed once we divide that.
38:21There's no coming back.
38:22OK, so we're happy?
38:23Yeah.
38:23Sure?
38:24Yeah.
38:24Yeah.
38:31The deed is done.
38:33With the kidney disconnected, they've cleared a major hurdle.
38:37But unless they can get the tumour out intact,
38:40they won't know if they've done enough to save Jasmine.
38:49The theatre has ten units of blood ready in case Jasmine has a major bleed.
38:57Surgeons at the QE are reliant on a steady stream of blood,
39:00arriving from the NHS Blood and Transplant Centre, just half a mile away.
39:06State-of-the-art surgery requires the blood bank to supply all the components of blood
39:12in immaculate condition.
39:14Red cells are used for volume replacement-drawn operations.
39:17They're also used for people whose red cells are not correct, like leukemics.
39:23Frozen plasma contains the main proteins, so they can be used again for volume replacement
39:30or to replace specific proteins, like clotting factors.
39:35These are where we stole platelets, which is a special clotting cell.
39:40They have to be kept again in temperature controlled conditions.
39:44They're also kept agitated. This is to prevent them settling.
39:47If they settle, they could start to aggregate.
39:50And once they've aggregated, they can't be used for a patient.
39:57The red blood cell units are kept alive in a solution of sugars and metabolites,
40:02and have a short shelf life of just over a month.
40:09A highly sophisticated tracking system follows each unit of blood all the way from the donor
40:15to the patient who receives it.
40:21And Bob's operation, they're five hours into surgery.
40:25All right, you happy?
40:27Yes.
40:27Yeah, okay.
40:28You turn the pump off and drain the patient a bit.
40:30Okay, it's around.
40:32Draining the patient.
40:34His heart has been stopped and all the blood drained from his body.
40:39And can someone start the clock, please?
40:42I have got the clock on here.
40:44The team has just 30 minutes to remove the tumour from the biggest vein in Bob's body,
40:49and then bring him back to life.
40:52You're under extreme time pressure.
40:55You've got about half an hour before you start causing damage to some of the vital organs,
41:02brain, heart, et cetera.
41:05All right, you can open the cave whenever you want.
41:07Okay, yeah, all ready.
41:08Okay, go, yeah.
41:11Then the risk of stroke, the risk of cognitive damage increases.
41:17So this is very high risk surgery.
41:22All of the banter stops, everyone focuses.
41:26Everyone's very much aware of how close to the wind we're sailing in that particular instance.
41:35I try to find out as much as I can about what I'm expecting before I go into the operation.
41:41But there are always going to be some unknowns.
41:45One of the unknowns which really can stress me out and will certainly keep me awake is
41:51what the tumour within the IVC is like.
41:57Okay, I need a blade as well, please.
42:00Rupesh must now slice into the IVC, the largest vein in the body.
42:06It's the most critical moment in the operation.
42:10When you make the first cut with a knife, it's pretty scary.
42:17It's absolutely going against the training.
42:22You think you've got it under control, but it's big stuff.
42:26It's frightening stuff. And it takes quite a while to sort of overcome that.
42:31And you realise that you need to be the master of that as opposed to the other way around.
42:34Some sucker up.
42:36Up on sucker.
42:39Despite all their planning, it's only now with the IVC open that they'll discover if they can remove the tumour
42:45before their 30 minutes is up.
42:48You're never quite sure whether the tumour is going to be stuck to the lining of the caver,
42:52and whether you're having to sort of scrape it off, or whether it's just going to lift out literally like
42:56a long tongue.
42:59The worst case scenario is whether the tumour is still attached to the vein.
43:04And you could leave little elements behind, so you don't want to do that.
43:07Think of porridge which is dried out, stuck to the bowl, and you're sort of peeling that away.
43:20Each surgeon places a finger inside the vein, one from the top, one from the bottom, and gradually release Bob's
43:28tumour.
43:31It's free. Ready? So that's my finger in.
43:35Yep, I can feel you.
43:35Fine. I'm taking it out now.
43:39There we go. It's out.
43:40Okay.
43:41Let's have a four out.
43:42Okay. There's the tumour.
43:43Got it. All together. Keep it together. Keep it together.
43:47Lovely. Okay.
43:49Quite a nice bester than this one.
43:52The kidney and tumour are out.
