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to the issue. I was talking to no one in my life. Now, uh, your live. Yeah. Hi, everyone. Sorry, there was a technical fault with me. I hadn't clicked. Go live. So welcome to the to the session. We are going to start in just a few minutes. Uh, I'm joined today by Phil, who works for medal, and he just wants to talk a little bit for a few minutes before we start about medal. It's and it's vision. Uh, it's mission, so we'll we'll just let Phil take it away, and then I'll take over from there. We'll go through colorectal cancer in its surgical management. Thanks, Adam. Um, so my name is Phil. Michael May. I'm also medic by training. And, uh uh, thank you so much for giving us a little bit of time to share a little bit about our work. Our our mission is to make great healthcare training accessible to everyone. Why does that matter? Well, we need to train 18 million more healthcare professionals by 2030 around the world. But the Lancet explains that we face severe institutional shortages in our healthcare training capacity. And those two things combined pose a bit of a toxic combination and, unfortunately, where the need is at its greatest resources are at their least. So there are 11 countries on the continent of Africa which do not have a single medical school there over 20 with only one medical school. And that is the continent that requires the most healthcare professionals over the next eight years. There's no problem that's confined to somewhere else around the world, even in high income countries. We have seen headlines like these across the major news. That's over the last couple of months. So in the summer we saw BBC news headlines, which were explaining that the NHS in England is facing its worst staffing crisis in history, for example. But when you look at the cost of teaching and training more healthcare professionals, um, that poses a problem in high income countries as well. This is a study from the Association for Surgeons and Training in the UK It points to the cost per year to the individual trainee of 1300 lbs of their own money, which is spent on courses and conferences just to meet their training needs and over the course of their entire training as a postgraduate. So not including their medical school, uh, debt or fees. Most surgical trainees rack up 22 26,000 lbs of costs, or up to 71,000 lbs if you're an oral maxillofacial surgical trainees. So it's a lot of money. And when you combine that with this is a relatively conservative chart, according to the British Medical Association. But between 10 and 20% loss of buying power over the last 10 years of healthcare professionals salaries again, we have a toxic combination in high income countries. For individual people, that causes a problem. So this is a doctor called Maria, Pray Will, um, and she's explaining that as a widening participation doctor, money is and always has been tight study budget covers one big course or maybe 2 to 3 small ones, and to meet course surgical training. Um uh, needs the wealthy can easily treat the application as a paid tick box exercise. We don't think that's right. And so that's why we're pursuing what we're pursuing at metal. We, uh, really believe in making healthcare training more accessible. But to tackle some of that big global need, we actually want to do that at scale. We want to make healthcare training more accessible to healthcare professionals around the world, and that's what we're doing. Um, and we thought, actually, the best way to do that is not to make it all about us, um, to actually enable and empower other healthcare organizations and healthcare professionals like, uh, Charles and Adam, who are delivering in credible teaching and training just to make their lives a little bit easier. So instead of them having to set up an event right to take registration and biting people to a zoom link and then in the zoom Link, pasting a Google form to collect feedbacks and then manually making certificates by copying and pasting names from a spreadsheet into Microsoft Word document template for a certificate downloading it as a Pdf and emailing it out to all of the attendees and then downloading a video from Zoom and then adding it to YouTube Irvine you for on Demand and then adding in another description, we thought, actually, we can see of healthcare busy healthcare professionals a lot of time in running their teaching and training by running that automating it end to end so instead of using about six or seven different tools in about 1 to 2 hours worth of admin per teaching session, we can actually automate that. Reduced that to about five minutes and let busy healthcare professionals focus on what they actually want to do, which is deliver more teaching and training and not all of the administration. And if we can actually build technology that allows them to do that in a really special way, that helps them to teach more people than what a zoom license will allow them to do. So instead of limiting that to 100 or 200 people based on their institutionalize um, license, we just wanted to lift the lid. So with metal, you can actually stop to 10,000 healthcare professionals on your event we don't charge. So if you're, uh, teaching is free and open access, we're really committed. Do you not be another barrier to accessibility? Were really committed to making our technology free and open access for colleagues who are doing that as well? And we're really passionate about that. Why? Well, when we look at this quote from Dr Tedros, who needs no further introduction, he said, this a tech conference two years ago. Ask yourself every day if your technology works to help the poorest in the world and to reduce inequalities. And that's something we're really passionate about. And it's why we do what we do. It's why we provide our technology free and open access organizations are running a free and open access event. We know that not every organization can do that. So we do facilitate paid for events on metal, and it's how we kind of sustain ourselves. It's how we kind of continue to to grow as an organization. But again, how do we put our cause in our mission ahead of everything else as a team and fair medical education is one way in which we're doing that are fair medical education scheme has signatories, including the people you see on the screen at the moment. So the Association for Surgeons and Training, the British Association for Pediatric Surgeons, the British Orthopedic Trainees Association, have all signed up to our fair medical education Um uh, ethos and what they've actually done with their events. Using metal is provide free and open access tickets to colleagues in lower middle income countries, to attend their paid for events, and they can automate all of that admin using metal. We think that's really important. Uh, we're a company. We're not a charity, but we really believe in being more than just the bottom line. How can we really make a difference? And this is one way in which we are doing that. What does that look like? So in the last 18 months, in fact, the slide is a little bit out of date. By a few weeks, we've helped about 1600 healthcare organizations deliver 5.5 5 and courses in 100 and 72 countries. So none of those numbers are correct. But it gives you an idea about the scale of the impact when we all work together in a space like this, if you want to join us, if you're ready to to join that mission, then you can actually start teaching and training others as well. Metal dot org slash host. If you want to find events that you want to join, you can join them at metal dot org slash events. Or, if you missed an event, you can actually join on demand sessions at metal dot org slash on demand and watch at a time. And, more importantly, an Internet connection. If you live INR oral nowhere like me, or if you live in a lures or setting, then actually being able to watch on demand is really important. And we've made that really easy for organizations to do. So you can actually watch events on demand at a time that situ metal dot org slash on demand. And, um, that's what it looks like. Um, it costs 50. It cost $700,000.15 years to teach artery and a doctor, and we really want to completely change the game. Does it work? Well, this is something that Mathias for a vary one of the senior authors is David not actually said about a virtual teaching course in, um uh, in the, uh, surgical