- 4 weeks ago
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00:00:01The clock is ticking.
00:00:03This is a serious life-saving operation.
00:00:07He's at risk of dying from this procedure.
00:00:13We can go from under control to emergency in the flutter of an eyelash.
00:00:19The beep means don't do that again.
00:00:22It is very personal for me.
00:00:30If you put a hole in here, he'd be at risk of dying on table.
00:00:35This is either life or death.
00:00:46They have a constant, severe, debilitating pain.
00:00:49And that pain drives patients to suicide.
00:00:52It just makes you feel like you don't want to do it anymore.
00:00:59We're trying to just move further and further and further into the depths of the tumour.
00:01:11You feel the worst.
00:01:13You think this is the finish.
00:01:15This is like cutting wires of a bomb that is about to explode.
00:01:28This is really serious.
00:01:30And if it doesn't go right, this could really affect the rest of my life.
00:01:33Very complex operation.
00:01:39There's lots of potential for disaster.
00:01:42This doesn't look great at all.
00:01:44There's no connection to the spinal cord.
00:01:45There's no connection to the spinal cord.
00:02:01Abigail, she's 28.
00:02:02And she's got severe facial pain from an epidermoid tumour compressing her trigeminal nerve.
00:02:11It's been growing in the brain over many years.
00:02:13And her quality of life is so affected by the pain that we hope that we can try and give some relief and get her back to some sort of reasonable quality of life.
00:02:22Because at the moment, she's really disabled by the severity of the pain.
00:02:28So the operation involves us going to an area we very rarely visit in neurosurgery.
00:02:34There's risk of injury to important nerves that move the face, move the eyes, involved in hearing.
00:02:42And we need to preserve all of these nerves and relieve the pressure on the nerve that's causing the severe pain for her.
00:02:52About five years ago, I started feeling like I had an ache in my jaw.
00:02:56I thought it was coming from a tooth.
00:02:58It'd go away for a couple of months and then it would return.
00:03:01And it was worse than the pain from before.
00:03:04You know, I've got this problem that comes and goes.
00:03:07It's hard for people to understand because when they see me now, oh, she looks fine.
00:03:11She hasn't got a problem.
00:03:13When I've got an episode and I'm crying and I can't get off the floor and I can't talk or eat, they don't understand that side.
00:03:19I've seen, it's just uncontrollable agony.
00:03:24There's no, it's, it's indescribable.
00:03:26You can't do nothing to help.
00:03:27If I could do something to help, if I could swap your place, I'd do that.
00:03:30It's just nothing.
00:03:32There's nothing that you can do to help.
00:03:33That's the worst part.
00:03:35It is nicknamed a suicide disease.
00:03:36I've seen that.
00:03:37Yeah.
00:03:38I've seen that about, it's nicknamed.
00:03:39You can understand why people can't take it.
00:03:43Because there's only so much pain a person can take.
00:03:48It's going to make me upset.
00:03:50Because it just feels like it's ruining your life.
00:04:03And you can't enjoy daily life.
00:04:08It just makes you feel like you don't want to do it anymore.
00:04:10There's only so much you can go through at the end of the day.
00:04:24This is Abigail's MRI scan.
00:04:43So, epidermoids are basically skin cells that become trapped in the brain
00:04:49during the development of the embryo.
00:04:51Over time, these form into a tumour that spreads like tentacles around the brain.
00:04:58This is the epidermoid all the way down here, coming down like this.
00:05:03Here.
00:05:05And this here, where it looks like somebody's punched a hole almost in the lower part of the brainstem.
00:05:14That's actually where the epidermoid is pushing and is leaning right into the brainstem.
00:05:19The epidermoid is also near the trigeminal nerve that supplies sensation to the face.
00:05:28And because the nerve is so irritated, then she's getting this terrible pain.
00:05:33So, the aim of the operation is to try and literally hoover out some of this epidermoid to take the stretch and the pressure off the critical nerves.
00:05:45The difficulty is the location in front of the brainstem is a difficult area to get to and access to this area is one of the problems.
00:05:55There is quite a lot of risk attached to it.
00:05:59If a vessel was damaged or injured during an operation or was bleeding, then that could be catastrophic and that could result in a stroke involving the brainstem.
00:06:09In terms of other complications that can occur after this type of surgery is that the nerve actually is more damaged.
00:06:18They have a constant severe debilitating pain that's even worse than trigeminal neuralgia.
00:06:24And that pain drives patients to suicide.
00:06:28Then we've achieved nothing and done a lot of damage to a young mum with a young family.
00:06:35So, today we are operating on Abigail.
00:06:45She's a 28-year-old lady who's got a large right-sided epidermoid.
00:06:50There's potentially a risk for major hemorrhage.
00:06:53We'll cross-match if we run into that eventuality.
00:07:02Can I go?
00:07:03Yeah.
00:07:04I'll go along.
00:07:05Yeah.
00:07:06This is, um, more psychic.
00:07:09Oh, yeah.
00:07:18Hello.
00:07:2710 hours, 12 hours, 24 hours, we don't know how long it's going to be.
00:07:30We're operating on her brain.
00:07:33One tiny slip and it's game over.
00:07:36The main thing is she comes out of it better than she went in.
00:07:40I think Gabby would take a lot of the risks, going deaf, partially sighted.
00:07:45I think she'd take any of that over what she's got at the moment.
00:07:48I'm scared of this operation, you know, I don't want to do it, but I feel like I've got to do it.
00:07:55It's my only option to try and get better.
00:07:58Yeah.
00:08:00Three, nine, six, four...
00:08:02Just to warn you, that lovely hair of yours, you won't be impressed by the haircut.
00:08:05No, it's fine.
00:08:06Although, you know, some people...
00:08:07I'm going to show it off and embrace it, so...
00:08:09Yeah, exactly.
00:08:11And then I think we've spoken through the rest of it, but you'll be fast asleep.
00:08:16OK.
00:08:17They'll take you through the checks and I'll catch up later.
00:08:19See you later.
00:08:20See you later.
00:08:21See you later.
00:08:22All right.
00:08:23Just keep it on.
00:08:25OK.
00:08:26All right.
00:08:27There's a bit of oxygen coming now.
