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Sadiq, surgical registrars and consultants. Before we start off, I would like to thank asset for helping us develop this course. Um MD you for sponsoring us And of course, uh, medal for providing us with a platform to provide you with the important certificate and, uh, you know, giving us feedback as well. Um, now, today's session, um, will be on colorectal surgery. Uh, that will be presented by Miss Claire Hama, who is an S t six register at the Royal Surrey County Hospital. But before we proceed onto Claire's presentation, I'm going to show you a video on surge. Could not time specifically hand tying at depth. And a surgeon does not. Um, So I'm just gonna one second guys. Uh huh. All right, hand tying at depth. The approach to tie a knot at depth is the same as a normal hand tie, which we covered last week. Tie you're not at depth is useful when you're tying off a vessel that's buried deeper in the body below the plane of the skin. A common early example is when tying the superficial subcutaneous veins during an open hernia repair start as previously starting with your downwards thrown when you perform it used the index finger of the left not to push the not vertically down. Maintain tension with the right hand, but avoid pulling up. As with delicate structures, you can cause them to tear or a pulse. Applied tension to the short end, bypassing the structure with the left index finger. By passing this structure, you can pull on the future in a vertical plane without pulling the structure. You're tying for the second throat again. Start as normal for performing an upwards throat. This time. Maintain tension with the left hand and use the index finger of your right to push the not down again to tighten the not push past the structure you're tying off and then tighten in a vertical plane. This is then repeated for subsequent throws. Tying at depth can be a balance between applying enough tension to allow you to easily push. You're not down and not too much that you're pulling up on the structure you're tying off. If you're struggling to push the not down, try adjusting your finger position, so that's not directly pushing on the not but slightly to the side when tying at depth Whether using the index finger of your left or right hand, you should ensure that you'll keep the not on the same side. This is done by pushing past the structure. You're tying on the same side for each throw. The surgeon is not. The surgeon is not is used in more challenging cases to limit not slipping between the 1st and 2nd throws, which can result in a loose knot. It can be performed either by a two handed or 100 technique. We're gonna go over both of those in this video 200 starting with the left hand set up to form a normal downward thrown on the short end of the suture on the side, away from you. With the right hand, hold the suture as though you're going to perform an upward. Thrown all the suture between the thumb and index finger with suture wrapping around your little finger. Now cross the long end over your left middle and index finger as normal. Now, with your right hand place, your little ring and middle finger under the short end, you should now have both ends of the suture crossing over both sets of fingers with the middle finger of the left hand to hook the long end of the suture behind the short at the same time, with the middle finger of the right hand hooked the short end behind the long. Now both ends of the suture can be gripped by the middle finger in a similar fashion to a normal downwards or upwards throat. Pull both ends of the suture through to lay down the surgeon's not. You should see the two loops of the not one handed technique again. Start with the left hand set up to perform a normal downward throw on the short end of the suture on the side, away from you. With the long end of the future, do a full loop around your middle and index finger, finishing with the long end going away from you once again with a trigger. Axion. Bring the middle finger behind the short end and then grasped this between the middle and index finger. Pull the short end through the loop and then tighten to lock the suture. The one handed technique can be used if wanted to perform. A certain is not at depth. Hand tying a surgeon is not can be difficult. We wouldn't recommend trying this in a theater unless needed, and you have enough practice to be confident. An instrument time surgeons not is much more consistent and easy to do under stressful consultants. Gays. So that's your video on a surgical on tying a tying at depth and a certain is not, um So today's teaching session will be on colorectal surgery given by Ms Claire Hammoud, who is currently an S t six registrar senior registrar here at the Royal Sorry County Hospital. Um, at the end of the teaching session, we will have a Q and A session to answer any of your questions. And, um, as many of you have asked on the teaching feedback forms, you wanted the sessions to be more interactive. So what Claire would do is she would ask you questions during the presentation. And then, uh, if you guys can get the chat box and just answer on the chat box and we'll be able to kind of go from there. So without further a do, I'd like it gives me great pleasure to introduce you to Miss Claire Hammer, who's a senior registrar here. There all Sorry, You cannot meet yourself. Not Claire. Thank you. Yeah, she can you hear me? OK, OK. Just if I can share my presentation. Hello, everybody. Thanks for joining. Mhm. Okay. Can you see it? Yeah, we can see it. Yeah, Okay. I can't get the chat up. Dashi, if you look at that because if you say a bomb box, there should be a chat box coming up. Let me have a look. So when I'm share in