endoscopy journal. Earlier on this year, they carried out a study. They compared online and face to face surgical skills training for, um uh for surgeons in their early years of training. And they actually find there was no significant difference in the competent screenings of delegates relieving, receiving online teaching or face to face teaching But more importantly, what they were able to do is actually scale up the number of people they were able to teach and train. And they taught 553 surgeons in 20 countries in a single day, and they use metal to do it. So you can really have an impact. By working together in this space, I'm gonna leave you with, um uh, one last story of the personal impact of this type of collaborative education. Um, on the right hand side in our chat, what an organization can actually do is verify the people who are joining. So it keeps their events really safe. It means that they can really make their events open access and welcome people from around the world in a really safe space. But occasionally people can't verify themselves. For whatever reason, we get a couple of them every single week. And in a single day in the spring of this year, we had high tens into the hundreds of people reach out to say, I can't verify myself for whatever reason. And so you heads up our support team actually reached out to them and said, Why can't you verify yourself and we have a manual process to help those people if necessary. And the same response was coming back every single time. They said. I don't have access to my institutionally mail address at the moment and you know what? I don't think it was important for me to get a letter from my dean or from my medical school to say that I could access medal before I fled the country. Thanks very much. And what we find out was what what was actually happening was an organization in London. An NGO had actually picked up our product and had recruited 250 doctors from around the UK And these were Ukrainian medical students who were actually learning. Virtually. They had their entire face to face curriculum replaced with a virtual curriculum. This organization was actually using metal to help them deliver that, and what they managed to achieve was in credible. They taught 202 150 teachers actually taught 2000 Ukrainian medical students seven times a day every single day for two months, and they didn't do that as some sort of imperialistic UK teach Ukraine thing. It was so that they could free up the clinicians on the ground who were delivering face to face medical education to provide face to face patient Darren bolster their medical resources during the war. And this is what one of those professors said, Thank you for everything you're doing for knee Pro. For all the people who are trapped in this situation, when we work together, we can really make an impact. We need to train 80 million more healthcare professionals by 2030. We radically believe that it's only by collaborating by sharing our teaching and training and by welcoming more colleagues to our courses, conferences and events in an accessible way that we can really make that happen. Charles and Adam are a really great example of that. And thank you so much for allowing us to share just a few minutes of our vision of our mission and the work that we're doing. I hope you have a great teaching session, and I'm going to hand straight back over to Adam. Thank you. Brilliant. Thanks so much, Phil. Just to echo what you're saying, um, we wouldn't be able to do what we are doing without the help of medal to kind of streamline access into help promote our events. So, yeah, just to echo what you're saying, it's been it's been such a help to have medal and, you know, just increasing increasing its visibility. And it's, um, uses it will only be a good thing as we, uh, delve into the world of more online teaching. Um, so yeah. So Hi, everyone. Um, for those of you I don't know, my name is Adam. I'm clinical teaching fellow work Russells Hall Hospital in Dudley. Um, if this is your second or third time here, welcome back to the surgical oncology teaching series. And if this is your first time, welcome for the first time just a bit about what we are. So, um, were, uh, me, Charlie and another colleague of ours, Antoinette were all junior doctors who are passionate about surgery and passionate about surgical oncology. We devised this teaching program structured around the six most common cancers in the UK, and we felt that, uh, surgical oncology was really quite a mystical subject when we were in medical school in foundation years. And we wanted to kind of demystify that. And for anyone who's interested in enthusiastic about surgery. Teach you guys a little bit about surgical oncology and surgical technique. Um, just to kind of pass on some of that enthusiasm, hopefully and some of that knowledge that that we've collected over the years. So, uh, Charlie started us off with kidney cancer and prostate cancer, and I'm taking over this week and I'm going to be covering colorectal cancer, and it's surgical management. If anyone has any questions, you can always put them in the chat, and I can periodically go to those. So let's go. So what we're covering today? Like I said, we're covering colorectal cancer. We're gonna be looking at the epidemiology of colorectal cancer in the UK and associated risk factors with developing it. We're going to have a brief word about the pathology of colorectal cancer and how it forms. Then we're going to go take you through the the present, the presentation, the diagnosis and the staging of colorectal cancer. And then we'll arrive at the management of colorectal cancer, and this is really going to be the bulk of the session particularly focused on surgical treatment and surgical techniques involved in managing colorectal cancer. Then we'll be talking about the peri operative care in colorectal cancer patients' and then, finally, a little on the surgical treatment options for metastatic disease. When we talk about the management of collect all cancer, we're going to be talking about management in the elective setting. Specifically, we're not going to have time to cover management of colorectal cancer in the acute setting where patient's present with obstruction, Uh, this is managed slightly differently, but using very similar principles to the ones will be covering today. So what is colorectal cancer? So it's the fourth most common cancer in the UK, Um, with 42,900 new cases diagnosed in the UK each year behind only breast, prostate and lung cancer. However, because of advancements in prostate and lung and, uh, breast cancer, um, colorectal cancer is the second leading cause of cancer death, behind only lung cancer. In the UK, the incidence of colorectal cancer is particularly high in developed countries like the UK That's likely due to what people describe as the Western lifestyle we've in the West. We've have higher rates of fatty diets, high races of obesity and in activity, as well as smoking and alcohol intake. So those modifiable risk factors in the orange box there, um, the higher prevalence of those in Western countries likely contributes to why, Why it's incidences is so high here in terms of non modifiable risk factors, Much like many other cancers, age genetics and specifically, genetic disorders associated with colorectal cancer are risk factors as well as associated conditions of the bowel, such as inflammatory bowel disease. So a word on the pathology of colorectal cancer. More than 90% of colorectal cancers are adenocarcinomas that developed from adenomatous polyps in the epithelial lining of the intestine, so the normal epithelium first undergoes hyperplasia to create a hyperplastic polyp. Hyperplasia is when cells reproduce at a quick rate following from hyperplasia. This then develops into dysplasia to form what we describe as an adenoma and then that adenoma. In order to become cancerous and malignant, it undergoes neoplastic changes within the cells as well as invasion of the cell membrane, which is required for carcinoma for for cancer to be considered malignant. There are also rarer types of colorectal cancer that we won't be covering today, such as neuroendocrine, squamous cell add know, squamous spindle cell and undifferentiated carcinomas. The main learning point from this is the vast majority of colorectal cancers you'll encounter in your clinical experience will be these adenocarcinomas. Around 