- 6 hours ago
Category
🎥
Short filmTranscript
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 right starting you
00:26think you know in your mind what's gonna happen that's nice to skin when we go into the operation
00:32it's never 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 always got some nervousness or trepidation something is wrong
00:58that's very angry that's trying hard not to let that little voice of fear creep in the pressure is quite
01:11high jump jump the surgeons bear the ultimate responsibility I need to keep this under
01:19control and cut you've got one chance this is what really happens behind the closed doors that's the
01:27specimen of their operating theatres we're almost there if you think that you're a good surgeon and
01:32nothing can challenge you something will come on to bite anyone who thinks that they've seen it all
01:37is kidding themselves the Royal Infirmary of Edinburgh is on the south side of the city over 21,000
01:56and operations are carried out here each year professor Steve wigmore is an expert in the liver and
02:09surrounding organs but medicine wasn't his first choice of career when I was at school I was probably more
02:19interested in art than anything else but my biology teacher told me that I could always do medicine and
02:26have art as a hobby but it'd be very difficult to do it the other way around I used to
02:32do quite a lot of
02:32sculpture it requires a three-dimensional visualization and construct and actually liver surgery is very
02:40similar and it requires the same kind of 3d skills Steve's patient has a life-threatening tumour in her
02:51liver to discuss the operation he's joined by senior clinical fellow Stefan Dreher so this is the case we have
03:0076 year old lady so you could see the tumour it's really quite large very close to the right abatic
03:08vein
03:08so I think we really have to try everything to get the tumour out four years ago his patient had
03:17a tumour in
03:17her womb it was removed but the cancer has now spread 70% of her liver the entire right lobe
03:26will have to
03:27be removed leaving behind just a small healthy part she's definitely on the limit and she will
03:35have 30% functional liver volume left which is very close to our comfort zone the biggest worry there is
03:43that it looks like it's involving the diaphragm the tumour has also invaded the diaphragm making a
03:49challenging operation even more difficult the diaphragm is effectively a muscular sheet which
03:59contracts and relaxes basically is the organ that you use to do most of the breathing effort it looks
04:07potentially quite a significant portion of diaphragm being involved which might need a reconstruction yeah
04:14absolutely I think it'll be quite a large hole I haven't actually had that any patients with this
04:20disease in my career because it's so rare but the ones that we've resected have done really well if she
04:29weren't to have surgery her tumour would inevitably grow it would extend through the diaphragm into her lung
04:36involve more of her liver and she would ultimately succumb to her disease within a matter of months to perhaps
04:42a year
04:50Steve's patient is 76 year old Kathleen from Aberdeen I used to go to the gym quite regularly I liked
04:58Pilates
04:59and like swimming but I haven't been able to do that for quite some time I haven't really been up
05:07to
05:08walking the dog it was the one thing that I really enjoyed doing he's been through everything with
05:14me and so where's bolly Kathleen was diagnosed with liver cancer a year ago but the tumour raised the
05:24calcium levels of her blood this metabolic disorder meant that an operation planned at the time could
05:33not go ahead when surgery was taken off the table it just felt there wasn't much hope
05:47it was mom's birthday and I just remember thinking this is horrible they were very much just like will we
05:57make sure that you're you're comfortable we did go and organize what would happen when I did pass away
06:07it's really horrible when you see someone that you love and care for in distress thank you very much
06:14but an unusually positive reaction to treatment recently brought her calcium disorder under control
06:22her potentially life-saving operation can now go ahead
06:29now we've got hope we've got hope again and it's amazing come on up here that's a boy up you
06:37come
06:37I am aware that it's a huge surgery and things can go wrong and if they do well I've given
06:47it my best shot
06:51Kathleen's eight centimeter tumor is at the top of her liver and has invaded her diaphragm the dome
07:00shaped muscle that operates the lungs to remove the tumor Steve will have to take the right side of
07:08Kathleen's liver and a section of diaphragm just millimeters from her right lung but dissecting the
07:17liver means controlling its network of blood vessels especially the right hepatic vein the drains into the