00:08:28All right.
00:08:29And then we'll start drifting you off to see once we've got those last bits of monitoring on.
00:08:32That's it.
00:08:40So we've got a long day ahead of us and it's a complicated operation.
00:08:44The main risk, from my point of view, is the operation doesn't actually help her pain.
00:08:48And so a patient goes through all the risk of having an operation.
00:08:53And then they have new problems that they did not have before the surgery.
00:08:57And worse still, on top of that, they still have intolerable facial pain.
00:09:18OK.
00:09:19OK.
00:09:20So on the word move, one, two, three, move.
00:09:21Thanks.
00:09:23Clip all the hair all the way back that way.
00:09:25Yeah.
00:09:26It's a highly complex operation that requires two surgeons.
00:09:30Before I can remove the epidermoid, my colleague, Mr Irving, will drill a pathway through Abigail's skull so I can reach the brain.
00:09:38We'll be doing most of the access to the bone of the base of the skull.
00:09:43She has normal hearing.
00:09:44We'd like that to be the case at the end of the operation.
00:09:46So we will be very carefully working around the structures of the inner ear without damaging it.
00:09:50We'll need neuro monitoring, so can we monitor three to 12?
00:09:55access to the bone of the base of the skull she has normal hearing we'd like
00:10:00that to be the case at the end of the operation so we will be very carefully
00:10:05working around the structures of the inner ear without damaging it we'll need
00:10:13neural monitoring so can we monitor 3 to 12 we've set up monitoring for all her
00:10:19nerves the nerves that are at risk from the surgery and that's needles that are
00:10:26inserted in the muscles of the face if we are operating and the result of that
00:10:35action causes stimulation to a nerve that will be recorded it's a warning system
00:10:42and it will tell us if we're working too close to the nerve and could end up
00:10:45damaging it it's on there so we're ready to start okay happy days
00:11:03okay and the colorado needle thanks so having gone through the skin I then use
00:11:16a diathermy to cut through the soft tissues and the muscle going straight down onto
00:11:23the bone
00:11:25so I'm going to lift up the soft tissues to expose her ear canal
00:11:32that's the ear canal yeah
00:11:37craniotomy will be here basically yeah
00:11:45so we've identified the ear canal which is the key landmark
00:11:52and we're going to do our craniotomy into the skull
00:11:57I'm ready for the craniotomy whenever
00:12:01yeah
00:12:02you're going to take a disc of bone off using a special type of drill
00:12:10and that's a disc that we can then put back at the end of the operation
00:12:14so that's come off really beautifully actually
00:12:21bring the microscope in here
00:12:26okay let's try that
00:12:31we need the microscope now to give me magnification when I'm working around the inner ear
00:12:39now I need to drill a pathway through another part of Abigail's skull to reach her brain
00:12:51the aim is to take as much bone as we can around the inner ear
00:12:57which is where the facial nerve is and the hearing and balance nerves are
00:13:02we're a millimeter or two from from those structures
00:13:08if we damage those Abigail could suffer permanent damage to her hearing and her balance
00:13:14this morning we have Kelly who's a 50-year-old policewoman and she had a devastating motorcycle injury in Italy
00:13:36she suffered what we call a brachial plexus injury where the nerves coming out of your spinal cord
00:13:41that operate everything in your arm have been significantly damaged
00:13:45today going to try and restore function to it the best we can very complex operation
00:13:51the nerves that we are exploring is in an area of the neck full of complex important structures
00:13:57there's lots of potential for disaster but if we don't operate she may never be able to use the arm again
00:14:11so this happened about six weeks ago this trip was a trip to Austria I have hit another motorcyclist
00:14:23coming the opposite way left side to left side the first person from our group to come around the bend
00:14:31saw bits of motorbike flying through the air and they knew it was me
00:14:38this is after the crash at the moment I have no use of my arm and my hand
00:14:46because it's you know quite heavy as a dead weight I can't even lift my own arm up
00:14:52can't shower myself I can't even get dressed myself
00:14:59it's just those little things that you take for granted all the time so it really has affected my life
00:15:07I've been a police officer in West Mercer Police for 28 years
00:15:12I am currently a detective chief inspector I am responsible for a team and suddenly I'm not there
00:15:19and you know the team are having to cope
00:15:23my career I've become experts in certain you know kind of things
00:15:27but overall managing crimes against vulnerable people
00:15:33I'm now the vulnerable one
00:15:35you know when I'm having a moment I just say oh for God's sake let's just cut the thing off
00:15:40let's just cut it off and be done with it because it doesn't work
00:15:43it's you know I'm carrying it around it's a dead weight
00:15:46but obviously I don't want that I want to be able to use it
00:15:50I want what I was doing back I want to go back to work
00:16:05so what we're looking at here is an MRI scan of Kelly from the front
00:16:09there is a huge zone of injury on the left side compared to the right side
00:16:13and if you look at her left shoulder where the injury is centered onto
00:16:17you can see a lot more thickened and lighter colored nerves here which are the brachial plexus
00:16:23so the brachial plexus is are these five nerves that come out of your spinal cord
00:16:29and go into your arm and they control all the movements and sensation or feeling in the arm
00:16:36I won't know the full extent of Kali's injury until I open her up
00:16:42we get in there and the roots are snapped very very close to each other
00:16:47and we can actually clean up the roots and repair them
00:16:51that would be the best outcome for Kali
00:16:53but if we find that the nerves have been pulled out of the spinal cord
00:16:57so if in essence the body has been disconnected from the arm
00:17:02and there's nothing that we can do to reconnect the arm to the body
00:17:06to fix that we'd have to do a second operation that's much more complex
00:17:10and there's no guarantee it would even work
00:17:12Kali, hi, how are you?
00:17:22I'm good, how are you?