5 to 10% of cases of colorectal cancer can be attributed to hereditary bowel cancer disorders. There are a number of these, but the two most common are hereditary nonpolyposis colorectal cancer, otherwise known as lynch syndrome and familial adenomatous polyposis. So HNPCC is an autism all dominant condition caused by mutations in one of four genes in what's known as the DNA mismatch repair system. Having HNPCC substantially increases the risk of developing colorectal cancer before the age of 50 as well as developing other cancers such as endometrial and ovarian cancers. Patient's with this condition should have surveillance colonoscopy as well as Upper GI endoscopy, as it's associated with not just colorectal cancers but other cancers of the GI tract. The second condition to talk about is a little rarer than HNPCC. It's familial adenomatous, polyposis, or fat. It's also an autosomal dominant condition, and it's caused by mutations in what's known as the APC gene. The Adenomatous POLYPOSIS. Coli gene, F A P results in a much larger number of adenomas in the colon. So patient's with F A P invariably developed hundreds to thousands of adenomatous colonic polyps by the pathology mechanism that we've previously described, which will undergo malignant changes because they develop so many of these polyps. The risk of colorectal cancer is near enough to 100% inpatient with F A P. It's almost inevitable that they will develop colorectal cancer. These patient's also need to have a surveillance colonoscopy every 1 to 3 years, and the only definitive treatment really with F A P is a prophylactic colectomy. These patient's need their entire large bowel removed, with or without a proctectomy, which is where you remove the rectum. So some patients will undergo a pan proctocolectomy where you remove the entire rectum and large bowel with an attempt to make an ideal pouch. Um, where the The Islay um, is, uh, ST most to the anal canal, and that's the only known treatment for F A P. So the the present team, the presenting features of colorectal cancer classically patient's, will have one or more of the following. They'll have a persistent change in bowel habit, either diarrhea or constipation lasting more than six weeks. These, um, the bowel habit changes are much more common in cancers of the left side of the colon and the rectum. Patient's may also present with rectal bleeding that's either visible in their stools or occult and detected on analysis of stools, which we'll talk about in a moment. Another Cardinals sign is iron deficiency anemia, and that's due to a cult gastrointestinal bleeding from the tumor. Over a long period of time, the patient's may develop a microcytic anemia that's found to be iron deficient. If a patient, um in in their elderly years above 65 say, develops an iron deficiency anemia without an obvious explanation, they should be investigated for cancer such as colorectal cancer. Iron deficiency anemia is more common in cancers of the right colon, because these cancers classically have a much more insidious onset. Those patients' won't develop the change in bowel habit. That's as obvious as in the left sided, uh, colonic cancers. And so they develop much more gradually and will eventually result in nine deficiency. Anemia are the less specific causes, uh, symptoms, I should say our abdominal pain and, as always, in cancer, unexplained weight loss is a red flag. So in terms of the diagnosis of colorectal cancer, if patient's present with features that we describe before and the G P or the emergency department doctor is suspicious of colorectal cancer, they should first have a fecal occult blood test patient's with a positive result. I, where microscopic levels of blood are detected in their feces, are referred on a two week wait pathway. And the gold standard test that they need to have is colonoscopy, which is an endoscopic evaluation of the entire large bowel. This offers full visualization of the colon and the rectum through the endoscope, and the added advantage of colonoscopy is any suspicious. Polyps found in the bowel wall can be biopsied and removed at that time for histological analysis. At that point, the histology can confirm whether they are benign polyps or malignant polyps. Malignant tumors, I should say now, word on bowel cancer screening. So this is a screening program that's offered nationally up to a quarter of diagnosis of colorectal cancer in the UK are actually as a result of screening of a symptomatic adults through this program. So all adults aged 60 to 74 in the UK are offered a home fecal occult blood test every two years. So what the patient's do is they provide six start six streaks of their own stool sample and then send that off for analysis. 98% of patient's have negative results. No blood is found in the stool, and that requires no further Axion, the 2% that of positive results that warrants further investigation. With colonoscopy again, a majority of those patients' won't have malignancy found, but a minority will. So in terms of other investigations, we've talked a little bit about colonoscopy and the fecal occult blood tests and biopsies. But what else? So in patient's, um, so as as in all patient's, that may need require any kind of treatment we want to do. A full set of blood to the full blood count will inform us specifically their hemoglobin levels were most interested in to see if they're anemic as well as your other standard blood test. You're using these your clotting profile group and save and cross match in anticipation for surgery. C. E. A is the carcinoid embryonic antigen, which is a tumor marker for colorectal cancer. It's useful in monitoring treatment response in patient's with the cancer. We've talked about colonoscopy. If patient's are unsuitable for colonoscopy or refuse colonoscopy for any reason. UH, slightly less good test as a CT colonography, which is a CT scan that obtains cross sectional images of the colon. It's not as good as colonoscopy, but it's a suitable alternative. Patient's with confirmed colorectal cancer should undergo a CT, thorax, abdomen and pelvis for staging purposes. We'll talk about that a bit later. And if patients have a tumor below the peritoneal reflection I of the rectum, they'll need an MRI of their rectum. And that's to assess for lymph node involvement in the mesorectum surrounding tissue. So staging of colorectal cancer. So there are two main staging methods that are in common use. One is the TMM staging system. This stands for tumor node metastasis. It's a non specific um staging system that applied to all cancers and then made more specific for each cancer as they determine what t one t two T three and t four constitute for that particular cancer. So we'll go through tnm first. So in terms of the tumor, the tumor can be considered carcinoma in situ, which it gets a T. I s t one, um to t four are then determined by the degree of invasion through the bowel wall T one carcinomas are confined to the submucosa and the mucosa t two carcinoma invade the muscular is appropriate layer underneath that, and then even further than that t three invade the subserosal that surrounds the bowel wall T four is given to is the name given to tumor's that, uh, invade beyond the bounds war bowel wall into adjacent structures. N stands for nodes so N is n zero n one or end to end. Zero is where there are no identified lymph node containing cancer cells. It does not spread to the nodes, and one is if it's spread to 123 nearby lymph nodes. And if it's in four or more nearby lymph nodes, that's given an end to classification. Finally, metastasis uh, simply can be m zero hour m one m zero being there's no distant metastasis and then one being that there is distant metastasis. This can be further classified in colorectal cancer into M one A, B and C a being if it's spread to distant site. But there is no involvement of the peritoneum be being if it's spread to too distant sites with no peritoneal spread or if there is peritoneal spread that is then considered M one C. The other commonly used staging system, a more classic one, is known as the Dukes Staging System. This is a bit simpler than Tnm because it's just a two D, where a is equivalent to a T one tumor that's confined to mucosa and submucosa and has no lymph node. Involvement be is equivalent to T two and above, where it invades muscle layers of the bowel. But there is no lymph node involvement. A Stage C is any