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I don't think I can do this man any justice with any introduction. So I'm just going to say sagger is here to talk to us about a topic of his choice if you can just give him a warm welcome. Thank you so much. Thank you very much for the current invitation. Um I was grumpy when I got this title because it implies that I'm retiring. And in fact, there's been some comments in our department about me retiring a few months ago. So I decided to announce when I was gonna retire. Everyone perked up. And I said, well, I'm doubly incontinent, killed off all discussion. I've enjoyed this afternoon. Sorry, I couldn't make this morning. II had family duties with child, three and the wife. Um, but I'm gonna talk to you today about some elements of my career and how they in may influence you and help you identifying co with some of the problems. There are times in life when you're flying high, you're flying high in April and you're shot down in May. No fall, no fall and there's gonna be times in your career when things go badly, wrong stuff happens when I was working in the States um in the late nineties, this is my favorite program, David Letterman and he always had a top 10 list of various things. So I'm gonna give you, this is the top 1010, top tips from me from my experience and most of this is pictures and stories. So there's not much data here. I apologize for that. Given the quality of the talks you've had. So 10 lessons for you Jews club people. First one develop a niche blessed are the colorectal surgeons. We're very lucky to do what we do. Laparoscopic colorectal surgery. It's interesting when I was interviewed in 96 for my job in leeds, they called me back into the room and said, right. But you've got the job, what would you like to do? I said, um, I'll do this key old surgery and they said, oh, that sounds good. And what else do you want to do? I said, ooh, this recurrent rectal cancer stuff. Oh, that sounds good. Crap on then. Go ahead and do it. Well, these days, of course, you couldn't just start doing laparoscopic or recurrent rectal because of the cost and so on. But that's where we were. But to give you us an idea of what was going on in the nineties, if you went to Acars, the American Society meeting in the early nineties, each year it moved from, can't be done. Can be done. Shouldn't be done then there were people in the bar saying, oh, I've done it and then let's all do it. So there were problems with that. I'll give you a case that really got me onto laps surgery. Here's a case of Crohn's and looking at that picture. Now, I don't think we would operate on it, but that's by the by, but we did, this was 96 and this was on the very first laparoscopic cases at the mayo clinic in the States young slim female with Crohn's. There. You are Crohn's resected on a Tuesday morning. These were the images. This was the picture when we finished the operation Tuesday morning. The next Sunday night, she was back working as a dancer in solid gold in Minneapolis, Saint Paul. So five days later she was on big money at the solid gold in Minneapolis. I wasn't there but some of the registrars where residents went, ok, understand the literature to go back to the mid nineties. And there was a big kerfuffle about this paper which was showing that you got port site recurrences after cancer surgery. And it really stopped things in the tracks. Why? Because up to 21% incidence of port site recurrences stop the surgery. But go back to the paper what they done. They found a bunch of patients, 14 who had had resections. This is mid 90. Remember three got recurrences in the port sites. Therefore, 21%. And that figure is still quoted regularly or was quoted through the two thousands. Cos no one back to the paper, they just kept quoting it. So always know the literature. What did happen of course was trials. And Steve talked earlier about the value of trials. Justin spoke earlier about value of trials. And this is what happened. We had the cost trial which was run out of mayo. We did some of the first cases, this was colon cancer. And then Pierre here in Leeds started the classic trial. So two very important trials that then did away with all that nonsense about port site recurrences. So know your literature, carry out the trials and always remember your patient. So those trials came out, we saw the data but patients perceptions were the laparoscopy was better than open, which makes sense if you were a patient, do you want me to know about this earlier on training that classic er hashtag you show that there are no training now, no surgeons tomorrow. The single best thing I have done as a consultant in the last 28 years is to run fellowships. So at 20 years, we used Ethicon to run our fellowship which went out of Leeds. And then there was Colchester Friley Saint Marks, et cetera training people remember in the mid two thousands, nobody was doing laparoscopic surgery. So we're gone from the mid nineties in the States to the mid 2000 here and a few people