07:25inferior vena cava the largest vein in the body a complication here could result in a fatal hemorrhage
07:37with the blood supply secure Steve will remove the sections of liver and diaphragm containing the tumor
07:46finally he must reconstruct the diaphragm using an implant made from pigskin
07:53this will close the hole and restore Kathleen's ability to breathe
08:05you'll be well looked after I think so she was put on a palliative care pathway and that must have
08:12taken an immense toll on her and her family right she has been on an emotional rollercoaster finding
08:20herself with the prospect of having potentially curative surgery again
08:27hi Kathleen how are you I'm fine thank you you're all set yeah so we've been through all of the
08:33concerns and you know happy yes okay well we'll see you thank you thank you the Royal Infirmary of
08:44Edinburgh has 28 operating theatres Kathleen's operation is in theatre nine where Steve is briefing his
08:52surgical team she's going to need to have a right hepatectomy piece of the diaphragm removed and then
09:00afterwards we're going to have to reconstruct her diaphragm great thank you I'll be fine you know
09:06I'll be fine okay you take care thank you very much okay I really didn't think that I would get
09:19this
09:19operation so this is an unknown territory going for the surgery we're not like very far I have no fears
09:28they'll do their best that's all I know hiya I'm Natasha I'm one of your anaesthetic nurses all right
09:34oh my gosh another one that's free I'm definitely going to be asleep then absolutely okay okay so
09:40so you're going to gently gently start drifting you off to sleep you're going to be by your side the
09:44whole time keeping you nice and safe and making sure that you're nice and comfortable when you wake up
09:48Zarina Khan Araxai is the anaesthetist for Kathleen's operation liver resection is a major surgery in its
09:55own right but then when you add in a diaphragm resection that just adds a whole other level of
10:01complexity because the operation involves the breathing system Zarina has to be able to ventilate
10:09each of Kathleen's lungs separately to do this she uses a double lumen tube it needs to be carefully
10:18positioned so that you can deflate one lung and ventilate the other lung there we go that's the
10:24arena that you can see by looks like it's in a good position Kathleen's operation is expected to last at
10:34least six hours in the moments before surgery I'm just imagining the operation that we're about to
10:42do so by the time I get to the operation I'm quite calm and quite considered about what's about to
10:50happen
10:52straight to skin Steve begins by making a 30 centimeter j-shaped incision across the abdomen
11:02medicine bones within 10 minutes Steve is able to begin exploring the liver
11:17okay left leg feels a lot of things I can feel the tumor just under my right fingers
11:26but that's um I've got a nice view of the liver now it feels like it's actually quite firmly attached
11:40up in
11:43the tumor has caused the liver to become attached to the diaphragm but more firmly than the scans suggested
11:53the major problem with the liver being stuck is one of safety the right hepatic vein is right at
12:00the top close to the tumor and the blood flow is enormous and getting around it is an important step
12:07in
12:07being being able to avoid major bleeding this is all quite stuck in response to the tumor probably the fact
12:18that the liver is stuck makes that control much more difficult that's really stuck there
12:39as well as expertise in complex liver surgery the Royal Infirmary of Edinburgh is also a center of
12:47excellence for procedures on the brain and spinal cord consultant neurosurgeon Eva Satyta takes on
13:02some of the most challenging operations whenever adults ask you what do you want to be when you grow
13:09up and I said I'm gonna be either a ballerina or a doctor both of my parents are doctors and
13:17but my dad
13:18sat me down and told me in a very way that four-year-old can understand like my dear you're
13:24not gonna be a
13:24ballerina Eva's next case will involve all her surgical skills her patient is an adult who was born with
13:37spina bifida a condition where the spine and spinal cord don't form properly in the womb when the
13:46babies are born with the spinal cord being outside of the spinal canal and it's outside of the skin and
13:53these babies need to have the surgery in the first 48 72 hours to close the defects and as the
14:00child grows
14:01you get a scar tissue forming over the decades the scar tissue in Eva's patient has caused her spinal cord
14:10to become stuck or tethered damaging vital nerves I've seen this 57 year old lady in clinic when she's
14:18walking she feels that her leg gives way basically and she falls over and this has become more frequent