cancer that has spread to adjacent lymph nodes. And if there's any distant metastasis, it's considered a Duke stage D. So it's a little less descriptive than the TMM staging system. But it still does have use. So now, onto the bulk of our session, the management of colorectal cancer so curative treatment of corrected cancer can only really be achieved by surgically resecting the tumor. The surgical procedure chosen depends on the stage of the tumour, as well as the location of the tumour through the colorectal tract will come onto that in a moment. Some broad principles first, generally a five centimeter margin or more is recommended for reception of colorectal cancer. Every single cancer has guidelines for the minimally accepted um, margins around the tumor that are used and this. This varies from cancer to cancer, depending on the degree in which it spreads typically as well as the extent of cosmetic deformity that will result from large resection. So, for instance, skin cancers, you can't have a five centimeter margin everywhere around a skin cancer that's going to have to severe cosmetic result. But with colorectal cancer, it's all contained within the abdomen, and so we use a much larger margin in terms of lymph nodes. At least 12 lymph nodes will be resected alongside the the tumor and the pedicle. For the analysis to confirm whether the tumor has spread to the lymph nodes, we can have a little bit of an inclination from the CT tap, whether there are any truly suspicious lymph nodes. But it's not until we've actually resected the specimen and sent for analysis that we can confirm that the tumor is indeed n zero. So the options for the actual approach to the surgery that that the manner in which the surgery is carried out are open, laparoscopic and robotic. And we'll touch on that in a moment. The resection specimen. So the tumor, um, the medicine tree and all the lymph nodes will be sent for histological analysis that will determine whether the resection margins contain cancer cells. What we want in all cancer surgery resection surgery is to have a clear margin. We want the margin to have no cancer cells that's known as a negative resection margin. Even though it says negative, it's a good thing. That's what we want to see if the tumour out. If the resection margins contain cancer cells, that's called a positive resection margin and could indicate that we haven't fully cleared the cancer. We haven't We're not really going to talk too much about the adjuvant therapies in colorectal cancer, although there are some because we're focusing, as we say on the surgical oncology side of things. But survival rates and colorectal cancer can be improved by chemotherapy and all radiotherapy alongside surgical resection. The terms, given our neo adjuvant adjuvant treatment near adjuvant treatment, refers to treatment that's carried out before the tumor is respected, and adjuvant treatment is given after the tumor is respected. As an example, Uh, rectal cancer in particular, is quite responsive to radiotherapy because it's below the peritoneal reflection. It doesn't have peritoneum in the way blocking the radiotherapy, and so radiotherapy is often used alongside surgical resection in rectal cancer. So now we're going to talk about the three approaches that I discussed. Open surgery needs very little introduction. I'm sure it's the traditional approach to colorectal cancer resection. Before the advent of other approaches to surgery, it was really the only the only option. It's performed by a single long incision in the anterior abdominal wall to grant direct access to the abdominal cavity. The scar in open surgery is often quite large and unsightly, and there can be a significant risk of postoperative pain that can lengthen stay. Around The 19 nineties, laproscopic surgery or minimally invasive surgery began to gain popularity. Today, laproscopic surgery is the most common approach actually, for colorectal cancer resection. So Charlie has discussed what color at what laproscopic surgery is, um, in previous weeks. But just as a recap, it's a minimally invasive technique where ports, as we can see, are placed in the abdominal wall for access to the abdominal cavity, the kinds of ports that we can have. We can have instrument ports that contain trocars for retraction and manipulating tissues, therefore operating effectively as well as an optical port to allow for visualization into the abdominal cavity. This will typically be a quite a large 10 millimeter port, through which we transmit a laparoscope, a kind of camera that we can visualize the abdominal cavity through, often in colorectal cancer surgery. Because we're resecting large specimens, we need to create an additional incision or extend an existing laproscopic excision as an extraction site for the tumor. But again, this won't be nearly as large as the incision that we do in open surgery. So laproscopic surgery is currently the gold standard approach for colorectal cancer resection. So a word on the advantages and disadvantages of laproscopic surgery. Like we said, it is smaller surgical scars than open surgery. That's a really big deal for patient's. It allows for better visualization of cavities that are quite difficult to visualize an open surgery such as the pelvis. It facilitates a faster recovery in a shorter inpatient stay because there's fewer complications, less inter operative blood loss and and less post operative pain. But there are some disadvantages to laproscopic surgery. Sometimes, uh, laproscopic surgery will require an open conversion. For instance, if a vessel is encountered and begin, a large vessel begins to bleed that cannot be controlled laparoscopically. An open surgical conversion, uh, may be required in that case. In that case, what we've done is we've actually multiplied the number of incisions that the patient has to experience rather than reduced. Laproscopic surgery also requires specialist training and laproscopic technique, although this point is probably becoming less and less relevant as laproscopic surgery becomes more entrenched and more frequently used. Surgeons nowadays are all being trained in laproscopic surgery, and many of them will be more comfortable with it than open techniques. Additionally, laproscopic surgery If you've ever assisted laproscopic surgery, you'll you'll know this. It presents certain ergonomic challenges that I'm just going to talk about now. So if you've ever assisted in laproscopic surgery, perhaps holding the camera or using the trocars, you'll know that it really is quite an ergonomic challenge. And what I mean by that is posture is a very important thing, and you can end up hunched over and twisted in quite awkward ways. So the ergonomics of laproscopic surgery are really important thing for surgeons to familiarize themselves with so that they don't end up giving themselves back pain in the future. So, like I said, it presents an economic challenge to the operating surgeons. And so there are a number of principles that we use to try to mitigate this and make the surgery easier. Firstly, we want to optimize the performance. There's something un in counter intuitive about laproscopic surgery. When you're using an instrument port, for instance, you want to actually move your instrument because of the fulcrum in the opposite direction, to the direction you want to move. And that can lengthen the time that procedures take, so to optimize performance. There's certain principles, so the angle between two instrument ports that we use is known as the manipulation angle, and studies have shown that a manipulation angle of about 60 degrees, give or take 15 degrees is associated with the optimal quality of not tying, but also reduced time for not time. The other angle to be aware of something called the azimuth angle, which is the angle between the instrument and the optical port in the middle. Studies have shown that they should be roughly equal to one another for the left and right instruments. If you're holding it in both hands, that will ensure faster operating time, as it's a bit more natural and intuitive for surgeons. In addition to the port placement, the monitor is another important consideration when we visualize inside the abdominal cavity through the laparoscope. That's then transmitted to a monitor in the room that the surgeon looks at. And studies have shown that the optimal monitor placement is quite important. It should ideally