43:54Remarkably, it has only taken four minutes.
43:57Now the two surgical teams have just 20 minutes to repair the IVC, the hole that's been made in the
44:04heart's
44:04and restore Bob's pulse.
44:08Good. Okay.
44:09Thank you very much.
44:12It's what's known as SLF, which is stitch-like. I won't finish it.
44:19He will close the heart. I will close the big vein.
44:23We'll have a heavy tie, please.
44:26Stephen has finished repairing the hole he made in the heart to access the tumour.
44:31How are you doing?
44:32Yeah.
44:33Halfway there.
44:35You guys just got to chit out of it, you know.
44:37Yeah, you're going to end up in an early grave.
44:38You're going to end up in an early grave.
44:42Can I get Ram to slowly start to fill the patient?
44:44Yes, you can, please.
44:45Okay, Ram, do you want to start filling the patient?
44:48Yeah, I can do it, yeah.
44:49So now we're putting his blood back in.
44:51Stephen begins restoring Bob's circulation to check there are no leaks.
44:57Let's have a look.
44:58Okay.
44:58There we go, Stephen. I've got it.
44:59Okay.
44:59Yeah.
45:00Back off.
45:00Yeah.
45:01Could we turn the timer off, please, Luke?
45:3213 minutes of rest.
45:33We're starting to have almost, um, sort of normal activity there.
45:37Yeah.
45:40As the blood goes back into the patient and the patient's heart starts beating again,
45:45well, that is a magnificent feeling. You're really elated. You know at that stage that
45:53the major obstacles, the major pitfalls are behind you and that you know that you're probably
45:59starting to look at a success story.
46:01Coming back online?
46:03Yeah.
46:03Hello.
46:04A bit of, a bit of a good relation.
46:08But I suspect it'll come back into, spontaneously come back into an organised rhythm.
46:15We'll just tear it off.
46:16It will if you lay your hands on him.
46:20Say the word.
46:21Thanks.
46:22Just get pumped off.
46:24And shoot.
46:25Shoot.
46:27Stephen shocks the heart to re-establish a normal rhythm.
46:32Despite a period of deep freeze, Bob is once more displaying all the vital signs of life.
46:38Yes.
46:38So, are you happy for us to come off?
46:40Uh, I am. Gases are good.
46:42And you've, you've not got bleeding going on?
46:44Yeah, I'm happy for it.
46:45Okay.
46:46Okay. Can we go lungs on, please?
46:48Bob is slowly removed from the bypass machine and his heart and lungs take over again.
46:56That's quarter flow.
46:58All right, that looks comfortable. You on a clamp there, please?
47:02Thank you. Clamping Venus.
47:04Venus is clamped.
47:05That's off bypass.
47:06100 left in the pump.
47:09Venus pipes out.
47:11So, we're off bypass.
47:13Pump is empty.
47:14Pump is now off.
47:17Are we going to start closing down this end?
47:18I'm happy.
47:19Yeah, yeah.
47:20Everyone good?
47:21Yeah.
47:22Yeah.
47:22After eight hours, Bob's operation is coming to an end.
47:26When surgeries like Bob's go well, you know, immediately at the end of surgery, you know,
47:32you've had eight, 12 hours of severe concentration. You're quite drained. I tend to be quite euphoric after that.
47:41It's just an incredible operation though, isn't it? I love it.
47:46If you think about it, it's quite surreal. You know, this is a patient where, you know,
47:52they've been frozen, where normally that wouldn't be survivable. You know, and the fact that the
48:02Bob before an operation will be the same as, hopefully will be the same as the Bob after as far
48:07as brain
48:08function, how he deals with his family, how the family know what Bob is. It's incredible that you can do
48:14that.
48:19Across the department, the end of an operation brings relief.
48:24I'm just savouring my Hendrix Gin and Tonic with cucumber and a good Fever Tree tonic water.
48:34I'd just kill a pint of anything. A pint of that would be fine.
48:42In theatre 15, Sam and David are nearing the crunch point of the sarcoma operation.
48:50Let's get this bastard out.
48:51They've almost detached Jasmine's tumour and are preparing to remove it.
48:56So I'm worried here that we're going to get right through her back and then onto the operating table.
49:01She's so slim and we're taking a muscle at the back to cover the tumour.