were doing. This is true. Right. Hemi appendicectomy. And that was about it. And then Ethicon came along approach the fellowships. We had lap co everything started to take up. We took an awful lot of time. I gave a lot of credit to the um the people that sponsored that, but we had difficult interviews, an awful lot of people applying for these jobs as fellows. So we had to put them through a very rigorous interview process before they could get the job as a fellow. He was one of our first fellows. We also do is expand it nationally as well. So we ran Australian fellows, New Zealand and Singapore. And this was me earlier this year in Singapore with that six of our fellows from before. So it's very rewarding. And what John was saying about training, I think it was one of his last slides with the light bulb on. It's very rewarding to train people and it's not that they're getting the benefit as much as they and you are getting the benefit. And I always feel you learn more by doing the training about your surgery than just knocking off the case yourself with no one there to be trained. So training is very important and very, very rewarding. One. Don't jump on a bandwagon. Steve was addressing certain issues with proctology in some but some things have come along and you think, oh, that's the way forward. I'll go down that road. Here's operation anubis. This was doing a laparoscopic cholecystectomy through the vagina came out in 2009. In 2009, you went to the conferences, particularly in the States. Everything was about notes, taking appendix out through the mouth gallbladder through the vagina, et cetera, et cetera. One year later disappeared completely. Why cos it was stupid? Half my patients haven't got a vagina and why would you go through the mouth, take an appendix out. So be careful what comes out and you think, gosh, this is the future, think hard. And just before I finish on that, um, Steve was right about things like PPH star procedure. The T ATM E coming up to COVID T at E was all over the place. Lots of institutions starting to do it. And boy who did medical legal work, you saw many ureters, er, not ureters, urethras injured, spread of cancer and so on. They died off through COVID doesn't seem to have come back, be very careful watching what goes on and don't just jump on that bandwagon. Be careful, find your own niche. Um Jim has just done a very good, excellent presentation on a colorectal cancer and this was really my niche for the last 20 odd years and we did look at various types. I I'll go through this 10 which time because we did the soft tissues, the large tissues, the bones, et cetera and it's gone very well indeed. And over the last 10 years as Jim has eloquently described it gone higher of the sacrum, wider out the pelvis and so on and yes, there is some resistance to this sort of work, but it needs to be done. Our estimation is about 300 recurr recal cancer cases a year in the UK. They need to be taken care of. Not all of them were now after the surgery, not all will need the major surgery that we, that Jim described, but there is a need for that sort of work. So find your niche, whatever it is and stick with it. You will get complications. I still lie in bed at night, worrying about anastomoses. I think the day I stop doing that, I will retire cos then you simply do not care but manage your complications and don't always blame yourself. There are other issues there. It's not always your technical side of things for bleeding. I was called to the theater yesterday. Um, a couple of surgeons who are reasonably exper pretty experienced doing a, a sub toomy open for various reasons. They got massive bleeding. I came in and what they weren't doing was getting dealt with. They were panicking, they weren't staying calm and they had called for help. But what they needed to do there was a pack so they had significant bleeding. They were dab dab dab buzz, buzz, buzz. What they weren't doing is putting packs down, go out of the theater go and have a coffee cos you're a surgeon, you work with your patients, they weren't doing that. You need to pack and press and wait once you did that 20 minutes later, the bleeding was controllable. A basic lesson. But major bleeding, you pack and you have to pack and send them off to IC and bring them about the next day. There's no shame in that. So pack and press, go for a coffee, then come back and then it's much easier to tackle the learning curve. I've got a big thing about a learning curve. People talk about learning curve being steep depending on your axis. If you've got time against experience, a steep learning curve means Monday, you start Friday, you've learned off. You go the great news about this job. It's a flat learning curve. You start along and you trundle along quite happily. I'm here, John's down there. You guys are down here cos we've been doing it much longer, but you're always learning and that's why the job's fun. There's always stuff to learn even towards the latter years of your career and have a mentor, things