be directly in front of the operating surgeon rather than to an angle and at the level of their hand, rather than their eyes. Now, obviously, this isn't always possible to achieve in theater environment, but this is the optimal technique. If you've been over the past two weeks, Charley has spoken at great length on robotic surgery. Uh, so robotic surgery is the latest, even more minimally invasive technique, Um, in in in in the field of surgery, it's perhaps used most in urology, which Charlie has covered over the last couple of weeks, but it is actually gaining traction as well in colorectal cancer surgery. So what is robotic surgery? So robotic surgery involves a surgeon operating remotely, a robot that performs the surgical procedures. So rather than using their hands directly to manipulate tissues, they'll be plugged into one of these robots that we can see in in the diagram here, and they'll remotely operate the robot. What it does is it facilitates more precise movements than laproscopic surgery, as large movements of the surgeons hands will translate too much smaller movements of the robot. Like we said, it's gaining popularity and colorectal cancer surgery. But centers are limited by whether they have access to these incredibly expensive machines. Studies have shown that it's associated as well, with a lower rate of conversion to open surgery in laproscopic approach. And it goes without saying that the ergonomic challenges aren't quite as cumbersome as in laparoscopic surgery. The operating time currently for robotic surgery is significant longer than laproscopic surgery, although this may well be due to a lack of familiarity. Uh, with it, the operating costs are obviously much higher as it use is much more advanced technology. But with each passing year, it does seem to be gaining more and more traction. And in 20 years time, we may well be talking about robotic surgery, the gold standard for many of these cancer resections. So we talked about the approach to the surgical technique that the approach to the colorectal cancer resection surgery. When I'm going to talk a bit about restoring continuity and what I mean by this is, once we've resected a section of a patient's colon or rectum, we need to then work out how we're going to divert the feces outside the body. Because currently, if we create, if we take out a specimen of bowel at the proximal section, we're going to end up in a blind end that feces accumulates and there's nowhere to go. So the two options that we have our anastomosis where we suture, um, the proximal and the distal segments that we've been left with following the removal of the cancer to one another and create a loom in in between. The other option is stoma, which is where we bring the proximal section of the bowel to the surface of the skin. Uh, where it can open out and patient's are left what's called a stone, and we'll talk about that in a moment. So firstly, anastomosis, like I said, cut segments of bowel in the anastomosis are joined to one another. They can either use certain use sutures much like we're using skin, or they can use staples. And we need stapling guns for that. Broadly speaking, the types of anastomosis, our end to end to the proximal segment, the end of the proximal segment sutured head on to the end of the distal segment. You can also have an end to side anastomosis, where the proximal segment end is switched to the side of the distal segment, or a side to side anastomosis, as you can see in the diagram. For any anastomosis needs to things to be successful and not fail, it must have a good blood supply to ensure that the tissue within the anastomosis doesn't break down in the crow's, and it needs minimal tension. Anastomosis that is too much. Tension will strangulate its blood supply and be much more likely to fail, causing a nasty Martic leak or dehiscent, where the wound comes apart. Anastomosis is generally better than a stoma. If it can be done, it should be done. It is a much better functional result for the patient. As an anastomosis, the patient maintains their fecal continents, and they can go to the toilet just like anyone else. However, anastomosis may not always be safe or feasible because of the risk of failure of the anastomosis. So in the emergency setting, an anastomosis is not always safe. A colon, two colon, anastomosis or colon to rectum anastomosis is too risky in the emergency setting. It's, uh, the the risk of, uh, the wound D hissing or leaking is too high to be acceptable. This is not true in the elective setting the elective setting. Because of advancements in technology, we are usually able to do a primary anastomosis. However, what's worth mentioning is even the emergency setting. If we need to suture, I'll liam to Kahlan in an anastomosis that is a much lower lower failure rate and is typically, uh, feasible, even the emergency setting. So stoma is the other option for restoring continuity. As we said, a stoma, broadly speaking, is just alumin of any holla viscus organ being brought to the surface of the skin. So in bowel surgery we can have an aisle e ostomy, where, uh, a Liam is transmitted to the surface of the skin and a colostomy where that's done with colon. However, this doesn't Stoma isn't exclusive to bowel surgery. It's important to be aware patient's can have nephrostomy. He's where the kidney is put in direct communication with the surface of the skin or even your ostomies. Where the ureter is done is sutured in the same way to the surface of the skin. But in bowel surgery, we're talking about ileostomies and colostomies, so I'll E Ostomies can be recognized on patient's as they are spouted that they almost mountainous in appearance. And that's because the fluid they produce the very watery, higher output fluid that comes out of a stone. Uh, Islay Ostomy is a bit more irritant to the skin than in a colostomy, so it needs to be spouted. A colostomy is lower output and more flush to the skin there typically found in the left lower quadrant, although that's not that's not as good a way of distinguishing an ileostomy from a colostomy as just looking at the steamer itself. As I said, a stone was functionally worse with patient than anastomosis because they lose their vehicle continent. They have a bag that they need to replace maybe several times a day on their abdominal wall. And feces is just, um, just just passes directly into their throughout the day. Stones are generally only use different anastomosis isn't safe or feasible, Like we said in the emergency setting, with colon to colon, anastomosis or colon, the rectum anastomosis. However, sometimes an anastomosis can be what we call reverse. Sorry, a stoma can be what we call reversed later on, and that's where we take the stoma away from the surface of the skin, back into the abdominal cavity and try to create an anastomosis with the distal segment. Sometimes a stoma may be placed approximately two, a primary anastomosis that we form, and that's called a D functioning stoma i e. As the anastomosis heals, we want to divert feces away from it to give it the time to heal. And also, if the anastomosis were to fail, the stool has another exit route that doesn't that isn't going to accumulate in the bowel or even worse than the abdominal cavity. So we're now going to talk about the specific procedures that are done based on the location of the tumor and colorectal cancer. But first, it's worth just very quickly recapping our anatomy so that, um so we don't get disorientated. So the large bowel comprises the cecum, the colon and the rectum. So the terminal I, Liam will feed directly into the cecum in the right lower quadrant. This then ascends up the right side of the abdomen as the ascending colon. The ascending colon turns to form the transverse colon directly underneath the liver, and that turn that bending point is known as the hepatic flexure. It's named because it's near the liver. It then traverse is the transverse colon. Traverse is the CO the abdominal cavity from right to left up to the splenic flexure, which is so named because it's right under the spleen, where it will turn downwards and go down the left side of the abdomen. In the descending colon, descending colon informs the sigmoid colon that creates an s shape and ends in the rectum, and finally, the anus. For a lot of you, that's going to be, um, just super simple stuff. I just think it's worth recapping before we go into the specifics of