00:17:23Good, so what we'll do is we'll go through a few things
00:17:25and I need to re-examine you again
00:17:27I'm just going to ask you to try and bring your arm out like this
00:17:30I can't do that
00:17:31Okay, just try
00:17:33So that's not working
00:17:36Try again
00:17:38So what I want you to do is just push down against my hand there
00:17:49Okay, so you have five roots coming out of your neck going into your arm
00:17:53Yeah
00:17:54Now the top three for yours aren't working basically
00:17:58The bottom two are working to a degree
00:18:01It's a bit of a spaghetti junction in there
00:18:03It's all going to be a bit scarred from the injury as well
00:18:06So we will be in your neck
00:18:09And you've got the carotid artery and the jugular vein there
00:18:12Now if there is injury to these vessels
00:18:15There's always, you know, a theoretical risk that there's some catastrophic bleeding
00:18:19Sure
00:18:20And which might cause you to have a stroke or even die
00:18:27Okay?
00:18:28Yeah
00:18:29There's a lot of other clockwork around the area
00:18:31Yeah
00:18:32Yeah
00:18:33There's a lot of other things that you can do
00:18:35And you can pull out of your nose and things like that
00:18:36So there's always a risk of damage to them as well
00:18:37Okay
00:18:38Alright, I'll see you soon
00:18:39Okay
00:18:40Alright, I'll see you soon
00:18:41Okay
00:18:42I was hoping to progress my career to the next level
00:18:46I was hoping to progress my career to the next level and that might be
00:18:53prevented because of this. If it doesn't go right this could really affect the
00:18:59rest of my life.
00:19:16So we'll make an incision today on the neck. There'll be a bit of dissection and a bit
00:19:36of exploring to get down to the actual brachial plexus, which is the spaghetti
00:19:42junction of nerves.
00:19:44We're going to lift her up and do it all in one.
00:19:46Yeah.
00:19:47Slowly move her down.
00:19:52Blade please.
00:19:54Okay to start.
00:19:56We're going in through the left side of Kali's neck to get to the brachial plexus,
00:20:01where the nerves controlling her arm connect to the spinal cord.
00:20:05So after we go through skin, we have a layer of muscle.
00:20:12I'm going up the neck as well.
00:20:14So we have, we're best positioned to see what we need to see.
00:20:18We're going into a minefield and you have to tread very, very carefully because a
00:20:26millimeter left, a millimeter to the right, you might get into a major vessel
00:20:30or a major problem with another nerve.
00:20:32I'm just going to divide this muscle.
00:20:35So this is the brachial plexus.
00:20:38Because everything is quite scarred, we're just clearing the tissue so that we can see
00:20:43a bit clearer.
00:20:44I'm looking for the three nerves I know are damaged.
00:20:47The first one I need to locate is connected to a spinal cord at the C5 level.
00:20:52I think you might be damaged here, look.
00:20:55And that's C5.
00:20:57There has to be C5.
00:20:59This is the main nerve root that operates a lot of the muscles around the shoulder.
00:21:04Rupture.
00:21:06Yeah, so we can see a stump of the C5 nerve root.
00:21:12Very little, isn't it?
00:21:14It's damaged there.
00:21:16Yeah.
00:21:17So this is the other end of it.
00:21:19It's been pulled up and just snapped.
00:21:22Oh, bad injury.
00:21:26So we know C5 has ripped out.
00:21:28Now we need to keep going to see the extent of damage to the other tuners.
00:21:33We are operating in the neck.
00:21:36The carotid and the jugular are right in that area where we are operating, so there's always
00:21:41a risk.
00:21:42Bleeding is the main one.
00:21:44What we need to do now is look at C6 and C7, which seem to be missing.
00:21:57It's quite difficult to find nerves coming out from the spinal cord.
00:22:05This looks like rootlets.
00:22:08Yeah.
00:22:09So that's going to be C6.
00:22:15So the C6 nerve root is the second root out of the five that come out from the spinal cord.
00:22:21And what the C6 does is it operates your biceps.
00:22:24The C6 root has been completely pulled out of the spinal cord.
00:22:29What if that is actually?
00:22:30C7.
00:22:31We just found another root, which is C7.
00:22:44It doesn't have any tension in it.
00:22:47C7 doesn't look great at all.
00:22:49There's no connection to the spinal cord.
00:22:52So these have been completely disconnected from the spinal cord.
00:22:56Hence, she's not going to recover down these.
00:22:59We can't repair them.
00:23:01We can't reattach a nerve to the spinal cord.
00:23:04The damage is far worse than we thought.
00:23:08So what we have to do is basically find healthy nerves and rewire them.
00:23:13That means a whole new operation, far more serious, far more complex, and there's no guarantee it will work.
00:23:20This is a devastating injury and it's a very high chance that Kali won't be able to do her job again.
00:23:29Sorry, what was his name again?
00:23:35Okay.
00:23:36Let me find out.
00:23:38It's very close.
00:23:57I'm going to have to get as low as we possibly can down here.
00:24:01But I'm, you know, I'm at the skull base there.
00:24:04Yeah.
00:24:05Yeah.
00:24:13Okay.
00:24:16So we've drilled to the limit that we can.
00:24:20Effectively, what's left behind are just the vital inner ear structures.
00:24:25So Mr. K is going to have to work around those structures.
00:24:28He'll be going into territory where he has to deal with the brainstem, the cerebellum, and all the cranial nerves,
00:24:37plus a major blood supply to those structures.
00:24:42So level of risk goes up.
00:24:48Just come around this way a bit.
00:24:49Mind yourself.
00:24:50Can I have a medium patchy to begin with?
00:24:59Mr. Irving has tunneled through her skull, giving me access to the brain.
00:25:04Now I need to create a pathway between two parts of Abigail's brain to reach the epidermoid at its centre.
00:25:12So it's like coming in from the attic and we're going into the cellar to try and hoover out the epidermoid.
00:25:19Very crowded space, a lot going on.
00:25:24A lot of very important blood vessels that are very unforgiving if they are a problem.
00:25:29The main danger of a catastrophic outcome is in relation to these vessels.
00:25:34Another ligand flip now.
00:25:35It's a bit tough, isn't it?
00:25:36Can you go in that, please?
00:25:38Very gently, make sure we don't catch.
00:25:40Are we seeing it?
00:25:41Yeah.
00:25:42OK.
00:25:43So we've got the first glimpse of the tumour.
00:25:44Pearly white structure.
00:25:45And we're just trying to improve it.
00:25:46So we've got the first glimpse of the tumour.
00:25:48Pearly white structure.
00:25:49And we're just trying to improve the exposure a bit.