and I can't see the chat, okay. Let me just look it up shut. Nine. So there is something there. I just don't know how I'm going to get that to be seen. When I'm sharing my screen, I'll give it a go, OK? Yeah. Give it a go. I can see. So can you still see my screen? I can see your screen yet? Just when I would share it. I can't Then see the chat anymore. Okay. I can see the chat, so I can tell you what everyone's written down. Okay. Um Okay. So, um yeah, My name is Claire. I'm ST six. And general surgery. I've actually been a couple of years out to, um do an MD and then hopefully get back into training afterwards. Um, I've been asked to do some topics on colorectal surgery and which is what my intended consultant Rob will be. Um, so I thought I'd talk about some common presentations for you. Um, so, first of all, I thought I'd talk about what colorectal surgery is, what it's about, what we do. Um, then I will talk about a case about diverticular disease. It's very, very common. Um, and then we can talk about the complications of it and then to go on to some code of actual sections, um, corporations we do. And some of the complications you might come across if you're a junior doctor on the board. And then the other thing that people don't really get talked about a lot is proctology problems such as like anal fissures, skin tags, hemorrhoids. And even now I have consultants referring patient's in with hemorrhoids, and it turns out to be skin tags. I thought I just go through a few things so that you know the difference, so hopefully that be useful. And then I'll conclude about why you should be registered and your chosen career, because obviously it's the best. Okay, so what is called a colorectal surgery about? So we treat a wide range of bowel conditions that affect the colon, rectum and anus. Um, I think colorectal surgery is very, very versatile, and we spend a lot of time in theater as registrars and consultants, and we also have a good load of ward work. Have to do a ward round every morning and usually do a ward round in the evenings. Um, we also have clinics. We have at least one clinic a week, and most of us have to. And we also get to be involved in endoscopy is not just scoping people, but actually doing the treatments for it as well as removing polyps. And we obviously have our own calls, which some people enjoy. Some people don't, um and then we have to be involved in MDT meetings as well, especially when it involves the cancer patient. So you get to work with a lot of different people as well as by yourself. It's the type of conditions we see. Um, the main thing is bow and anal cancer, and that's our main bread and butter. Um, we also get involved in patients with IBD when they fail medical management. Um, diverticular disease, which we can talk about it later. And there's like the bottom things like hemorrhoids, anal fissures, anal fistulas, pelvic floor problems. Um, like, uh, people in confidence or if their rectums prolapse in. And then, of course, we've got our major emergency work as well, which is where all the exciting stuff happens. Um, and we haven't really got a subspecialty, but people do tend to go to one area. Um, so some people who specialize in cancer and although most of us would want to do some sort of cancer works why we do it and you have some people that would be or go to for inflammatory bowel conditions and they work on like, all the Crohn's receptions. Um, so some people take up a specialist interest in that, um, there's a few of us that get involved in pelvic floor problems. So you'll have, like a pelvic floor clinic. Probably have, like an anal rectal physiologist with you. Um and then something just got to the bottom where, like hemorrhoids and things. But generally we all have a little bit of a touch in all of it. Um, so that's basically it. And the training pathway. So you do f one F two. Then you usually go for core training, CT one C t. Two, and then you apply for a general range number, and it goes from ST 32 s t eight and most people do a fellowship before applying for a consultant jobs. That's kind of the training pathway for it. So the common operations we do So a lot of people still get a bit confused about what the operation actually means and what part of the bowel were taken out. So I thought I'd just stick some pictures up here for you guys. So you can see. I mean, generally, the most common operation to do is an anterior section which faces looking at the first two pictures. I don't know. Can you see my mouse here? Yeah. Yeah. So it's taking out the rectum in the anterior sections. You can either have a low anterior section where you take it quite close to where the anus is, or you can have a high anterior section where you leave a bit more tissue basically, and those ones are a bit safer to do. Um, you got stigma. Colectomies left hemicolectomies right hemicolectomies down the bottom. There you've got extended right hemicolectomy a abdominal perineal reception is where we'll take out the basic signaling director. Also, the whole perineum, the end up with no bump whole basically, and then end up with colostomy. A total proctocolectomy doesn't happen very often. It's usually an elective setting. So if you have someone with like a psychiatrist, you usually end up doing a sub total colectomy. Because what you want to do is just take out a bit of affected bow and not start playing around this bit when they're on steroids. All sorts of things, which I mean the bottom wouldn't heal. Very well. Um, so these are the different types of receptions we do, but generally, the most common ones were an anti reception taking out the sigmoid aura. Right, Hemi, Um and occasionally we do the a p. R. For the tumor is very, very low down. The other