14:27Eva with fellow neurosurgeon Chandru Kaliapurumal is planning a complex operation but this is an exceptional
14:35case the surgery will try to free the patient's spinal cord from the scar tissue and prevent further nerve
14:42damage we know that the scar tissue is going to be around this area and it's difficult to pinpoint in
14:50the
14:50scar tissue what is what the challenging part is to go through the scar tissue without causing damage to
14:58the spinal cord itself so the spinal cord has all the neural tissue from which impulses from the brain
15:06travel through the spinal cord and out through the nerves into the tissues into the muscles and that's
15:13why we can feel and move our legs the operation is not a cure but without it the patient's condition
15:22is
15:22likely to deteriorate and could lead to paralysis the main goal of the surgery is to stop her symptoms
15:30getting worse if you take up the specialty like neurosurgery you have to understand that in a lot of times
15:38you are holding someone's life in your hands Eva's patient Dawn is from Kincardine in Fife she has come to
15:52the Royal Infirmary with her parents when I'm walking about and things like that sometimes it feels okay
15:57okay and then out the blue my leg will jerk and I'll fall and then sometimes it's unbearable to walk
16:07just stand just pain all the time when you walk and then you go again and then it's a bit
16:15better and
16:15then it goes again right my family is very very important to me I kind of said to them the
16:26other day
16:26I hope I'm gonna put you through too much because they are very nervous because well they've been
16:31through it before when I was a baby this will be only the second time in her life Dawn's had
16:36spinal
16:37surgery it's a high-risk operation I'm willing to do it because things are just getting worse as time
16:44goes on the pain's worse they're stumbling about it feels amazing actually to be told that possibly
16:53something can be done to untether Dawn's spinal cord prevent further deterioration and potential
17:05paralysis Eva will first remove bone from vertebra to access the spinal cord then she will open the
17:14dura the spinal cord's protective membrane so that she can peel away scar tissue as she works down the
17:22cord millimeter by millimeter she must avoid damaging the cord or any nerves which control bowel bladder and
17:32lower limbs or it could lead to a permanent loss of function Eva must then find a flexible fiber called
17:40the phylum terminale which in Dawn's case has become stuck but this fiber can be confused with vital nerves
17:49that surround it Eva must correctly identify and then cut the phylum to fully free the spinal cord
17:59one of the biggest challenges is always basically manipulating around the nerve tissue which is
18:05always extensively scary and extensively risky Dawn's operation will be in theater 39 at the department of
18:17clinical neurosciences where Eva briefs her 13 strong team she's a 57 year old lady who was born with
18:26the open myelomeningo seal the spinal cord seems to be tethered so we'll try to untether the spinal cord
18:33okay okay thank you
18:50it's impossible to say what will happen hopefully it'll make a difference
18:54Eva has said to me there's no guarantees of everything but she's hoping that nothing will get worse
19:03and now you just breathe normal we're doing great we'll see you when it's all finished
19:07well we get me of a leash out and let her know that we're good to go
19:14surgical neurophysiologist Maeve Kavanagh will play a key role in the operation
19:19she'll check Dawn's nerve responses throughout well the main nerves that we're worried about
19:24are the motor nerves that control movement of the hips the legs the feet particularly nerves that
19:31innervate your bowel and your bladder function we have some corkscrews in the scalp that stimulate
19:36the motor part of the brain and then we record the responses from the muscles
19:42tracking the responses of nerves in real time will allow Eva to navigate the spinal cord
19:49I would not consider this kind of a surgery without neurophysiology I would think it is unsafe
19:56that's everything for me guys thank you
20:02Dawn is positioned on her front for the operation
20:09the scar on Dawn's back is from the original surgery she had as a baby
20:15it's also where the scar tissue underneath is tethering her spinal cord
20:19I'm going to start from this bit and then probably this bit
20:23I'll leave the middle for the time being
20:27can we crack on?
20:36the patient is on my mind
20:38because any of the steps that you do may cause damage to Dawn
20:43and that's something you want to try to avoid
20:47if you're operating on someone's brain or spine
20:50a millimetre to the left
20:52you can leave them paralysed
20:54a millimetre to the right
20:55and then don't wake up
21:01starting?