the surgery. And we're also going to talk a little bit about the blood vessels that are ligated in each cancer surgery. So it's worth recapping, um, the blood supply to the colon rectum so the colon and rectum are part of the mid gut and hind gut. If we remember, the mid gut begins at the second part of the duodenum and we'll go to two thirds away along the transverse colon. The the hindgut will be the transverse colon through to the end of the GI tract. So the blood supply to the colon and rectum are therefore supplied by the superior mesenteric artery that supplies the mid gut and the inferior mesenteric artery that supplies the hind gut. And I've just listed the names of the blood vessels as they go along, going from the beginning to the end of the large bowel. We start with the Eylea colic artery supplying the terminal part of the I'll, um, and the early and the and the cecum as well. The right colic artery will supply the ascending colon, and the middle colic artery will supply the, um transverse Carolan. The descending colon will be supplied by the left colic artery, sigmoid artery supply, the sigmoid colon and the rectum. The upper part of the rectum is supplied by the superior rectal artery between the left colic and the middle colic artery. We have what's called a marginal artery that receives blood supply from both the uh inferior and the superior mesenteric arteries. It's kind of a watershed area where it receives blood supply from both of those, and that's towards the left of the transverse colon. So we've done the recap of the anatomy. Now let's go into the surgical procedures. So we're gonna start at the proximal part of the large bowel and will end in the distal part. So, firstly, a right hemicolectomy, this is a procedure that's performed for tumors of the ascending colon and the cecum. It involves removing the terminal part of the area as well as the cecum, the ascending colon and the hepatic flexure. In the right Hemicolectomy, the ileo colic, right colic and the right branch of the middle colic artery are ligated. The reason it's important to litigate arteries is because the lymphatic drainage of the colon, like anywhere will follow the arterial supply. And so by doing that, we ensure that we actually remove the lymph nodes as well. We ligate the arteries and we remove the entire mesenteric pedicle around the arteries to guarantee that we removed the lymph nodes that the cancer would drain too. An idea Colic. Anastomosis can usually be formed even in the emergency setting on a right hemicolectomy. So a stoma is rarely required. The next procedure is an extended right hemicolectomy. This is a right hemicolectomy, but we also extend it to remove the transverse colon. This is for tumors of the transverse colon and the splenic flexure. Here. The arteries are ligated are much the same, except we legate the entire middle colic artery, as well as the right branch of the left colic artery. To ensure that we get the vascular territories and lymphatic territories. Uh, supplying these areas a left hemicolectomies performed for tumors of the descending colon. It involves removing the splenic flexure on the left side of the colon as well as the descending colon and the first part of the sigmoid colon. We we generally will litigate the entire inferior mesenteric artery at this point, and we generally can perform an end to end colon, the colon anastomosis of the segments that can be done via a trans anal circular stapler, which is a kind of circular device with a handle beneath it that's inserted through the rectum and then sutured and then, um, sutured onto the end of the colon so that we can mobilize the too. So we have two instruments that are pushing together one in the distal part of the colon and one in the a proximal part of the colon. We join them together. We create, um, we make sure that there's a tight seal there, and then we do a circular staple around that to form the anastomosis so you can see on the right side the bottom of this slide. This is the use of a transitional circular stapler. So for orientation, the bottom part there is that the the rectum and the distal part of the colon, and the proximal part is the proximal segment. There. It's it's helpful if you either need to see a video on this or be in surgery, um, to watch one of these to fully appreciate what's going on. I recently observed one of these a high anterior resection last Friday. And it wasn't until I'd really gone into that surgery that I understood how the anastomosis was formed. So hi, interior resection is the next procedure. We're going slowly down the large bowel. As we can see, this is, uh, the procedure chosen for tumors of the sigmoid colon. In this we remove the distal descending colon, the entire sigmoid colon and the proximal part of the rectum. It can be done entirely within the abdominal cavity. As we pull the rectum up again, the inferior mesenteric artery is going to be ligated, and we have an end to end colorectal anastomosis via the circular stapler. Low anterior resection is chosen for two for tumors in the upper part of the rectum. In order to do a low anterior resection and not the next procedure that we're going to talk about an abdominal perennial resection, the tumor must be more than five centimeters clear of the anal verge. The artery ligated in a low anterior resection is the superior rectal artery, the terminal branch of the inferior mesenteric Artery. Research has shown in rectal cancers often ligating the superior rectal artery at its origin is generally as good as ligating, the inferior mesenteric artery above it. Except that you get to spare a lot of the blood supply to the other areas. So the important thing about low anterior resection and high interior resection, all the surgeries that we've just described as they're known as sphincter preserving surgery, I'II they spare the anal sphincter complex without the anal sphincter complex. We lose fecal continents, and a patient has to basically have a stoma for life. If we do a low anterior resection and we preserve a rectal stump, this will allow for end to end colorectal anastomosis so the patient can maintain continents tumors of the lower rectum less than five centimeters from the anal verge. Unfortunately, those patient's aren't so lucky because they need to have an abdominal perennial resection that involves the removal of the distal colon, the rectum and the entire anal sphincter complex in order to guarantee resection margins of five centimeters. The artery ligated here again is the superior rectal are three, but the difference is that there is no distal rectal stump in an abdominoperineal resection, so a permanent nonreversible colostomy has to be formed, so those patients' it is associated with the worst quality of life but is sometimes needed. If you've done some reading in colorectal cancer surgery, you may be familiar with the term total mesorectum excision. However, if you're not just to as an overview, what it refers to is excision of not just the rectum in rectal cancer surgery, but also the surrounding mesorectum. Mesorectum is fatty tissue infiltrated with lymph nodes, and it's the lymph nodes that drain the rectum. They are located within this layer, the mesorectum and the pro. The principle of total mess erectile excision is that by following this traced out, red dotted red dash line. Here we follow what's called what is thought to be an embryonic plane. And if we remain outside this embryonic plane and resect tumor's there, they have a much higher success rate than if we go into this embryonic plane and leave tissue within that plane behind effectively. What a simple way of saying it is that rectal cancers are likely to spread within and along this plane, So if we remove the entire mesorectum as well as the rectum, we have a much higher success rate It's one of the most important advancements in colorectal cancer surgery in recent decades. It was first described in 1988 by a professor who worked at Basingstoke Hospital in the UK so, like I said, it ensures removal of the tumor as well as pararectal lymph nodes. And importantly, it preserves structures that are functional importance outside this plane, such as pelvic nerve fibers so that patient's can still, before most of the functions that they're able to perform. It reduces local recurrence and has been shown to improve survival. Rectal cancer is is quite a nasty form of cancer, actually, that has