operations we do is the proctology like hemorrhoids and inject Botox. And we've also er emergency stuff where we would do like cases where they've got IBD and do a sub total colectomy or do a Hartman's procedure. Um, generally code elective surgeries laproscopic now. So that's sort of a mainstay of our work. And we still do some open things. Actually, if people have had previous surgery got scar tissue, we can't do it laparoscopically. Um, we also do endoscopic receptions so some people can even have cancers removed endoscopically. And But we tend to use that for more of the earlier stage. Cancers and robotic surgery is available in covid at all. But the learning curve for it is still quite small because it's not available at loads of centers. So it's not something that I've taken part in yet. And I'm ST six. I haven't even got involved with that yet. So it is there, and it's on the rise. So there's a load of different varieties of different types of surgery we can do. So I'm gonna go into the first case about diverticular disease. Um, so diverticular disease is, um, the presence of the diverticulum. A diverticulum is a small pouch which bulges out from any hollow structure in the body. But most people think of it is coming from the sigmoid. So you think of sigmoid diverticular disease. But you can get diverticulum that happen in the duodenum. The bladder you got like Meckel's diverticulum. It's basically just an outpouching. Um, sigmoid. Diverticular disease is very, very common in western countries. And I would say probably half of the people aged over 50 would probably have some evidence of some sort of diverticular disease. I've shown a picture here of a colonoscopy in these little pouches is showing what the diverticular look like. What? It's not faint, Um, and there's just a schematic picture there as well. Don't you know what causes it? Um, but considering in the Western world, it's probably something to do. Our diets and people don't eat enough fiber are probably going to do that. We feel like there's pressure in about that. The juices is the outpouchings. But whether or not that's the real thing or not, we don't know. And so those people have this these diverticular. But only about 15 to 20% of people actually get any sort of complications. Um, one of the complications we see quite a lot in hospital is diverticulitis. Um, so people seem to use that interchangeably diverticulitis, diverticular disease. But it's not the same. And diverticulitis is when you actually get inflammation or infection of one of these little pockets. Um, so you people have diverticular disease or diverticula OSIs, but never have an episode of diverticulitis. Okay, so this is the first bit of interaction. Hopefully, um, if I can see the chat dashi, I don't know if I'm going to see it. Um, but I'd like to know if people know some of the complications of diverticular disease. So one person said hemorrhage. Uh, good. Good perforation. Yep. And dive dive diverticulitis. Just give a massive flew to that one about obstruction. Which one? Obstruction or small bowel obstruction? It'll be. It'll be obstruction. Yeah. Obstruction. Yeah. Fistula. Yeah, I think that's it's one more I've done a picture of. So I'll show you the complications now. So the first one is uncomplicated diverticulitis, which is just inflammation of some of the pockets. And we don't know if this is caused by bacteria or if it's just inflammatory. So I'll go through the evidence about antibiotics use afterwards. That's probably the the run of the mill stuff that you see. Some people just get a bit of information there and then it gets a little bit more serious where one of these little pockets can get inflamed and burst a little bit, and it forms a localized abscess. You get that little pocket of fluid again. For this, you probably would have to give some sort of antibiotics and thinking it's an abscess there, like you would have any other abscess, then worst is perforation, so you can have a localized perforation. Um, where people can remain quite well. You can have, like, a four quadrant muck everywhere. Really, really horrible. Um, so perforation is what we don't want people to have. Um, then this is a stricture. So this is where you can get obstructed. So when the bowel gets inflamed, it gets very stiff. And sometimes if you get lots and lots of information, it can get stiff, stiff, stiff, and then it doesn't get compliant anymore. Where it can stretch, you get stricture. And this can cause obstruction so you can actually get bowel obstruction from diverticular disease. Uh, fish. And I was very impressed that someone mentioned official uh, so the bowel gets a bit inflamed, gets a bit sticky, and it can stick onto things like the bladder or the vagina. Um, so you might get people complaining of, uh, lots of urine infections if it's the bladder or maybe whistling when they we, um there's another thing. Um, and some people say their urine can look very bubbly. Um, and if it's like a vaginal fistula, they can get some really mucky discharge, which is really, really quite gross for them. And the other one is hemorrhage as well. So someone mentioned bleeding. And then we are bleeds. We get quite a lot of presentations with that, and it usually ends up being rather than bright red blood. It's kind of a slightly altered looking blood. Um, but that's very common. The chance of having like a major hemorrhage from diverticular disease is very, very rare. So symptoms of diverticular disease. So, um, I'd like some people to think of some symptoms of what you can get. So if you just got diverticular disease, just the pockets and what sort of symptoms people get, but also, if you then develop some complications, what sort of symptoms you might