21:02okay
21:15in theatre 9
21:17Steve is trying to release Kathleen's liver
21:21if we do a little bit more work around the back here
21:24just to get this freed up
21:26if the liver remains stuck
21:29there's an increased risk of uncontrolled bleeding
21:32when Steve tries to remove the right lobe
21:34containing the tumour
21:42it's good
21:43she doesn't feel too bad
21:44it feels quite good
21:45I think we should be able to get up enough to hang the liver
21:50hanging the liver
21:51is a technique to lift the organ off the body's biggest vein
21:55the vena cava
21:57while also improving access to the right hepatic vein
22:02the hanging manoeuvre is a really important step
22:06because it gives us a much higher level of control over bleeding
22:11first, Steve needs to create a tunnel between the liver and the blood vessels
22:18the trickiest part has to be done by feel
22:21there's a risk of damaging the vena cava with an instrument
22:25so we need to be very careful doing that
22:29the tunnel is vital for the next stage
22:34what it involves is passing a tube
22:37and bringing it out at the bottom of the liver
22:39so that effectively if you pull up on the tube
22:43then it exerts pressure on the back of the liver
22:50here we are
22:52here we are
22:53here we are
22:54here we are
22:54here we are
22:58here we are
22:59here we are
22:59here we are
23:00here we are
23:00now the liver is lifted off the major blood vessels
23:07Steve can safely separate the large diseased lobe
23:12from the smaller healthy lobe
23:15here
23:16someone tell me what the blood loss is
23:17there is about 200
23:20here
23:21can we take echelon steve for it
23:23it is 45
23:2445 echelon
23:27ok, lovely
23:35we're right through here with the liver divided steve can now finally see the major blood vessel
23:43he has to cut the right hepatic vein just at the point it drains into the vena cava
23:51so the great view of the vena cave river if we were to lose control of the right
23:57hepatic vein not only would the patient have a massive blood loss but they would also be at
24:03risk of sucking air into the heart and that would cause a major problem with air embolus
24:09as well as observing kathleen's lung function sarina also tracks her blood loss
24:16these patients who are having major and complex surgery will be monitoring them very very
24:21carefully from my perspective i obviously worry what will happen if steve was not able to get
24:27control of the hepatic vein my thoughts are moving on to sort of dealing with major hemorrhage at that
24:33point i attempted to just put a calm from that let's do old-fashioned stuff the length of the
24:40right hepatic vein outside of the liver before it goes into the vena cava is only about five millimeters
24:46it's a difficult area to control if you have limited movement
24:53the modern way is to staple both sides of the vein and cut through the middle of it
25:00in kathleen's case what i want to do is to use an old-fashioned method of using two clamps and
25:07cutting between them because that gives us greater clearance
25:30the only thing securing the hepatic vein
25:35is a clump double-ended for a program it needs to be sealed permanently
25:41the closure of the right hepatic vein requires intricate suturing to control it
25:48if the sutures fail kathleen would be at risk of losing her entire blood volume
25:54in just three minutes great thank you
26:06perfect needle back to you so have a look where we are now the right lobe is more mobile we
26:15can pull it
26:16down a bit and it's actually much more evident that the diaphragm is involved with cancer
26:22it's about to make a hole in the diaphragm is it stuck down to the diaphragm so the the
26:27liver is completely detached now from the vena caver and it's just attached by the diaphragm
26:36so that the section stuck to the liver can be removed as well but it reveals a new problem
26:44as we open the diaphragm i can see inside the chest cavity and i can see that the lung
26:50is attached to the diaphragm what i can't tell is whether the tumor is actually going into the lung
26:57section okay let me just pop my finger inside the chest if the lungs involved then from a cancer
27:07perspective it's not good because the cancer has obviously extended across two body cavities
27:13and is involving other organs we may have to remove a piece of lung which will reduce her breathing
27:23capacity lung is a little bit stuck nobody expects the unexpected there's no taking away from the fact
27:38that it's major surgery isn't it and it's complex but scary
27:46but she could potentially be cancer free this time next week and that's
27:53a pretty awesome thought i just want to see her feeling better
28:01kathleen's operation along with 70 others at the royal infirmary today
28:06would be impossible without a dedicated team of around 90 porters
28:12they ensure patients equipment and supplies are in the right place at the right time
28:20i'm ex-military so i've done 22 years in infantry
28:23i was struggling in different roles when i first came out of the military couldn't find my feet
28:29and they helped us that's me logging on the air radio
28:31and then i started porting and i thought this is for me today andrew has to ensure important blood
28:39supplies reach an operating theater
28:43there we go excellent thank you when somebody comes in an ambulance or been here for an operation
28:49the theater will call up for bloods every year over 8 000 units of blood are transported around the hospital
29:02it's very important because you're taking bloods from point a to point b and the patient requires it
29:10along the corridor joe is in charge of patient transfer
29:15here's my man hi lorraine for me personally i come in no matter what's happening outside you come in
29:22and your focus is your patience you can get a wee bit cold do you want me to take a
29:27wee thermal blanket