00:25:53So we're just going to start to try and take some of those white flakes away.
00:25:54So we're just going to start to try and take some of those white flakes away.
00:25:55And we're just trying to improve the exposure a bit.
00:26:00So we're just going to start to try and take some of those white flakes away.
00:26:01We haven't really seen any nerves clearly yet.
00:26:02So we're going to have to tread cautiously.
00:26:03My colleague Sackabar and I need to carefully suck out the tumour.
00:26:06So we've got the first glimpse of the tumour.
00:26:08Pearly white structure.
00:26:09And we're just trying to improve the exposure a bit.
00:26:14So we're just going to start to try and take some of those white flakes away.
00:26:23We haven't really seen any nerves clearly yet.
00:26:25So we're going to have to tread cautiously.
00:26:30My colleague Sackabar and I need to carefully suck out as much of the tumour as we can piece by piece.
00:26:35But the tumour is wrapped around the brainstem.
00:26:38And if we damage that, it will be catastrophic.
00:26:44We're trying to just move further and further and further into the depths of the tumour.
00:26:49Above the brainstem.
00:26:50Yeah, just gradually sucking around, creating space for yourself.
00:26:54So just get all the low-hanging fruit, basically.
00:26:58That's it.
00:27:00The more tumour we remove, the closer we get to Abigail's trigeminal nerve.
00:27:05We're in dangerous territory, so must be extremely careful.
00:27:11Easy, careful, because it could be nerves that have gotten more.
00:27:13Don't do something you just end up regretting and she lives with the rest of her life.
00:27:19There's some bits that are a bit firmer than others.
00:27:21And some bits are a bit more stuck to, you know, membranes and layers and things like that.
00:27:26I don't know.
00:27:27A blood vessel is bleeding close to the brainstem.
00:27:45If we can't stop this, it will lead to a catastrophic stroke.
00:27:46Good morning theatre reception.
00:27:47That may help you.
00:27:48Good morning theatre reception.
00:27:49That may help you.
00:27:50So today we are operating on 81-year-old Brian, who's got stage 3 kidney cancer that has spread to the lymph nodes around the kidney.
00:28:07We're doing a robotic radical nephrectomy to remove the tumour and remove the lymph nodes.
00:28:26The robot allows us to do this big operation, but to do it with key holes and small incisions.
00:28:34It's got the manoeuvres to go around the bends and do complex stuff that you can't really do with conventional laparoscopic surgery.
00:28:45This is quite a risky operation, but if we don't do it, the cancer will progress, probably spread,
00:28:53and eventually affect his life and kill him within a year or two.
00:29:08So on this scan, you can see both of Brian's kidneys.
00:29:11This is the left kidney, which looks healthy and normal.
00:29:14And on the right side here, there is a rounded tumour sitting there,
00:29:19probably the size of a big apple occupying half of his kidney.
00:29:23And if we look further up, there is a round shadow here, which is the lymph node.
00:29:31Brian's only chance to get rid of this disease or cancer is to remove the entire right kidney,
00:29:38but also remove the lymph node that is involved with the cancer.
00:29:42On this occasion, we are going to use a robot that will help us to do this with keyhole surgery.
00:29:49With the advantage of doing it with a keyhole, Brian is not the youngest of patients.
00:29:54And a bigger operation can have a big impact on his physiology, on his post-operative recovery.
00:30:01The tricky part is the location of that lymph node, which is sitting in a very awkward position
00:30:09behind a major vein in the body called the vena cava,
00:30:13which needs a really delicate dissection to make sure we don't cause bleeding,
00:30:19which can be catastrophic.
00:30:21And we may have to do an emergency conversion.
00:30:24That will mean that we will have to open him up, try to control the bleeding.
00:30:28We'll have to do it within seconds to stop any bleeding and save his life, if it was to happen.
00:30:38And how are you feeling about today?
00:30:41Blood pressure might be up a bit, but not too bad.
00:30:44I'll check that for you in a moment, if that's all right.
00:30:47Yes.
00:30:48I had a hernia, and I did a scan.
00:30:54I said, we're very sorry that you've got a tumour on your kidney, and it'll have to come out.
00:31:05It happened about two months ago, so it's moved pretty quickly.
00:31:11You fear the worst.
00:31:14You think this is the finish.
00:31:17And cancer is an horrible word for anybody.
00:31:20But I've got to be positive and look for the future.
00:31:25You all right?
00:31:26Yeah.
00:31:27Got your gown on?
00:31:28Yeah.
00:31:29Have a love anyway.
00:31:30Love you.
00:31:31Love you.
00:31:32Yeah, love you.
00:31:33Here you are.
00:31:34Dad, here you are.
00:31:35I think you'll be all right.
00:31:36I love you.
00:31:37It's OK.
00:31:38And you.
00:31:39Look after you, Mum.
00:31:40I will.
00:31:41See you in a bit.
00:31:42Bye.
00:31:43Everybody's broken-hearted.
00:31:44They're just devastated.
00:31:52Forty-eight years ago, we got married.
00:31:55It's just my world, really.
00:31:58Come on.
00:31:59He's my hero.
00:32:00He is.
00:32:01Don't know what I'll do without him.
00:32:04I love you, and he's good for me.
00:32:07What?
00:32:08Dad, here you are.
00:32:09You'll be all right.
00:32:10Yeah.
00:32:11I love you.
00:32:12about him. He's got faith in the hospital and the doctors and the surgeon and that so yeah
00:32:18hopefully I think it's going to go well.
00:32:20So when was the last time you had any help?
00:32:24That's not about how to go.
00:32:29I have to get through this operation because I've got so much love for my wife. She's a
00:32:35world to me. My world, I really, really adore her. We're a very, very close family and I live for the family.
00:32:46You alright? Yeah. You're doing good.
00:32:59Well there's a lot of things going in my head.
00:33:03First, can we get in safely without damaging any bowel?
00:33:11Second is how accessible that lymph node will be. Will we be able to see it? Will we be able to move the cave away from it safely without causing major bleeding?
00:33:23If you're not very careful, the bleeding could be so severe. If we can't control it, there is a risk of him dying on the table.
00:33:33Okay, let's do the checks.
00:33:37Any potential significant blood loss?