experience? What people would tell you about that would give you a black red flag or they might be suffering with this any any ideas. So someone has mentioned pain. Mhm. Abdominal pain, weight loss. Mm, constipation, mhm fever. Anything else, Guys? Diarrhea. So, alternating bowel habits. Yeah, someone mentioned black stores. Um, Melena if there's bleeding. But now Molina is more upper GI bleed, so it's it have to be the It's gone through the whole digestive system. Basically, there's even the stomach or the duodenum. Normally that you get Melena because it kind of gets altered. And that's why it turns into Molina. But normally colonic. It's, um, even like a dark, dark blood or bright red. Someone's mentioned loss of appetite. Yeah, um, maybe a symptomatic. Yeah. Good, Good. And a pressure feeling. Yeah, people do sometimes describe that. So with diverticular disease, if you've just got the pockets, no inflammation. Some people do actually get intimate and left it out. Fossil pain and it tends to be relieved on defecation, and they can sometimes get a bit bloated with it. They can alternate between constipation, diarrhea? Um, I suppose when you're feeling really bloated, some people do go off their food. But what makes you start thinking is they might have a bit of inflammation is when they're pain gets more severe, so it tends to be a bit more constant in nature. Um, generally, the pain would be in the left of the fossil because that's where the sigmoid usually lays. But you can get some lower tummy pain. And also, the sigmoid is quite floppy, so it can actually flop onto the right side of the tummy so you can get right there for the pain and it be diverticulitis. Uh, change in bowel habits that ch be up on there. So if using the abbreviations, but yeah, so they can have a lot of constipation, diarrhea, bleeding. So if they've got a bit of diverticulitis, they can have some bleeding. Fever gives you an idea that they're probably getting some sort of systemic not being very well. Yeah, anorexia is not eating nausea, vomiting. So those are the things that came up with as well. That's very good. So, like, if you're suspecting someone's got diverticular disease, what sort of investigations could you do to prove this? And also, if they've got diverticulitis, what sort of investigations would you do to prove that this is the diagnosis for them? so, uh, peasants as a CT scan. Uh, colonoscopy. There's another one that's quite new at the moment that we're trend into now for diverticular disease. So I won't go there. I can't see the check. So someone said MRI is suspecting fish love. Another person said fecal something OK, ct colonography colony. Yeah, that's the one I was thinking of. Um, so I mean, if they've got diverticulitis, you can do some blood from that. They've got an inflammatory response to it. CT of the pelvis. If they've got diverticulitis, you want to basically see if they've got a complicated diverticulitis, So that's what you do that for. So ct Colon, That is something that we don't do in an emergency situation. But it's very good for diverticular disease because I don't know if anyone's actually seen any colonoscopies happen for diverticular disease. But generally they've had a bit of scar and information and trying to get colon out. Their colonoscopy is so, so difficult ways. Um, it's like it's almost impossible to get through the retrosigmoid. Um, so, generally, if we think it's just diverticular disease, um, then we'd probably go for a CT colonography. Um, so what this is is in this hospital at all. Sorry, we give a drink of gastrograph in, which is like a contrast media, but it also is quite a potent laxative. Washes out the colon, get them done on their side, stick a tube up the bum and put some air into the colon so it just ends it up. They can kind of give you a roadmap of of the diverticular, Um, but it's actually also easier to see if there's any information because a lot of people they don't tolerate the colonoscopy because it's painful and the endoscopy issues. It gets quite irritated because you can't proceed with the procedure. So for a sort of a moral elective setting, it's either a colonoscopy or a CT colonography, Um, and for the more acute settings of CT abdomen, pelvis. So that's what I'd go for as well. So management. So again for diverticular disease, it's a different management from diverticulitis. So for diverticular disease, what would you tell someone? So say you've seen someone in GP land and they said, Oh, you said, Oh, they got diverticular disease on their colonoscopy. What sort of management options have they got? And then again for diverticulitis. What sort of things can you do for that? Um, so someone's mentioned changes and diets, depending on severity. Yeah. And may, uh, anti inflammatories. Mm. Interesting fluids. Um, and someone's mentioned No antibiotics. Yeah. Yeah. Cool. So for diverticular disease when they just got the pockets, diet is supposed to be the things we recommend people to change. Um, there's not that much evidence for it, to be honest. Um, so some people can stick with a diet but still get load of symptoms. So when they're not having pain, we say to have a higher fiber diet and avoid things like seeds or things like sweet corn and all those things you can imagine that you pull out at the end. You want to try and avoid, because those are things are gonna get stuck in the pockets. Um, but when they have got pain and we say to go on a low residue diet, so it's kind of the complete opposite, and there is quite a lot of them Information leaflets. If you like Google low residue diet and NHS, you can come up with a leaflet for your patient. Um, and you know, sometimes it makes a difference. So it's worth doing. Um, antibiotics. I go onto