29:28or are you a cardigan over the back take a wee cardigan for your shoulders yeah yeah if you've got
29:34that
29:34kind caring and compassionate side to you there we go that's it if you genuinely want to help people it's
29:41a
29:41great job the porters are constantly on the move when i first started it was about 30 to 40 000
29:48steps a
29:49day and that is in an eight hour period you never stop 40 000 steps is equivalent to about 20
29:57miles
29:59you could have 15 patients a day and i like to be busy active and meeting new people
30:05that's us arrived okay see you in a wee bit all right thank you cheers thank you bye-bye
30:12on the end of the day when you leave here and you've helped a patient that's when you get a
30:16lot of
30:16joy and you think this is the best part of the job the way i look at it whether you're
30:21a surgeon a doctor
30:22a nurse a porter we've all got a role to play we've all got a job to do in here
30:36in theater 39 okay so i reached the spine neurosurgeons eva and chandru have exposed dawn's spine
30:46the bone of life their first task is to remove the lamina the bone that encases the spinal cord
30:57it's always a bit challenging because for bony work you do require some force
31:04but the moment you're onto the spinal cord all of that needs to disappear
31:10so that's beautiful all right so that's the normal anatomy
31:18eva can now see the dura the spinal cord's protective membrane
31:24so that's a normal dura and everything there is all scar tissue
31:29that's the crucial bit of the surgery to try to peel the scar tissue of the lining
31:35so it's too scarred you need to get something better uh scissors please
31:55okay so that's right
31:58eva must cut through the dura to access the spinal cord inside
32:05okay it's all clear microscope in the spinal cord is just six millimeters across
32:11the nerves inside a millimeter or less once i open the dura i'm on the nerves that's where the
32:18neurophysiology is irreplaceable under the dura are the nerves that control dawn's lower body
32:29eva relies on mave to help guide her to a safe place for the incision all right let's do a
32:36bit of
32:36stimulating so when the current is flowing through the probe eva's placing it on different structures
32:43nothing there 0.5 i'll just bring it up and go i go up i'm looking for responses specifically for
32:48motor responses twitches in the muscles that i'm recording from in the lower limbs and also
32:53the anal and urethral sphincter if the current from the probe causes a muscle response then eva is
33:02on or near a nerve nothing there one milliamp i'll just bring it up again nothing there are two i'll
33:09just bring it to three no response is good but mave increases the current to make sure anything here
33:17nothing there are three okay okay all right eva is now confident she can make her incision safely
33:27let's start opening the dura can i have number seven please
33:51a micro instrument used as a back plate stops the scalpel going too deep
34:13in this kind of cases which take long hours i don't feel thirst i don't feel hunger i don't feel
34:21that my back is hurting anything this is all here you go needle back you completely disconnect from
34:32everything else and you concentrate on what your hands are doing eva's incision through the dura
34:39has exposed the nerves of the spinal cord itself she dissects slowly towards the lumpy scar tissue
34:49and you can see what's going on and you can see what's going on and you can see what's going
34:52on
34:52i'm a bit cautious doing that because we don't know what's underneath yeah okay
34:58i don't know what is stuck under the dura and the spinal cord it may be that some of
35:03the motor nerves are right under it can we simulate yeah just one moment
35:14anything here there i'll just start at 0.5 yes please okay that's on there at 0.5 particularly
35:22in a case like this it's very involved it's just constant back and forth there's nothing there at
35:270.5 i'll just bring it up to one anything here no nothing at one milliamp i'll just bring it
35:33up higher
35:33stimulated there stimulated there there's nothing there can have number seven please
35:43that's the scar tissue right over there the only thing you can do is just keep stimulating
35:48and then cut
35:51so stimulating starting at one milliamp oof oh
35:58a major muscle spasm means eva is on or near a critical nerve trapped in the scar tissue
36:06sheesh can you stimulate again must be l3 yeah i'll bring the current down yes please the l3 nerve
36:11controls the thigh muscles and knee movement what was the current on two if that was up at one i'm
36:18just
36:18one oh that is not good anything here yeah yeah that's right l3 they just had responses from there at
36:27one sugar spice and everything nice
36:38in theater nine steve is facing a new challenge during kathleen's liver operation
36:43it might come off yeah the tumor has not only penetrated the diaphragm but has compromised the
36:52right lung as well
36:56we are undertaking a very major cancerous section we've already exposed the patient to a risk
37:04and so i would rather slightly increase her risk by taking a piece of lung rather than risk leaving
37:13tumor behind operating on lung tissue does have the problem that the lungs are moving through breathing
37:22and the tissue is very delicate and easy to damage we should just stop ventilating through that lung while we
37:29do this serena would you be able to let the right lung down the double lumen tube inserted into kathleen's
37:36airway earlier now plays a vital role serena can stop the right lung while keeping the left lung fully
37:45ventilated so when we're converting from two lungs to one lung we need to reduce the amount of volume that
37:52we're ventilating our patients with and make sure that the pressure in that lung that we are ventilating