will go wrong. Hence, the Clint Eastwood clips, things will go wrong. You must have a mentor and it's always helpful to have a trainer from before or a boss from before who you can trust, who doesn't necessarily work in your institution. So there are problems that person won't care about the politics of your hospital, he'll care about you because he or she trained you up. So have a mentor and use them when you need to. Everyone's got a friend. Things go badly wrong. Bye. And don't tell fibs. I bored people with this story. I'm not gonna give you all this story cos I've done it many, many times, but I bore people on purpose of this story. I was mentioned earlier about going to the Coroner's Court. Here's the secret. Do not tell lies, do not tell fibs if it's a little fib like, um, well, actually called six anesthetists. I couldn't get one when you called three and don't say, oh, well, I did look at the scan when you didn't why? Because the police can check your phone records and the hospital can check whether you look to the scan and barristers love liars cos you've been caught in a lie even it's a white lie. They will destroy you. So the one thing to remember when you go to a coroner's court, first of all, the coroner's not blaming you for what happened. Looking to see who's died when they, when they died, what they died of and where they died, they're not looking to blame you. It's not adversarial. So don't get worried about it. The only thing to worry about in a coroner's court is you're gonna tell a fib. Don't big yourself up in this particular case that I won't go into detail. Current enough time a the surgeon told a couple of white lies in the coroners. A year later, the same two white lies, the police interview. And then when it went to court on the hill, Bailey, the barristers knew that they had all the transcripts, they destroyed this guy who went to jail wrongly, in my opinion, for 18 months, for a man for, um, Hartman's that went wrong manslaughter charge and the whole ball rolled down the hill because of those two white lies two other cases just on the same thing. This was a urologist in Bradford who changed the, um, medical notes over a weekend from a Friday to a Monday, 37 year old died on the Monday when he went to court. They nearly changed all of the notes and that's why he went to jail for 3.5 years. And this guy going for a job interview, s question, what's your favorite operation? It's almost like saying, what's your favorite color? Um, a laparoscopic sigmoid colectomy? Oh, how many have you done? Um, 85. Any complications? Well, I've had one death gets the job. Three years goes by a series of complications. A few deaths. We then go back through his records. They find little pieces of white paper that we fill in when we're doing the job interviews and found that he'd written that had been written down by three of the people who did the interview he'd actually done seven laparoscopic resections in total, went to jail for six years and also had to pay back the three years salary he got from the hospital. So again, a little fib or was it a little fib in a job interview? Six years in prison for fraud and don't do stupid on the rice anus is at the back. Vaginas is at the front. Ok? Don't shove the gun up the vagina. We had one recently and the theater of staff were saying afterwards, oh, Pete's very funny about that. He always says, oh, that's a woman. It's the vagina. It's an a no, it's not a joke. It's because people can easily stick a stapler in the vagina and fire it. I've come across three cases in my career. Fortunately, no done by me. There's no wood but it'll happen unless you really think about it. Easy mistake to make the reasons, you know. But remember if it's a woman, there's a vagina, don't stick the staple gun up there. Don't bring out the wrong end. 1999 a surgeon in a parish not far from here brought out the wrong end. Patient discharged him eight days later, having not had any bowel movements came in two days later and died. Police call at his house the next day, arrested and spent two nights in Mil Garth police station in, in leeds, but bringing out the wrong end, he didn't go to jail in the end. But that was 1999 don't leave stuff behind. If a scrub nurse says there's a missing swab, there's a missing swab. Ok? Don't argue with the scrub nurse. Many cases have gone through when there's been a swab left behind and the surgeons in. We didn't believe the nurse. And if in trouble, as I say, call a friend and finally surround yourself with talent. If you want to be in a top band, the street band play for Yorkshire Cricket. I was gonna had leads on originally about taking off to your loss today. You need to surround your tail with talent. And also the other thing about this slide is the legacy. So if you are coming towards the end of your career, have two super people, great men and great surgeons Aaron and Jim to take over that work for you. So finally, all right, that's it. Let's roll. Hey, let's be careful on, be careful. Goodnight and good luck.