00:33:39Yes, potentially we could have a big bleed. We've got cross match four units.
00:33:43Duration?
00:33:44Duration?
00:33:45Three hours.
00:33:50Have a knife, this.
00:33:53Okay, knife to skin, guys.
00:33:56So we're going through the muscle layer now.
00:33:59I need to create incisions in Brian's stomach and fit several ports in. These will allow me to insert the instruments into his abdomen.
00:34:11I'll then use the robot to control these instruments and remove the tumour.
00:34:14Can I have the port, please?
00:34:20We'll put the camera in and have a look.
00:34:26So let's see if we've got enough space.
00:34:28Yeah, it's fine. We're good, we're good, we're good.
00:34:41So now we're going to connect the robot to the ports.
00:34:45Point the scope at the target anatomy, then press and hold the targeting button.
00:34:52Targeting complete.
00:34:54So these are my surgical instruments.
00:34:56Some of them are graspers, some of them are scissors, and some of them are connected to a heat where it can cause cauterization and you can seal tissue inside.
00:35:08So now I'm done on the bedside, I'm just going to move to this console where I'm going to start to control these instruments now.
00:35:19Somebody has checked the blood, the blood bank.
00:35:21Yeah.
00:35:26Now I need to work my way past Brian's liver to access the kidney tumour and remove it.
00:35:32It's crucial I don't damage the liver, that could cause major bleeding.
00:35:37So my colleague on the bedside can now get an instrument to come in, as you can see on the right hand of the screen, and then he will retract that liver out of my way.
00:35:48Yeah.
00:35:51If you grab a bit, yeah.
00:35:53That's good.
00:35:55There we go.
00:36:01This is the tumour there.
00:36:03You can see it now.
00:36:04I need to carefully separate the cancerous kidney from its blood supply before I can remove it.
00:36:14This is out and I have a robotic hemoglobin.
00:36:17First, I need to clip the artery to stop the blood flow before I cut it.
00:36:21So I'll just clip.
00:36:26Beautiful.
00:36:28Good.
00:36:29Excellent.
00:36:30I've disconnected the blood flow going into the kidney.
00:36:31Now I need to disconnect the blood flow going out, which is the renal vein, but it's in a very dangerous position.
00:36:39Now I've just managed to see the big renal vein.
00:36:40So there is the inferior vena cava.
00:36:41I'm going to cut the vein very close to the inferior vena cava.
00:36:42I'm going to cut the vein very close to the inferior vena cava.
00:36:43If that fails for any reason, we will suddenly not move.
00:36:45Then we can go out of the sickle cell.
00:36:48And this is the inferior vena cava, which is my implant.
00:36:50Here's my implant.
00:36:51It may be using an implant.
00:36:53A למ�ement.
00:36:54It's also a part of this implant.
00:36:59I've disconnected the blood flow going into the kidney.
00:37:01Now I need to disconnect the blood flow going out, which is the renal vein.
00:37:05But it's in a very dangerous position.
00:37:08Now I've just managed to see the big renal vein.
00:37:11for any reason, we will suddenly see nothing
00:37:14apart from blood filling up all his belly.
00:37:18So this needs to be done,
00:37:20any tearing of the vina cava,
00:37:22otherwise we will have a bloodbath.
00:37:29Staplers coming in.
00:37:31Yeah.
00:37:33Okay, you've got control.
00:37:37This is like cutting wires of a bomb
00:37:41that is about to explode.
00:37:43So trying to defuse it.
00:37:46This is where it can all go wrong.
00:37:59Is somebody keeping on a sucker?
00:38:06Let's love around the brainstem.
00:38:11It's very difficult to sort of control it,
00:38:15and it's just the angle's a bit difficult.
00:38:19We need to act quickly to stop the bleed.
00:38:22We need to act quickly to stop the bleed.
00:38:26Micropathically.
00:38:38There's a little hole here.
00:38:40We'll coagulate that.
00:38:41I'm using a coagulant to apply directly onto the bleed.
00:38:51Can I pat it quickly?
00:39:00Yeah, that's good.
00:39:01Lovely, jubbly.
00:39:03Now that we've stopped the bleed,
00:39:04we can continue on towards the trigeminal nerve
00:39:07and clear the epidermoid off it.
00:39:10We're working down a tiny little corridor,
00:39:12and then we want to create a bit more room
00:39:14so that we can then navigate the nerves and the vessels
00:39:16and try and find the trigeminal nerve
00:39:18that's causing all the grief.
00:39:19Shall I hold it here and see...
00:39:21So are we seeing it? Yeah.
00:39:24Can you see it OK? Yeah.
00:39:26So we've got the epidermoid
00:39:26that's on the trigeminal nerve there,
00:39:28which is causing all the grief.
00:39:29So we want to create a bit more room
00:39:30so we can then navigate the nerves and the vessels
00:39:31and try and find the trigeminal nerve
00:39:32that's causing all the grief.
00:39:34Shall I hold it here and see...
00:39:35So are we seeing it? Yeah.
00:39:39Can you see it OK? Yeah.
00:39:40Can you see it OK? Yeah.
00:39:43So we've got the epidermoid that's on the trigeminal nerve there,
00:39:47which is causing all the pain.
00:39:49There's a layer on the outside of the nerve,
00:39:51and that's quite stuck to the epidermoid
00:39:53because they've been together so long.
00:39:55We're just trying to peel it off.
00:40:00This is the crucial moment of the operation.
00:40:02We're peeling the tumour off the nerve to stop her pain.
00:40:05But if we damage the nerve,
00:40:07she could have permanent pain for the rest of her life.
00:40:10I've got it off the lateral part of the trigeminal nerve fine.
00:40:23We just now need to clear it from the southernmost area where it sits.
00:40:33I'm close to the brainstem, so I'm going slowly,
00:40:36freeing it up bit by bit.
00:40:40There's quite a few little vessels around the place.
00:40:46You should have the lower cranial nerves coming into view.
00:40:51You really don't want to damage those.
00:40:54We've just got to work around here, and then release things up here.
00:41:07That's fine, thank you.
00:41:09OK.
00:41:11We're at the final stages of the operation now.