37:57and doesn't go too high just wonder they could put an echelon across that bit
38:10while it's motionless steve can safely remove a slither of right lung
38:17his surgical instrument cuts the lung tissue while simultaneously sealing it with staples
38:34the tumor and the whole of the right side of the liver are removed
38:41when the specimen comes out it's a moment of relief for the whole team and a big release
38:46it's pretty good actually i think yeah looks okay doesn't it good happy with a bag up
38:52can we call it right hypotectomy diaphragm and a little bit of lung
38:59there isn't much time for celebration because we need to reconstruct the diaphragm there is a an
39:07eight by ten centimeter hole and so we need to put in a patch i want to really put a
39:13small like a
39:14corner like that and then just put it in our lips yeah the patch is prepared from sterilized pig skin
39:23it has the same properties as diaphragm tissue i think what i'll do is i'll put this level on the
39:31stitch in the other corner and then hold it out to make sure we don't prying the lung
39:40if the patch was too tight then there's a risk of ripping and the patient developing a hernia through
39:48the diaphragm into the chest but as we conclude the closure of the diaphragm with the patch
39:57and finish the suturing i can see that it's forming a nice shape which is good
40:04should you start ventilating through the right lung again thank you
40:10there we go looks pretty good
40:12oh this is not doing well what's going on there what i can see is that now that serena has
40:22re-inflated the lung and the patient is breathing normally air is escaping and collecting behind the
40:29diaphragm i try and squash some of the air out to make sure that it's not just been displaced air
40:36from somewhere else in the chest and the problem continues with the diaphragm ballooning
40:43it must be an air leak yeah we've got a bit of an air leak the diaphragm blew up
40:53i've just turned the flow rate down so if there is a leak then i'll notice it from the side
40:58you should be able to see it yeah with modern ventilators you can see the volume that you're
41:04delivering to the patient and the volume that the patient is breathing out and there was a massive
41:08discrepancy between the inspired volume and the expired volume
41:14there is a leak okay there's a risk with each breath that the patient takes more air accumulates
41:23in the chest cavity outside of the lung and eventually as the pressure increases
41:28in this air it collapses the lung down and stops the patient breathing properly at all
41:35pressure builds up um in the chest wall and it compresses important blood vessels and it can
41:40compress the heart leading to a cardiac arrest so we need to fix that we can open this and see
41:52it's annoying having to undo the patch to try to find the air leak but in this particular case
41:59it's not removing the patch entirely and it's a necessary procedure for Kathleen
42:06nearly four hours into the operation steve must retrace his steps to find a tiny puncture in all the folds
42:14of the lung i just wondered whether we um put a um hole in with a stitch
42:27which is quite a strong dilution it's 10 mils diluted in 20 mils so if you want it diluted more
42:34let me know
42:36searching for the air leak is quite difficult we're just trying to spot exactly where it is
42:50so we used an underwater bubble test like you would for a puncture in a bike tire to identify the
42:58leak
42:59but i can't see any obvious air leak
43:23the puncture is where the lung had been stuck to the diaphragm
43:31it looks like something that would be possible to close with a stitch but obviously using a needle
43:37creates another hole and so there's a risk of making it worse by stitching
43:44what we'll do is we'll put some glue on it because still see a little bit of a bubble of
43:48air yeah
43:48what we're doing the surgical glue works in a similar way to help blood clots
43:59the resulting plug will seal a leak even when wet
44:04you know we try and put this stuff on your bike tire and it's um yeah i've fixed my puncture
44:10the
44:11day with the blister pasta yeah that's a good idea so just what you had handy it's working okay at
44:18the moment
44:20yeah it's definitely not bubbling the same as
44:26okay that's great thank you we've got the leak so we're in good shape
44:39okay can you start ventilating again through the right lung please
44:45when we repaired the diaphragm the second time and repeated the air test there was no continuing air
44:52leak from the lung that was a big relief so we're just about ready to close
45:00the lungs steve secures the remaining left lobe of the liver to the body cavity
45:05this will stop the liver from twisting as it regrows the liver is a remarkable organ liver regeneration
45:14is incredibly fast it is probably back to almost 100 volume by three to four months after surgery
45:23it's got a beautiful healthy looking liver the bed that's left are you happy i'm very happy just
45:31saying we've got a gas to be proud of so i see could a corner stitch please thanks
45:48good job interesting person yeah yeah yeah steve phones kathleen's daughter
45:58so we've taken the tumor out and all of our organs look really healthy you're just going to go to
46:05the
46:05recovery room now you're very welcome all right see you soon i'm really delighted for kathleen that we
46:12have been able to do this operation successfully pathology results will tell us really the extent of
46:19the tumor it's possible that she may need to go back on to chemotherapy or immunotherapy
46:25oh
46:34in theater 39 neurosurgeons eva and chandru are attempting to cut through scar tissue
46:42without damaging any of dawn's nerves anything here dawn's l3 the nerve that controls her upper leg
46:50is the most entangled.
46:53Nothing there at one milliamp.
46:54OK.