traditionally been associated with poor survival rates and total mess. Erectile excision has really transformed this trans anal total knees. Erectile excision done via the anal canal, uh, was first described in 2010 and has since been shown to be safe and effective in the treatment of rectal cancer. So I said we'd talk a little bit about the peri operative care in Colorectal Cancers Patient's and the big headline for this is Eras. Eras stands for enhanced recovery after surgery. It's a nationally used protocol that defines the optimal care of patients undergoing elective surgery, specifically elective colorectal surgery through the preoperative peri operative and post operative phases. By standardizing this, we ensure that patient's receive the optimal care and by standardizing it in a protocol, it just enables that to be to be done more consistently and reliably in the preoperative phase. Correct. All cancer patient's should have hydration and carbohydrate rich meals up to two days before their surgery. They often require bowel prep to clear the bowel of contents. They may require oral antibiotics prophylactically before their surgery, and they have to be kept nil by mouth from midnight on the day of their surgery. In terms of the peri operative phase during the procedure and and immediately after it, it's important to control patient's pain, um, as well as any other symptoms they may have, such as nausea with antiemetics. And that careful fluid balance needs to be done to ensure that they don't go into, uh, an acute kidney injury. The name of the game and eras postoperatively is early mobilization. Traditional wisdom had patient's who are having large colorectal cancer resections sitting around and kind of losing their functional ability for, you know, a number of days after their surgery. However, evidence has shown that early mobilization as early as Day one after the surgery is associated with reduced length of hospital stay and improved outcomes. In addition, we want nutrition as early as possible, as well as pain control and control of symptoms such as post operative nausea. It's important also to have clearly defined discharge criteria. This is not only to make sure that patient's who aren't suitable for discharge are kept in hospital, but also to ensure that patient's who meet all the criteria for discharge are encouraged to go home and resume their normal lives as that. If they can do that, they should do that. That will be associated with better outcomes than staying in hospital unnecessarily. Finally, a word on metastatic disease. So the most common site of colorectal cancer metastasis is the liver. Now in a limited number of liver metastases. If we can define a small, limited number of them, we may actually still be able to do curative resection. That's what's quite interesting about colorectal cancer and metastatic disease. Usually, curative treatment isn't an option, but if there's a limited number of liver metastases, we may be able to remove them at the same time as removing the colorectal tumor. However, if there are more distant metastases or more widespread liver metastases, curative resection may not be an option. These patient's may, however, still benefit from surgical treatment to relieve their obstruction. Stenting, as we know, is where we pass what we call a stent, a kind of mesh through alumin, in this case, the bowel, and we opened it out to relieve the area of obstruction. We haven't removed the obstructing tumor, but we have opened out that to remove the obstruction so patient's are less troubled by the unpleasant symptoms associated with that. The other options for doing this are bypass surgery and diversion stoma. They don't have curative intent, but they are intended to improve patient, symptomatic control. Patient symptoms in the palliative setting. In addition to this patient's may benefit from more widespread chemotherapy with things like five F U and and oxaliplatin as well. So we've come roughly to the end of our lecture here, um, so to summarize, correct all cancer is one of the most common cancers in the developed world. It typically presents with features such as change in bowel habit, rectal bleeding and or anemia, as well as less specific symptoms such as abdominal pain and unintentional weight loss. The definitive diagnosis, achieved through colonoscopy and biopsy and a quarter of diagnoses are generally as a result of the national screening program we have. The only curative treatment for it is surgical resection, and the procedure that we've gone through as we can see it depends on the site of the cancer. Currently, laproscopic surgery is the gold standard for colorectal cancer resection. Although robotic surgery is gaining traction, optimal care of elective colorectal cancer patient's has been standardized with the era's protocol that should be followed in all Elective um elective patient's and patient's with limited metastatic disease may still be eligible for curative treatment. And if not, surgical options still exist, as well as chemotherapy. For palliative colorectal patient's, these are a few references that may be useful for your further reading, um, kind of taking us through the updates of colorectal cancer, things about laproscopic and colorectal surgery. If you're very interested in this idea of total mess erectile excision, I'd recommend that article by RJ Heels Reference five. They're the holy plane of rectal surgery, which really transformed erectile surgery there. But thank you for listening. Um, if there are any questions, I'll just move to the chat here, Uh, someone asking when we get slides. Yes. We'll get the slides. Um, will be uploaded onto the catch up continent. Sure, Charlie can talk about that, but if anyone has any questions, um, I'll wait around for a few minutes in the chat. Uh, if not, thank you very much for listening. And we'll see you next week for, um, skin cancer surgery where Antoinette will be taking us through the surgical approach to skin cancer, but yeah. Are there? Are there any questions? No. Well done, Adam. I feel like I learned loads from that. I've never actually heard of total and read erectile excision. So, um, yeah, I learned something new every day. Um, as well as quite a few things, actually, from that talk, So yeah, really, really insightful. Um, I was just thinking, um, about because it's when I was doing a general surgery. Actually, a lot of the reason why they stayed in hospital. A lot of the reasons why I would get called as a junior was uh, for the POSTOP complications because, um, it's one of the most complex surgeries. A massive operation. Do you mind talking a bit more about the complications of potential complications of, uh, colorectal surgery? Sure. I mean post operative complications. You can generally divide the meter kind of early, mid and late, can't you? And a lot of a lot. A lot of the complications that we're discussing are going to be quite common to almost all surgery. So early complications you could get infection, particularly of the wound. You can get bleeding as well, not just in the intraoperative face but post operative face. When we talk about anastomotic failure, an anastomotic leak in particular, we generally suspect that in patient's who are 3 to 5 days post operative and they start to spike fevers and they might get a little tender in the abdomen, and that makes us very concerned about that. Um, anastomotic leak is something that invariably will, even if done, even if the surgery's done perfectly in perhaps about 5% of even the elective colorectal cancer surgery patient's, I'm sure as, um, techniques, surgical techniques develop and with, you know, um, the Advent of new technologies will be able to reduce that further. But Anastomotic leak is a is a really big one that that that that scares surgeons and keeps them awake at night. Um, yeah, and then and then the anastomosis as well is a really important one to be to be aware of. I suppose with the anastomotic leak, it's kind of, uh, it's your anastomosis that might have caused the problem, Which is why the surgeons stay off at night rather than sort of a more avoidable or less accountable kind of thing. Yeah, and and and it can't always be necessarily identified. Um, uh, colorectal surgeon that I was operating with last Friday had been in that previous night about sort of four. AM, because one of the elective Pan Proctor, collectively patient's of his who had familial