a slide about that. There's been some nice guidelines now about not giving antibiotics, but even diverticulitis. You have to say it still makes me feel a little bit uncomfortable because I think the diverticular disease. Yeah, definitely don't give them. And I see quite a lot of GPS have actually treated diverticular disease with antibiotics just cause I've got a bit of pain thinking it could be a diverticulitis, but I think it's always worth getting a blood test first, see if there's any information before you give it, but usually if someone's coming to see me in the hospital, it's usually because they're quite unwell with the diverticulitis. So I think it's because of antibiotics. I still feel like it's better, but again, we don't know if it's inflammation or infection. It kind of makes you feel better that you're treating them. Um, and then surgery is the other thing. So if they do have complications, it's about what we do about it. So if they perforated, they're also gonna have to go to theater for a laparotomy and Hartmann's procedure, where we remove this sigmoid and bring out a colostomy that would be the mainstay for it. But some people do laproscopy washouts and have some drains. Um, if you got fish a lot, you can elected procedure where you remove the fish to take out the sigmoid, and you can join it back up again or give them a stoma. There's a lot, a lot of different things we can do. But the diet things it's a high fiber for when they haven't got pain and low residue when they do have pain is the is the advice we give a menstroidals. Um, so I actually give, um, menstroidals for people with pain. But there is some papers out that is a should give them my profin diverticular disease. Um, but the evidence is love for me not to describe it. I use it as part of my allergies, the bladder. So these are the nice guidelines. Just got to stick up for you guys. Um, it's easy to find on the Internet, but obviously the diverticula OSIs of diverticular disease obviously don't offer antibiotics because it's not going to do anything. And then for acute diverticulitis, they say, if they're well, consider not prescribing if they're unwell, which is usually when I get to see them. Then I probably would offer them some antibiotics. You can even go oral and we tend to in my hospital pick metronidazole. It's got anaerobic cover and the bio bio availability of it is the same oral and IV s if they say Oh, well, you can give them the oral. You don't have diabetes. You can manage them in an ambulatory thing to make sure they're not gonna Perth. But if they are have a complicated, like abscess or anything, it's just a that's diverticular disease Nutshell. Um, so next I'm going to go onto chronic receptions. I thought for this I talk about what you might see on a ward. And so you're the F one R S H o. And you get asked the a patient by the nurse who's a 70 year old man, you stay to post anti reception and he's got fever. So I just put a picture again about what Anti reception is about. What you're thinking about, Um, his background is he's got a bit of BP is type two diabetic, and he's got some osteoarthritis. So what's your approach to this? Like when someone rings you saying, I've got this person with a fever and his day to POSTOP? How do you go and sort of approach it? Um, any suggestions, guys. So someone's mentioned postop infection, But I think the question that Claire was asking is, How would you What you do? Yeah. Would you go? Would you go and do you go up to the ward? Then what you do? So someone's mentioned. Get a good hand over and then examine using a to eat. Yes, that's exactly what I'm looking for. So I think anyone who's poorly you get bleeped about 80 years standard and it's exam Answer. 80 assessment because then you can get away with anything, so I would go with that. So eight we So So it's your patient has given you a history. He's only feels a bit sick. He's had some lower abdominal pain since the operation. It's got it the worst today. He had his catheter out this morning, and he's not open his bowels, and he hasn't passed laters yet, and he says the nurses really had a fever of 38 so you think you're better examining? He sounds like it could be a little bit calling so you can have respiratory rate is 22 saturated, all right on air. And when you listen, he's got a bit of decreased air entry in both faces. Um, his heart rate's up a little bit. It's got a bit low BP. You don't know what his urine output is because on the chart it says O t, which apparently means on toilet. So they've not recorded it so that, you know, he's passed his to walk, but then on toilet, what does I mean, you don't know what you're an apple is? Um, he feels warm when you touch him, and he's got a cannula in his right hand. Still bms All right. Jesus is all right when you look at his belly is distended and he's got some tenderness. You're not sure if he's parasitic. You haven't felt like many belly's, but you think he feels a bit tender and you're a bit worried. Um, so that Is that So you think, Oh, I better have his blood. Hopefully, the team had done some blood today, so he's had some white cells done. And they've gone up to eight yesterday, and they're 16 today. And also, you think CRP has gone right up as well? It's 300. It was only 75 yesterday. HB looks okay. Kidney functions off a little bit. Um, and his iron Ours. Okay, so all that sort of thing you're thinking about is going on with him. Um, any suggestion, guys? So someone's mentioned a query, you know, hap slash at eight electrolysis. Yeah, it's probably a bit of a sepsis. Yeah, maybe someone's mentioned anastomotic leak or peritonitis. Secondary to perforation. Yeah. So a leak would be on my top thing CRP of 300 day to POSTOP. They usually