00:41:14The key thing is that we've been able to clear the tumour off the trigeminal nerve,
00:41:18as far as we can see.
00:41:19That was our principal aim in the operation, was to free that up,
00:41:22and I think we're going to be able to do that.
00:41:25Jonathan and Alex are teasing the last little fragments out from the bottom.
00:41:32Now we need to use the monitoring to check the nerves.
00:41:36Let's see, stimulating there.
00:41:38Sorry?
00:41:39Stimulating there, let's see.
00:41:41Say that again.
00:41:42We have seen a reduction in the hearing signal.
00:41:57A strong indication that the cochlear nerve has had some stretching or manipulation that will result in hearing loss.
00:42:03Nothing at 0.2.
00:42:08Now lowers.
00:42:33So we're going to see Callie, and I'm just going to tell her what we found during the operation.
00:42:40The damage was far worse than we thought.
00:42:41Three of the main nerves going to her arm have been ripped out or pulled out of the spinal cord or torn,
00:42:46and she has lost function to her arm.
00:42:49Today what we aspire to do is use healthy nerves that are working and rewire them so that she can regain this function.
00:42:59Hello.
00:43:01Hello, good morning.
00:43:02Hi.
00:43:03Hi, Callie.
00:43:04Hi.
00:43:05How are you doing?
00:43:06I'm okay.
00:43:07Good, good.
00:43:08So, essentially, five nerve roots that come out of your neck.
00:43:10The second and third completely pulled out of the spinal cord.
00:43:13Okay.
00:43:14And the first one was snapped, was ruptured.
00:43:17Right.
00:43:18Okay.
00:43:19So what we need to do now is we need to reconstruct the functions of those first three nerve roots.
00:43:25We'd have to go into your ribs, basically, to take your intercostal nerves.
00:43:30So those are nerves that travel between your ribcage.
00:43:33We take those out, bring them out here, reroute them into the arm, into the nerve that we need to reconstruct.
00:43:41Wow.
00:43:42So we'll need two or three of those.
00:43:44It's going to take all day.
00:43:45Lots of microsurgery, lots of work under the microscope and things like that.
00:43:50Once you're all rewired, it'll take a while for everything to recover.
00:43:54Sure.
00:43:55So just be aware of that.
00:43:58Thanks.
00:43:59There's no guarantees that this will work.
00:44:03We know that from the previous nerve transfers that we've done, there are good outcomes from them, but there's no guarantee with anything.
00:44:14And if it doesn't work, Callie's quality of life will be significantly affected.
00:44:21Yeah, that's good.
00:44:22That's fine.
00:44:23Yeah, that's good.
00:44:24I'm just going to bring the height of the bed up.
00:44:25Yeah.
00:44:26I've come to realise just how bad it is.
00:44:31It doesn't look bad on the outside, you know, but the damage internally is pretty significant.
00:44:40Yeah, that's come home.
00:44:45Is that painful?
00:44:46Do you want to sit up?
00:44:47No, no, no.
00:44:48No, no, no.
00:44:49It's fine.
00:44:50I'm just getting one of them.
00:44:52And the fact that there's no guarantees that they can fix it.
00:44:59Yeah, let's come home.
00:45:09Go and live life, you know?
00:45:11That's the whole point of this, isn't it?
00:45:14Is to try and get back to some semblance of normal so I can go and live life and do the things that I've always wanted to do.
00:45:29I don't want them taken away from me.
00:45:32Ready, steady, roll.
00:45:33So there are quite significant risks of this operation.
00:45:39You have to go in between her ribs, right on top of her lung to get the nerves there.
00:45:44There's a risk of causing what we call a pneumothorax, which is air in the lung, or a hemothorax, which is blood in the lung.
00:45:52To restore Kali's arm function, my colleague Lila Saeed and I need to find healthy nerves to connect to the damaged nerves.
00:45:59So I'm just marking some landmarks out.
00:46:00So we're going to take this nerve, rewire it to this nerve, basically.
00:46:06Starting!
00:46:07Starting!
00:46:08Starting!
00:46:09So what we need to do is that we need to do this operation.
00:46:10We need to do this operation, my colleague Lila Saeed and I need to find healthy nerves to connect to the damaged nerves.
00:46:15So I'm just marking some landmarks out.
00:46:18You can only control those of us.
00:46:19So we're going to take this nerve, rewire it to this nerve, basically.
00:46:22nerve, basically.
00:46:29Starting!
00:46:38So what we need to do now is get through the muscle
00:46:41that will find the nerve that we need.
00:46:44We've got the nerve stimulator there.
00:46:47So we'll now go and see if we can find the nerve.
00:46:53And we should see a jump once we get close to the nerve.
00:46:58There we go.
00:47:00So we know it's going to be in this vicinity here
00:47:02because we can see the shoulder twitching.
00:47:06So the yellow slip's going around the shrugging nerve.
00:47:09And now we've found that.
00:47:11The next step is now to find the nerve
00:47:13that we're going to reconstruct.
00:47:17It's quite difficult to find this nerve.
00:47:19There's a lot of feel involved in this.
00:47:21There's a ligament.
00:47:23And the nerve travels under this ligament.
00:47:30So we've found the nerve.
00:47:36We're going to stimulate this.
00:47:38So that's not working.
00:47:39And if we stimulate our donor nerve,
00:47:42yeah, nice good function there.
00:47:45So we're going to cut the nerve now.
00:47:48So we're going to put this nerve
00:47:50onto our donor nerve, basically.
00:47:53Cutting the nerve.
00:47:56Happy?
00:47:57Need the microscopes?
00:47:59So Lila's just going to put the two nerve ends together.
00:48:01We just need a couple of stitches just to hold it together.
00:48:07The stitches are very, very fine.
00:48:10They're thinner than someone's hair.
00:48:13And then we use some glue to basically keep everything intact.
00:48:20We're done with the first nerve transfer.
00:48:22Now we're going to close the back up, turn around and move on to the front.
00:48:28For the next stage of the operation,
00:48:29we must turn Kali over and go in through her armpit.
00:48:33It's very risky.
00:48:34We'll be operating right next to the arm's blood supply.
00:48:43Our plan is to get into the nerves underneath here.
00:48:47What we're now putting a sloop around is the main artery supply to the arm.