adenomatous polyposis and had suddenly crashed on basically on the day of, uh, the day after her surgery, which is very early. And they couldn't work out why she was so hypertensive and, uh, parity Knittig. So they had to take her to theatre. And and even with a thorough explanation, exploration of the entire bowel as well as the what we call the I Leo anal pouch. They couldn't find, uh, obvious source of leaking. And so they had to kind of assume that it was the anastomosis that was the culprit, and then tunnel that out into an Islay ostomy which, unfortunately meant would would would be permanent for her. Um, so it's it's not always super obvious. Doesn't always follow the the patterns that we expect it to. But that's that's the one that I think most surgeons are most frightened of. Do you know if the patient got better off the ileostomy? Well, so So I I saw the patient the morning after, so she was still in I t u and, um, was still was still looking quite rough, so I don't know. I don't know what the, uh what the current update on that is, I'm afraid I think I think she'll have a long post operative stay if she is to make it through. But it's just to illustrate the point. Really. I think that anastomotic leak is is a terrifying thing for surgeons. Um, and you can't always identify and obviously can. Sometimes you may have to assume that the anastomosis must be the culprit if you've got a patient crashing like that. Yeah, yeah. Absolutely. Absolutely. So any other questions from the floor? Guys, Um, please go into the chat, ask anything you like. Um, very happy to take questions even. It's about, you know, surgery. In general, if you're interested in a career in surgery, we can talk about that as well. Um, because you're very much in the thick of it when it comes to that respect. And just as another point. I remember in my third year Osofsky getting a patient who was POSTOP for colorectal cancer and a hepatic segmentectomy so she'd had. That was the first time I ever knew about patient's having a liver reception, post bowel cancer. Hadn't heard of that before. It was it was very surprising to me when I first found about it. You know, heard about it because generally the rule of thumb is if someone's got a distant metastasis. Um, curative treatment isn't really an option, but it does seem like colorectal cancer with with limited lim liver metastases is an exception to this rule, where we where we do think that we might be able to offer them. Um uh, you know, suitably acceptable cure curative rate, given the risks of the surgery, and it can be done done at the same time. I think what's really exciting? What's really interesting about correct or cancer Is that a patient that presents in the acute emergency setting, even though we haven't covered that today, really, it's the same principles. Um, they can. They can come in, they can be in bowel obstruction and we can reset the cancer there and then And we may and, you know, there there may be just metastasis If there aren't we we we have cured someone's cancer within days of them presenting to hospital, which I think is such an amazing thing to think about. Obviously it's better to do it in the elective setting, but you can have a patient come in overnight. You get rid of their cancer, you know, obviously they'll need a longer postoperative state, but you can actually cure the head cancer in, uh, you know, in a in a very short space of time. Okay, Ben has a question. Ben Ben Raga, just to clarify tier me indicates in all cases where where cancer surgery would take all or part of the rectum. So would that also include tumors of the sigmoid colon, where the proximal rectum was also removed? Very, very good question. Know is the answer to that. Um so I was in a high interior resection last Friday, which was very useful for this presentation. It help me visualize it, and I did ask about this. They don't remove the mesorectum unless it's a rectal cancer, because there's also miso colon surrounding the mesentery surrounding the colon. And that's where the lymph nodes will be contained for a sigmoid, uh, colon cancer. And so in those cases we remove the miso colon surrounding that, as well as the pedicle and the all the vascular supply. And in doing so, we have we have removed the lymphatic spread there. A sigmoid colon cancer won't metastasize. Won't sorry. Matassa won't spread to the mesorectum. It's a rectal cancer that does that. So if if the cancer is of the rectum, that's when we need the total mess. Erectile excision. It was a really interesting article, the one by Andre Filled, actually, because it's it's just, you know, a professor who did a lot of research and had an idea and had a theory surrounding the anatomy and the embryology of the pelvis and said, I I think this, you know, if we remove these areas, this layer, I think it's really gonna help up rectal cancer. Patient's rectal cancer is still a nasty thing. It still has, you know, difficult outcomes of patient's. But he transformed the surgery and doing that in that idea, and it's now a gold standard. I just think it's a really inspiring story, but yeah, thanks for the thanks for the question, Ben. I probably should have made that clear in the presentation. But thanks for, uh, thanks for asking it so we could clarify that Ferb um, there are no additional questions. I'm happy to wrap up Adam. That was absolutely amazing. I learned so much from that myself. Um, I would have met. I haven't actually seen any colorectal cancer surgery myself. Super interesting stuff. Super interesting stuff. I mean, I'm a little biased. I just like Charles leans into a urology. I've I've got a soft spot for Jen Surge. Um, but it's it's very interesting stuff. Yeah, well, yeah. No, exactly. I loved like, yeah. Part of the part of the reason I wanted to start this is because when I was reading more into what exactly? A left hemicolectomy right? Hemicolectomy? Oh, I didn't know you had to remove all of the vessels. Oh, and yeah, the lymph nodes as well. Okay. And what is an ape? Um, why do you do that instead of a higher alone until what Earth is going on? And and then, as Adam mentioned, the the emergency settings changes slightly. And when do you do what type of ileostomy and, uh and so on and so forth? You know, it really gets much more interesting if you can actually sort of understand what these all mean, rather than just all you know, they're going to surgery. Okay? Which unfortunately, is what I found. A lot of like med school level teaching was yeah, and and even even on the wards. When, when? I don't know what what sort of grade are viewers are at. But if those those who are medical students, it's easy to think when you're on the wards, say, in general surgery or in urology that you'll you'll just naturally encounter these things because you encounter patient's who've had these, but actually your role as an F one f two doctor. There is generally to be on the wards to do the ward based jobs through the discharge letters to maybe admit patient's, uh, and to look after them on the ward. So that, um, such that when I had my general surgery block, I actually didn't really learn any of these things because the environment wasn't really right for it. So I'm hoping this presentation, for for those of you who go on to have general surgery, right stations in your foundation years, I'm hoping it will be useful for you to, um, start with now and come back to a bit later when you're when you're in your f one F two years and just just have that appreciation that I didn't really have. When I was when I was an F one on general surgery, I'd hear about all these pouches and all these anastomosis, and I just didn't know what was going on. And so I had to kind of take to the books and learn it and take two theaters and learn it. Yeah. Uh, well, thank you all for coming um, I'll say it again, but do please try and provide feedback. We do greatly appreciate it. Um and actually, I just want to give a shout out to fill at the beginning as well. Just not to forget that was an amazing talk as well. And yeah, definitely. Try and use medal for your events. Uh, the for conferences and everything because it's it's such a good resource. Um, but yeah. Thank you for coming. And we'll see you next week. Antoinette will be delivering, I believe skin cancer. Is that correct? Yeah. Skin cancer next week with Antoinette, and it's gonna be an amazing session, so hopefully see you all there.