day two day three. So be thinking about leak a collection as well. So you could have had a collection of the pelvis and they could have bled a bit. All those HB looks all right, and you could have a chest infection, But a lot of people when they're distended, they've got a bit of decreased air entry in their basis anyway, because they're not breathing properly. And perhaps there in a bit of pain. Um, So you think you know it could be a league that could be a collection. What you're gonna do about it. You can't just call your veg bike straight away. You can't do that. You have to. You have to come up with a management plan. So what would the management Plan B guys, So? Yeah. Sepsis. Six. Yeah. Mhm. So you start that, But is that going to make him better if he's leaked? What you gonna do? Surgery again? Okay. So I wouldn't expect you to. Guys could be going into surgery, but yeah. You want to give some antibiotics, Do you accept it? Six. Um, and I'm gonna wanna Sorry. I'm gonna want to know about it. So, um, you need to call me to let me know that this patient's you think he's leaked, and then we can organize a CT scan. Um, if someone's sick, I probably like a gas as well. That gives me an idea about how quickly we have to act. But even in the middle of the night, if you think someone's leaked any register, I would want to know about this. So leak is on top of your radar for post your So you're the colorectal F one s h o got me thinking about these on the walls. They're not very common. I'd say probably only 5% of people after anti resection leak if they've got an ileostomy. Which we do sometimes to defunction the bow and the chance of them getting six quite quite small. Um, but it you know, it is It's a significant thing for us, and, uh, I don't want to know about it. So leak is one collection of bleeding after an operation. You probably know because they're HBO below. And the other thing where you see quite a lot is I'll ius as well. So that's when the bowel kind of I just described is about going to sleep a little bit. So they get a bit distended, They haven't passed wind yet, and then they start getting nausea and vomit. Um, so for that sort of thing, you sticking a big riles, big, large bought n g tube, given some fluids, and hopefully they settled down by themselves. You know, they settled down as they start passing bit of wind. So those are things to think about when you're on the wards, is alias after it bleeding wound infections leaking. So that's it with that? So now I'm gonna move on to common proctology problems. Um, so there's a nice picture of bum here. So this is showing you, um an anal fissure. Looks like, uh, this is the anus here, and you can see there's a little bit of, like, a tear if you like. Um, and here, this is a bit more of a chronic E one. It looks like they've been scratching as well. They've got a fissure here, and they've got a little skin tag here, which kind of goes hand in hand with having them fishers. There's a fissure heals up. You get a bit of a tag there. Um, so people generally describe anal fissure as I've had a bit of bleeding on the tissue. It hurts when I go for a poo. It kind of feels like I'm passing glass, and those sort of things alert you to think, you know, they might have a fissure there. Um, generally, people with fishers and I tend to get a flexible sigmoidoscopy for them because they're having bleeding. And I'm thinking I need to make sure they haven't got anything else causing the bleeding. Can I just put it down to a fissure? Um, so how you manage it, Um, you say to them to avoid constipation? Um, so most of the time they have this because they've constipated, passed a big, hard store, and it split, um, things to avoid. The pain is, too. You can sit in a bath after they've been for a PU. You can give them some instill, injure or local anesthetic ointment to put on it. There's some creams that we use and a lot of people don't know about, and don't give them so One of them is refugees sick as an ointment. And it's a GTM base thing which relaxes the anal sphincter. So you tell them to put it on twice a day for six weeks. They put it around there a nurse a little bit inside. Um, that one gives you a splitting headache if you use it properly, so you'll know if they're using it. Um, but they have to use it even when it heals up. So even if they feel better after two weeks, they to use it six weeks, the other one that's a bit more expensive. And I think it's still on licenses, deals them, which is still tires them a cat and channel blocker again twice a day for six weeks. So that's how you treat an anal fissure. If those creams don't work, Um, and they're starting to pu better, and they're still having symptoms. Then I'd usually bring them in for an EU way. So an examination under anesthetic and stick a bit Botox, in which relaxes the sphincters and gives them a chance to heal up. So that's what we do for them to skin tags and hemorrhoids. So the amount of referrals I've had saying they got hemorrhoids, and it looks like this instead. These are skin tags, so you can get skin tags when you've had hemorrhoids, and it's left a bit of residual tissue. Or when you've had a fissure and it's healed up left a little tag. So this is the difference between skin tags and then on this side. This is what hemorrhoids look like. It's a bit different. Um, so hemorrhoids there abnormality. Um, there are swollen like vascular mucosal cushions. So everyone has these mucosal christians. Um, and they think that these mucosal Christians help us with our with our continent. So after you've been to the toilet and things and helping to close the anus afterwards to stop you from having incontinence, um, the main cushions lie in the free 7 11 o'clock positions, but