00:48:55So this is, you can feel her pulsing there.
00:48:57So the danger of damaging this is she loses the blood supply to her whole arm.
00:49:04So we need to get to the ribs.
00:49:07So this white bit you see here is Kali's rib.
00:49:12Now we need to get underneath the rib and behind the rib, essentially,
00:49:16to get to the intercostal nerve that we're going to use to renovate the triceps.
00:49:21That will make Kali be able to straighten her elbow.
00:49:25So this is probably the most tricky part of the operation
00:49:28in terms of trying to harvest these nerves.
00:49:33You've got the arteries, the nerve, all underneath the ribs,
00:49:36which means we're right on the lung.
00:49:37If you make a hole in the lung and you've injured those arteries,
00:49:40you can cause blood to enter the lung.
00:49:42If blood enters the lung, Kali could suffer catastrophic respiratory failure.
00:49:50That's the nerve, the intercostal nerve, and that's the lung.
00:49:54It's going under a big vein.
00:49:57Right on the edge.
00:50:02It's trying to reduce the tension on the repair by, you know,
00:50:05getting it from point A to point B in the least distance.
00:50:11All right, we'll need the microscope in.
00:50:17This is the last thing we're doing now.
00:50:18We're joining two intercostal nerves to the triceps nerve,
00:50:23which is the nerve that operates your triceps.
00:50:25That will make Kali be able to straighten her elbow.
00:50:29So what we have now, we've cut one nerve which is functioning.
00:50:34So that's a live wire.
00:50:36And we've connected it to a nerve that's not functioning,
00:50:38so that's the other wire.
00:50:44There we go.
00:50:45We've finished the operation now and we've managed to do all of the nerve transfers
00:50:54that we set out to do in the first place.
00:50:57We managed to do that without causing any major bleeding.
00:51:02We can't test it at this stage because the nerve cells need to grow down the new nerve
00:51:06and form new connections, which will take a few months, basically.
00:51:09So we're just going to close the skin.
00:51:18She will have quite a few scars and quite long, significant scars as well.
00:51:33Having a brachial plexus injury like this is devastating and, you know,
00:51:36getting her back to about 50-60% of her function is actually a very good outcome.
00:51:46We just have to sit and wait now for the nerve cells to grow down these new nerve transfers.
00:51:51But because they're nerve transfers, the distances are quite small,
00:51:54that they need to grow back.
00:51:55So hopefully we'll start to see something in about, you know, three months or so.
00:51:59It's not guaranteed at all that we'll be able to fix this problem,
00:52:06so we're trying to do the best that we can for her.
00:52:09When the patient's ready.
00:52:10That's it.
00:52:11Oh, right.
00:52:12Okay, yeah.
00:52:13Transfer the patient and then do it.
00:52:14That's fine.
00:52:15They'll call you when they're ready.
00:52:16Okay, that's okay.
00:52:17Then.
00:52:18You want me to do anything with a sucker?
00:52:19No, thank you.
00:52:20This is really like walking on egg shells.
00:52:27Any wrong move, we can end up with a hole and the tiniest hole in this one.
00:52:30You want me to do anything with a sucker?
00:52:33No, thank you.
00:52:34This is really like walking on egg shells.
00:52:43Any wrong move, we can end up with a hole and the tiniest hole in this one.
00:52:56The tiniest hole in this vena cava will cause a massive bleed.
00:52:59You can suddenly have a whole abdomen full of blood in no time.
00:53:05He could lose all his circulating blood in seconds.
00:53:11Slowly, delicately.
00:53:21Good for you.
00:53:22Now the kidney is disconnected from both the artery and the vein.
00:53:27Okay.
00:53:28Everything is so far under control.
00:53:30Staple it out, please.
00:53:33Now the kidney with the tumour in it is completely detached from its blood supply.
00:53:40I can remove it.
00:53:42But it's crucial that I take the lymph node out as well.
00:53:45Otherwise, we could be leaving cancer behind.
00:53:48And that could be fatal for Brian.
00:53:50Down here, this is where the lymph node is.
00:53:56I'm trying to dig it out now and take it out with the kidney.
00:54:00Going into a dangerous territory now.
00:54:03This is where the veins can become a nightmare and it can grow in the whole thing if it bleeds.
00:54:13It's quite stressful to work around this.
00:54:18We don't want that last part of the operation to be a blood bath.
00:54:24I've just managed to remove the lymph node and it's now hot up here with the kidney.
00:54:42This is the tumour there.
00:54:43You can see it now.
00:54:46Take the instruments out now.
00:54:53We're now done with the robot.
00:54:55We will carry on the operation manually using the ports and tools to get the kidney out of Brian's stomach.
00:55:00But it won't be easy because it's so large.
00:55:08Can I have the bag piece?
00:55:13This is the bag that we're going to use to extract.
00:55:15So it goes inside like this.
00:55:18So now I'm going to deploy and open the bag.
00:55:24It's opening now.
00:55:27It's vital we take out the kidney tumour in one piece along with the cancerous lymph node.
00:55:32So I'm using this bag to collect everything together.
00:55:42We don't want the tumour or the cancer to touch the skin.
00:55:45Otherwise it will spread.
00:55:47Okay.
00:55:48Okay.
00:55:49Guys off.
00:55:50Another empty stretch to take down.
00:56:02Now we'll make one of the keyholes in Brian's stomach bigger and pull the bag out through it.
00:56:06You can actually see the bulge of the kidney there in the bag.
00:56:13Okay.
00:56:14Okay.
00:56:15Okay.
00:56:16So now you want to take the...
00:56:18shots.
00:56:34This is like delivering a baby.
00:56:36Oh.
00:56:39Yeah.
00:56:40That's not small.
00:56:42Okay.
00:56:43Fine.
00:56:44Here's your specimen.
00:56:47All right.
00:56:49So now I'm done.
00:57:06So this is the tumour there.
00:57:07All of this here is a tumour.
00:57:11And this is the lymph node in question that we managed to take out.
00:57:21People can live with one kidney without major problems.
00:57:24And I hope that would be the case for them.
00:57:27This other kidney looks fine on the scans.
00:57:29So I'm not anticipating major problems with living with one kidney.