46:56I can't distinguish structures in that scar tissue.
47:00It's like flying blind.
47:03That was all three.
47:05No, no, I'm talking about this.
47:06I won't know where that nerve is actually sitting,
47:09and that's the crucial bit,
47:11why we actually need MAV and stimulation.
47:16If MAV confirms there are no muscle responses,
47:19it means that part of the scar tissue is clear of nerves.
47:24Nothing there at one.
47:25Just going to do 1.5.
47:27Nothing there at 1.5.
47:29Just going to check 2 milliamps.
47:32At 2 milliamps, briefly got a response.
47:35OK, the same shenanigans.
47:37OK, fine.
47:38By a process of elimination,
47:40they can identify a safe way to dissect the scar tissue
47:44away from the nerve.
47:46Stimulate.
47:47Just going to start at 2 milliamps this time.
47:49That's fine.
47:51Nothing there at 2 milliamps.
47:52OK.
47:53Let's check if you're lying to us or not.
47:55And I'm guessing that this should be the motor.
48:00Hopefully.
48:02Yeah.
48:03Yeah.
48:04Right, L3.
48:04Big response is there.
48:06Agreed.
48:07Now, just get the microscope focused from here.
48:12I think, yeah, you can open that.
48:15We've gone through the main part of the scar tissue.
48:18They have successfully untethered the spinal cord,
48:22separating its nerves from the scar tissue.
48:26As a surgeon, you always feel a bit of relief when you go through the crucial bit of the surgery.
48:32You take a deep breath, and then you literally feel, we're getting there.
48:38Four hours have passed, but one more crucial step is needed to fully untether Dawn's spinal cord.
48:47Cutting a fiber called the phylum terminale.
48:51We all have phylum terminale, but in Dawn's case, that phylum terminale also became a bit thicker and less mobile
49:01in her,
49:01and it was contributing to the tethering of the cord.
49:06The phylum terminale anchors the spinal cord to the base of the spine.
49:12The narrow fiber looks almost identical to the dozens of nerves,
49:17which fan out from the spinal cord to the lower body.
49:22Using an electrical probe, Eva will need to identify which ones are nerves.
49:29When there's no response, Eva can deduce it's the phylum.
49:34Because Dawn's phylum is less mobile than it should be, Eva will then cut it.
49:40This causes no harm, and means the untethering of her spinal cord is complete.
49:49So that's the tethered...
49:51That's the tethered bifed part, which you can see in the scan.
49:53So the phylum has to...
49:55...be somewhere there.
49:57Between all of those nerves sitting there, we need to distinguish which one of them is phylum terminale,
50:04and cut that exact one.
50:08Like finding the correct needle in the haystack.
50:13There's going to be L4-5 and probably sacral deeper.
50:19So now these are functional, right?
50:21These are functional.
50:22You want to make sure that whatever you're stimulating is working, and you will know that the phylum is going
50:29to be the one that will not give you any response at all.
50:33Is it this one?
50:35Yeah?
50:35That's the phylum.
50:37If you think that this is the phylum, then you do stimulation.
50:43That's the crux of whatever we want it to do until there.
50:46Let's see if we get the phylum done.
50:49A bit of EMG starting up from S1 on the left again now.
50:53There's an unexpected response from another nerve that controls Dawn's lower leg and foot.
50:59Can we stimulate bipolar?
51:03Yeah.
51:04Actually, that's bilateral S1 now, by the way.
51:06Ugh.
51:09Why?
51:10Oh, why?
51:12If they're on the phylum, Maeve shouldn't be getting a response.
51:17If there's any motor responses coming in, that might suggest that there's some motor fibres stuck to the phylum.
51:23It's on a 1 milliamp.
51:25Well, if I was to make a mistake and cut enough, I can cause permanent damage to Dawn.
51:32Nothing there at 1.
51:33Just going to bring it up to 2.
51:35Nothing there at 2.
51:36Anything here?
51:37This is sensory.
51:39Oh, just there, I had L4 on the right.
51:42Yeah, there I'm getting some...
51:43I got a left side response around L4 or 5.
51:46Is this from phylum stimulation?
51:48Just give it a second.
51:49Let it settle so we can know what's going on.
51:51Ugh.
51:53So were you just simulating the phylum there when you were getting those other...
51:56Oh, it's still getting S1, isn't it?
52:01Yeah, it's still ongoing.
52:05Well, I'm directly on the phylum.
52:07I'm 99% sure that that's the phylum.
52:09Mm-hmm.
52:10But it's got nerve roots around it, so we need to dissect them around it.
52:16Can I get two small patties, please?