you can get them a little bit different anatomy. Um, so that's what they typically describe. Um, so here about different grades of hemorrhoids, people talk about the different grades, but clinically, it doesn't really matter to me about the grades. They have bad hemorrhoids and do so very, very mild. Um, so you can get external hemorrhoids where the hemorrhoid is covered with perianal skin. Um, so these ones tend to be the painful ones, the ones on the outside, um, and their inferior to the dentate line. And then you can get internal ones which are above the dentate line, and they tend to be non painful unless they fall out so you can get different grades of hemorrhoids. Grade one is one that do not prolapse grade two prolapse, but they spontaneously go back in again, uh, grade free, they prolapse. But you have to manually put them back in and grade for, um, they are prolapse and you can't get back in again. Uh, the symptoms of hemorrhoids. Only one. Think of some symptoms that people generally complain about with hemorrhoids. That's any suggestion, guys. It's a pain itching. Yep, Bleeding. Yeah, yeah. Okay, So most people describe some sort of lump at the back passage, and it's usually painless bleeding, and it's bright red, Um, and when the hemorrhoids are out, they can get a bit of itching. You get bit of mucus like discharge that comes around there and to get pain. It's usually when the hemorrhoids have actually prolapsed or they got external ones. So when the hemorrhoid prolapses the anal sphincter kind of constricts it, cuts of its blood supply is it gets painful. The main thing is to stick it back up if it's prolapsed and to stop it from being constricted. And a lot of time people actually present when they've got from Bose hemorrhoid, where they it's been constricted for so long. The Bloods, then like, got clotted in it. When they're from Bose, there's no point. Put it back up because it's not gonna It's not going to go back up, but when they're still soft and squishy you can stick them back up again. So in any get referred a lot of hemorrhoids and basically they're squishy. Stick it back up. If they're hard and from Bose, just leave them alone. They're going to resolve. They just get naturally resolved over the next 2 to 4 weeks and how big they are. So I thought it didn't show you some pictures. This is, like normal sort of hemorrhoids that be like if someone's complained of P R E S P are you doing any you weigh? You put them in the bottom of the hemorrhoids kind of stick out like this. Um, this money has shown a bit of a skin tag here, but these two are hemorrhoids. They don't look from those to me. They look like if you give them a push to go back inside. Uh, this one here is a from Bose hemorrhoid, Um, and probably an external one. You can see that looks a bit more purple in color, and that would be probably be painful to touch. I think a lot of G p still refer them in thinking they were going to do some surgery on them, But we don't tend to do it. I mean, I suppose you could cut it, get a bit of the blood flow out, but they tend to just bleed and bleed and bleed and bleed and bleed, so we just tend to leave them alone. One down the bottom here is another from Bose one. This one to me, looks like it's an incarcerated hemorrhoid, as if it's come out. It might still be a bit squishy, so you could try and reduce it, and if you reduce it, it might get rid of the pain. If you left it alone, they'll probably just end up from bows in like this one here. It would be a big from those one. It probably takes a good four weeks to settle completely, the one here I've come to last. This is one that's an incarcerated hemorrhoid, so it's fallen out. It looks like it's been out for a while. It's probably from bows in a bit necrotic, and these the ones that can cause a bit of problems, which probably would keep in hospital. And they can get infected a little bit sometimes, and a few people will do an emergency hemorrhoidectomy on them. I've never actually had to do one. Um, and I've been qualified 11. Yes, I've never had to do one or even consent someone for an emergency hemorrhoidectomy. And the reason why we don't do them when they're all out and in inflamed because you end up taking away too much tissue. If you take up too much tissue, they're gonna end up with an ankle stenosis. So you try your best emotion conservatively. Um, not do surgery. So then management. I can ask you again about how you manage them. So you've got someone who's got, like, a thrombosed hemorrhoid what you're going to say to them about what you're gonna do. Uh hmm. It's probably cause it isn't actually a lot, So a bit of pain killers. It's going to go away by yourself. You just have to sit out. Basically, um, some people can put some ice around the area, and there's some ointments and things you can use for hemorrhoids, but none of them really work, and they can make it feel a bit better when you've been through a poop. It's got bit of local anesthetic in it, but generally it doesn't work. So the mainstay is to avoid constipation because people are getting hemorrhoids because they're constipated, restraining. And nowadays, rather than sit on the toilet reading magazines, people are sitting there with their iPhones. There's no support. Be a bum. So they brings the hemorrhoids out a bit more. So you got to tell them not to sit on the toilet. And you can also tell them to use a squatty potty, which is basically a footstool. They put your body into a more natural prune position. Um, which can help, um, sit bath. Yeah, if there are at their front bows, they're still getting the bath afterwards. Would be okay. Local anesthetics again. You can stick a load of instead of gel on it. There's some German Lloyd stuff or