49:05If the tumour was breached, then all is lost. These types of tumours have a real potential for
49:12seeding. Even one or two cells have the potential to survive and cause tumour recurrence. So we need
49:19to remove the tumour in its entirety and remove it with a healthy cuff of tissue.
49:25The tumour's not quick enough, is it? No.
49:27Right, be careful. There's all sorts of stuff here stuck on the back. There's lung here.
49:30Yeah.
49:31As it becomes released and you start and you've almost fully mobilised it, there's a danger that
49:37the sheer weight of it just tends to sort of tear itself out of the abdomen.
49:43Just be careful now. It's okay. We can see. We've got the dame with the diaphragm.
49:46You've got the... That's lung stuck to it.
49:48Okay, let me see. Let me see.
49:51Right into the chest here.
49:53Jesus Christ.
49:55No, let's just take a stand.
49:56Yeah, exactly. We're about to lose it here.
50:00In every operation, there is a sort of bugger it factor,
50:03which is just before you finish removing the tumour, you're getting a little bit
50:08crossed, a little bit tired because you've been going for some hours now and you know it's going
50:13to come out and you get to the stage, you know, bugger this, it's coming out and that's when you
50:18make a mistake. Take your time now.
50:26Trolley for them.
50:27Yep.
50:27Trolley behind, please.
50:28Over the top.
50:29Trolley behind.
50:30Big swaps, please.
50:31Go away.
50:34We'll just get this off. Get the bloody tumour out.
50:37So, Dave, you've got the caver. You have the caver there.
50:39I've got the caver on my side.
50:41Okay.
50:41Where's the aorta?
50:42So, aorta is...
50:43Not a million miles away.
50:44Not a million miles away.
50:45My fingers on the aorta.
50:46Okay.
50:47Fuck.
50:49There's a hole. There's a big hole in something.
50:52There's a bleed, but until they take out the tumour, they can't see where it is.
50:57Just take it. Just bloody take it.
51:01Okay, let's go. Go, go, go.
51:03I've got it. I've got it. Don't worry. I've got it.
51:07Jesus Christ.
51:08I've got it. Don't worry. I've got it. I've got it.
51:10I've got it.
51:17Although the tumour's out, they can't relax until they stem the bleed.
51:22Open the packs up, please.
51:25Come on.
51:27It's okay. We don't need it. It's packing.
51:28It's packing. It's packing.
51:31Open it up, Ariel.
51:33Yeah.
51:34One back.
51:35Got a whole run.
51:37Okay. Right. Let's do one extra minute.
51:41What's that?
51:42Franklin.
51:42It's taken seven hours, but it's finally done.
51:47All right.
52:00One back.
52:02I think it's officially plus size.
52:05That is absolutely enormous.
52:09It's pretty much 16, 17.
52:12She's going to feel very, very different when she wakes up.
52:15Do you have to buy a new wardrobe?
52:17How on earth she'd be able to carry that around for months is anybody's guess.
52:25I think I'll get first guess.
52:28Get out of it.
52:3018.
52:3118.
52:31Small, small, small, small.
52:33Prof.
52:33Right prof, mate.
52:3515.
52:38Damien.
52:3922.
52:39During the operation, the atmosphere in a theatre can become quite tense and challenging at times.
52:44And in order to lift our spirits somewhat, we'd like to run a sweepstake and guess the way to the
52:50tumour.
52:51I never seem to win, even though I've actually had the tumour in my arms beforehand.
52:55Go on.
52:56Don't keep it in suspenders.
52:5819 and a half.
52:59James, it is then.
53:01Well done, James.
53:02So you get to buy the first round of the plough.
53:03That's great.
53:05Well, a case.
53:07That's why we come here, isn't it?
53:10We're done.
53:11We're about to close.
53:14James is going to zip this one nicely up.
53:17It's a hell of a tummy tuck.
53:19Yes.
53:20Oh, she'll be light on her feet now, like a spring chicken.
53:23You grab it.
53:26You got it, Anna?
53:27Yes.
53:28Despite all their worries, it seems the operation has been a success.
53:32It's been a long day.
53:35We're in this specialty because we enjoy it.
53:37We enjoy the surgery.
53:37We enjoy each other's company and we enjoy the whole spirit of the theatre and the spirit of adventure
53:43that this sort of surgery brings.
53:47Good job.