52:20Eva isolates the suspected phylum from nearby nerves, so Maeve can test again.
52:27I'm always nervous at that time, because you can really only say that, you know, I'm not
52:32getting any motor responses at this current, but sometimes you have in the back of your mind,
52:36and what if I needed to put the current up a bit more?
52:41It's going to 1.5.
52:44Go to 1.5, just a second.
52:46Nothing at 1.5.
52:48It's kind of a fingers crossed moment.
52:49You're hoping that everything goes how it should go.
52:53Nothing at 1.5.
52:56Go to 2.
52:59On 2 now.
53:03No responses at 2.
53:05Okay, Eva.
53:06Okay.
53:06That's the fellow.
53:07We are clear that this is phylum.
53:09This is kind of a final step of the procedure to make sure that there's no tethering left.
53:16Which one?
53:23Okie dokie.
53:24Untethered.
53:25All good.
53:26So that's the untethering done.
53:30You see that there's a gap between that where we cut it.
53:34Do the motors now.
53:36There's one more test of the motor nerves to ensure that they weren't inadvertently damaged
53:42when the phylum was severed.
53:45My heart is always kind of in my mouth for those few seconds, because you want, you know,
53:49you want everything to be stable.
53:52When you see all the responses are the same size as baseline, everything is looking how
53:56it should, I can kind of breathe that sigh of relief.
53:59Motors are stable.
54:02Okay.
54:04Beautiful.
54:06As a surgeon, you definitely feel relief when everything is done and see that you haven't
54:12caused any damage.
54:13And I think that's very rewarding.
54:17Iva and Chandru stitch the dura closed and cover it with a surgical sealant.
54:39Thank you guys.
54:43Hello Dawn.
54:44Hi sweetheart.
54:45Hello.
54:46Are you able to open up your eyes?
54:47Nice.
54:49Good job.
54:52Dawn, you can relax your hands now.
54:54That's it.
54:55Perfect.
55:04It's been 10 weeks since Dawn's surgery to free her spinal cord from scar tissue.
55:11Before any kind of back surgery, I make my patients promise me that physiotherapy after
55:18the surgery is going to be the new best friend.
55:21Dawn is attending a local hospital in Dunfermline for a physio assessment.
55:27The plan today is just a bit of a discussion about how things have been going, about how
55:30your recovery and things has been up to now.
55:33Things on the whole are looking a little bit better than they did before.
55:36And I feel a wee bit brighter.
55:38I just hope to be a wee bit more independent.
55:42How do you feel with the sticks?
55:43I feel not too bad actually.
55:45Am I doing it properly?
55:46You're doing it fine.
55:46You're doing great.
55:48I feel good because I know it's going to happen.
55:53The team, absolutely marvellous.
55:55The nurses, the doctors, the surgeon, fantastic.
55:59Even us surgeons love to know that we've done everything and the patient's up about
56:04and running.
56:05It takes time in these cases to make sure that there is improvement.
56:09But in Dawn's case, I would hope that she's back on her own two feet.
56:14Her mobility is unaffected and she continues going forward and enjoying her life.
56:23It's getting dark.
56:25Nine weeks after her operation, Kathleen's back for a checkup with Steve.
56:32How are you doing?
56:33I'm doing very well.
56:34So the tumour has been completely removed.
56:38That's fantastic news because it means that you're cancer free.
56:42I'm not expecting anything to come back.
56:44It's amazing.
56:45Yeah.
56:46And I feel so...
56:47I think I actually feel better than I've done for a long, long time.
56:51Good.
56:51I've just been so pleased to do normal things and take the dog out for a walk.
56:56I mean, he's old and he likes to take it easy too, so we're fine.
57:00So what makes my job worthwhile is seeing people, you know, in better circumstances than they were before.
57:07Thank you so much.
57:08Happy to see you.
57:09You take care.
57:10OK.
57:10I understand.
57:11Bye.
57:11Bye.
57:12I didn't think that I would be able to get this operation.
57:16And now that I have, and he's done all this for me, and he's telling me I'm cancer free for
57:21now, it's just a miracle.
57:26Come on then.
57:28Oh, look at him, he's happy.
57:32Oh, it's good to be out in the park.
57:35No two people are exactly the same.
57:38In Kathleen's case, one of the aspects that was quite amazing was her turnaround from having a really major complication
57:47of her cancer to being well again and us being able to remove it.
57:54Both myself and the rest of the team are absolutely delighted for her.
57:59And I expect her to live a full and normal life with many more dog walks for Enzo.
58:29I'm sorry.
58:47I'm sorry.
Comments