00:57:36Brian will go to recovery now.
00:57:38The operation has gone well.
00:57:39But you never know what kind of complications could happen.
00:57:42Time will tell.
00:57:47C-19, 60 shoot.
00:57:49C-19, 60 shoot.
00:57:50I'll take those.
00:57:56Emulating.
00:58:03Walking slowly.
00:58:06The reduction in signal that we've seen wasn't enough to make us concerned.
00:58:11There will be some impact in terms of hearing loss.
00:58:13But the time will tell.
00:58:1570%.
00:58:16And then we're going to start thinking about trying to put it all back together again now.
00:58:25So where we've removed bone, the lower part where we've drilled out, if we didn't put something here, it would leave a dead space.
00:58:34Earlier in the operation, we harvested some fat from Abigail's belly.
00:58:35Now we're going to use that to fill the dead space.
00:58:39And leave it at the front where the soft tissues are thicker.
00:58:40Looks good.
00:58:41Looks good.
00:58:42Looks good.
00:58:43Looks good.
00:58:44Looks good.
00:58:45Now we'll replace the bone flap back into the hole in Abigail's skull.
00:58:46Now we'll replace the bone flap back into the hole in Abigail's skull.
00:58:47Now we'll replace the bone flap back into the hole in Abigail's skull.
00:58:52Oh wow.
00:58:53Awesome.
00:58:54we harvested some fat from abigail's belly now we're going to use that to fill the dead space
00:59:00and leave it at the front where the soft tissues are thicker
00:59:08looks good now we'll replace the bone flap back into the hole in abigail's skull
00:59:18oh wow awesome
00:59:24looks good so we're finally getting to the end bone flap has been replaced now we're going to close
00:59:33the soft tissues now whether or not we've relieved the trigeminal neuralgia is clearly going to be the
00:59:40big question we have removed all the disease from around that nerve but if that irritation was caused
00:59:48by a permanent damage intrinsic to the nerve from the disease then even removing the disease might
00:59:54not necessarily reverse it and she knows that but this is her best chance there's a long way to go
01:00:00on this because you know she's got to heal recover wake up and get over the operation so this is just
01:00:06the beginning really
01:00:18so we're going to see cali today um it's been five days since a very complex operation and we're just
01:00:25going to see how she's doing in terms of pain i just also want to check that the some of the donor nerves
01:00:31that we used hasn't compromised a function hello hi cali how are you doing good good well it's nice
01:00:40seeing you sit sitting out um it's good um so i'm ready to ready to heal heal good excellent just want
01:00:48to check that everything's working okay where we took the nerve from so can you just shrug your shoulder
01:00:52yep shrugs working good good so that's working so yeah okay okay if i just support it there yeah can
01:00:58you try to bring your wrist in okay that's good um great so it's it's all a waiting game now yeah
01:01:05okay so it's waiting for the nerves to recover and go grow into the muscle that we've re-innovated
01:01:09you won't see anything happen for a good couple of months three months time you might see something
01:01:15if i can work towards a target yeah it just makes it easier so in terms of like not moving my arm what's
01:01:22my what's my what's my kind of target okay you can't move your arm until another three weeks from
01:01:28the start of the surgery yeah and then we need to go then we need to hit it hard move you as much as
01:01:33we can okay okay great brilliant thank you i think i can see the road to recovery now if i'm given
01:01:41milestones it's like anything if you're disciplined um and you're given milestones to achieve you've got to achieve them
01:01:48life is short and you've got to get on with it i am determined that i will get as much function
01:01:59in my arm and my hand back as i possibly can because i want to go back to work
01:02:05and i want to be able to do the things that i i love doing
01:02:18so now we're going to find brian's family and um talk to them about how the surgery went
01:02:36hello hi you're okay yes so we managed to do it all through keyhole we didn't have to open up
01:02:45overall the outcome is is great um the kidney and the lymph nodes are all out and i've checked
01:02:52it after taking it out and it looks all it's all gone overall it went really well i'm quite pleased with
01:02:58it thank you so much no problem thank you no worries okay thank you thank you so much all right take care
01:03:11yeah yeah brian's wife was quite emotional to hear about the outcome of the surgery and
01:03:17it's probably one of those reasons why you do this job it's just to see that you manage to help people
01:03:24get people back to the families and enjoy the things that we take for granted for life
01:03:28that's good
01:03:33this is just so much
01:03:42hello hello mr k how are you doing well thank you are you okay yeah survived your operation yes
01:03:58are you feeling a bit sick i would imagine yeah quite bad sickness dare i ask about the face
01:04:04no face it's been fine any any pain or anything no pain no right okay now obviously after the
01:04:11operation the nerve could swell up a little bit and then hopefully it'll then settle back down and
01:04:16the brain stem that was all pushed across that started to move back into a normal position
01:04:22any source it feels quite full yeah really full yeah okay really blocked yeah so that when we
01:04:28when we prepare the skin and clean it and everything you probably find there's some prep solution
01:04:32quite often what happens is it gets all dry and crusty and it feels a bit full yeah all right
01:04:37thank you very much cool pleasure thank you during the dissection around the hearing nerve you had
01:04:45a reduced signal it was reduced enough to make us concerned that the nerve was stretched whilst
01:04:51manipulating the tissues in that area now if she's got stuff in her ear canal that we need to get
01:04:59washed out by the ent surgeons that could be causing some of the hearing reduction that she's got so
01:05:03her hearing actually could be a little bit better than we we feel it is but she's she's definitely got
01:05:10serviceable hearing at the moment the main aim of the operation was trying to relieve that intolerable
01:05:14facial pain she had so far that seems to be successful hello maddie oh that's lovely oh keeps kissing the screen
01:05:34say bye mommy bye that was a big relief waking up and not having any pain because that was a fear
01:05:44before the operation that i'd wake up that would have met like set the nerve off and i would have
01:05:49woke up with that trigeminal neuralgia constant pain but i didn't have any of that it's a big risk
01:05:56very big risk but i'm glad that i chose to go ahead with the surgery and had it done
01:06:01just to know that i might not have that pain ever again once fully recovered hopefully start for baby too
01:06:16fingers crossed
01:06:31so
01:06:45so
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