53:48Yeah.
53:49Great.
53:49Thanks so much.
53:50No, it's fine.
53:50I'm done it.
53:52I'm only here for you.
53:54This is an exceptional case.
53:56And so it comes as no surprise that we would wish to pit our wits against the tumour and have
54:04it out and take it out.
54:06And that's what drives us, really.
54:08It's sheer arrogance.
54:13Get you tuckered up, lovely.
54:17All right, lovely.
54:17We're going over.
54:21Let's go.
54:23When I got home, having operated on Mrs. Harkness, I was putting my son to bed and he likes me
54:29to
54:29carry him upstairs.
54:31And I lifted him up and I thought, gosh, he's a heavy boy.
54:34I'll just put him on the scales to see how heavy he actually is.
54:37And I'll do enough.
54:38He weighed exactly 20 kilograms.
54:40So Mrs. Harkness's tumour weighs the same amount as a five-year-old boy.
54:51Two days after his operation, Bob is recovering in intensive care.
54:58It was my cup final, this one.
55:00And I thought to myself, I've seen big, big players in the cup finals break down, you know.
55:06They haven't performed.
55:09I've won the cup final, definitely.
55:14OK, how are you doing, Mr Moran?
55:16You're making pretty good progress.
55:17Yeah, it's going very well indeed.
55:19Yeah.
55:19We'll keep a pretty close eye on you.
55:22I can only thank you.
55:24God you no more, you made me a very happy man.
55:28My family.
55:32Can't thank you enough.
55:33I believed you from the first day I met you.
55:36And I said I'd try to be a good patient.
55:42I'm all right now.
55:44The soap.
55:46I'm not upset.
55:47I'm thrilled.
55:50Just emotion.
55:52Yeah, I know.
55:53There's all sorts that happen.
55:55Where we are in 2017 with the NHS, the complaints come thick and fast.
56:00So it's quite nice to hear that.
56:04Nowadays, people generally expect treatment.
56:09OK, whether that's surgery or surgery with other things.
56:13And they're more demanding as far as what they expect from surgery.
56:19It's only human nature.
56:22But it does put a lot of pressure onto surgeons and surgical teams to keep pushing the boundary
56:28and to keep getting good results.
56:37Back in hospital, Jasmine is starting to recover and is adjusting to life without her tumour.
56:44I feel much better now than I did.
56:47And it's nice to be on the mend.
56:49Well, it's nice.
56:50It's like a miracle, really, that you've got a second chance.
56:54Look, look.
56:55Hello, Jasmine.
56:57I feel as if I could float.
56:58You all right today?
56:59You know, it's like a cloud.
57:02You know, sort of somebody's taking the worry out of your mind and you can just float on air.
57:08That's the feeling you get.
57:10OK, how was that?
57:12Fine.
57:13Yeah?
57:13So these ones are a little bit steep.
57:14I quite often ask my junior doctors what the most important gland in the body is.
57:19And they say the pancreas or the thyroid or something like that.
57:23And actually, the most important gland in the body is the up for it gland.
57:26Are you up for it?
57:28And if that's working well, you can do things to people that you wouldn't be able to do to
57:33a patient who was struggling with motivation.
57:37I thought she put up an extraordinary effort to get through that sort of surgery.
57:41I feel all right.
57:43Yeah?
57:44Should we, do you want to turn around and have a look?
57:46As recently as certainly 10 years ago, it would be very unlikely that someone in her
57:52reduced condition with this massive tumour and poor physiological reserve would be offered
57:58this sort of surgery.
58:04What's changed in recent years?
58:07We've just got a bit braver, I think.
58:18Next time, surgeons put experimental techniques to the test.
58:23Gene therapy trial, everyone's eyes should be covered.
58:27I'm taking a high-speed drill, I'm making my way inside the skull.
58:30There are huge risks.
58:32The liver might not function at all.
58:34And rewards.
58:35If this works out, you'll feel marvellous.
58:38Today's research is tomorrow's standard of care.
59:16Today's research is tomorrow's standard of care.
59:16Today's research is tomorrow's standard of care.
59:17Today's research is tomorrow's standard of care.
59:17Today's research is tomorrow's standard of care.
59:17Today's research is tomorrow's standard of care.
59:17Today's research is tomorrow's standard of care.
59:18You