preparation H. They're basically just stuff that suits for a little bit, but it doesn't really work. It doesn't do anything. Um, and Sergio options? Um, there are some, but generally we would do a flexible sigmoidoscopy again to make sure there's no other cause for bleeding. Get them sort out their bowels and then, um, then do something about it. So there's some nonsurgical and surgical options. Um, the nonsurgical options very common for us to do, especially because you sent me for a flexi is to do Bounding s basically see a hemorrhoid. Use a little bit of obstruction. You stick a rubber band on this sort of area Here, Um, this can actually be quite effective. Um, and it doesn't involve doing anything. You have to get it above the dental lines of some cause pain. That's what we do very commonly for hemorrhoid, especially the small ones this is gonna favor now, which is injection or sclerotherapy. They said there's like female injections, hemorrhoids, which makes it from both inside again. It shouldn't be painful, but we've gone. It's gone out of favor a bit more. I think she don't know where you're injecting. You can cause some complications. Um, operations wise. Um, this one down the bottom here isn't open hemorrhoidectomy, which is the traditional thing we used to do. We used to exercise them on the outside, but this hurts and it takes about six weeks to hit up. It really, really hurts. So you try not to do that and reserve it for people with really, really bad hemorrhoids. This one here is a picture of, um, like it's called a. They've got different words from one of them is called a halo, which is a hemorrhoid archery, um, ligation operation. It's also called a t h d trans A nor hemorrhoid d arterial ization operation. Basically, you stick a proctoscope in stick a probe in and it tells you where the blood vessel is and you stick a stitch around the blood vessel, and then you kind of put a few more stitches in and then bring it all up. So you're hiking it up, and this is supposed to be like a less painful one and work quite well. So halo or th d is what we do, and the other one is a stapled hemorrhoidectomy or you might hear it called a PPH, which is a procedure of prolapse of hemorrhoids. Um, basically, you you make a little like a, um, perspiring, um, sticker amble, win. Join the things together and you staple it and take out a big bit of tissue. But there has been some problems with this where you can get like an air tracking all the way up the retro personal space, and they can be quite poorly so not as many people do that as much as the halo. So generally, if they've got little hemorrhoids and a little bit symptomatic bit bleeding and it if they've got like, medium grade ones, you can even do a halo THD or a stapled. If they've got massive second, torrential, grateful prolapse everywhere, they're probably gonna need to open hemorrhoidectomy. So those are the things we do for them? Um, try to think there's anything else. Um, So I've just given you a little whistlestop talk, traditionalism, common colorectal problems. And we talked about diverticular disease and the complications, which is something you're gonna come across a lot if you do a surgical job. We talked about chronic resections the different types and complications to be aware of switch you if you're on the ward. And then I just told you a little bit about fissures, skin tags and hemorrhoids, what you do about it and the difference between them, which also helps. Um, why should you pick kind of like to like, Okay, I'm inspired you That is so brilliant. It's really, really versatile. Um, it's fast paced, um, with different types of surgery, the cancers in kind of actual surgery do very, very well, whereas if you do something like H B, B and O. G, they all end up dying within two years generally, so we've got a good outcome. So it's nice to think you can do it. You can do an operation. The morbidity from It's not that bad and they live. So it's quite nice. Um, also are complication. Rate is low, so we're talking about leaks. So when we do a large bowel anastomosis is supposed to be a 5% leak rate. Um, so that's not as bad as the HPV. Once we have 50% of them having some uh um, And the other thing is, you can do it. Any hospitals, you can work at D. G H. You can work at a teaching hospital where everyone needs a colorectal, whereas the other specialties you tend to have to work at a territory place. You have to move all your family and everything to work at certain hospital, whereas this one you can do anywhere. So that's why it's very good. Um, this this cure code thing that you put in for me, dashi. Thank you. So guys would greatly appreciate it if you if you would be able to fill out the feedback forms. And once you've completed the feedback forms, um, you will be able to get a certificate that would be very useful in your future. Um, we're going to have, like, a quick 10 minutes Q and a session where you can ask Claire any questions you'd like. Um, yes. Any questions, guys, she's mind if it's about that or about career wise. And you can also send me a personal message if you want as well. I don't mind that I can't get the chat up blood. Actually, can I stop? Share It is everyone used to cure thing. Can I If you just, uh, if you you're on full screen. So if you get rid of the screen, like, come out of full screen. Yeah. All right. So if you leave it like that and then if you look at the bottom, there should be a chat box ASCII share my, um my agent, my computer literacy. Uh, Any questions, guys, that was a bit of a whistle. Stop. So, um, sorry about that. I just It's hard to pack it all in It's obviously like you can do an hour on each topic. Know? So someone's asked, Do you think the future of colorectal surgery is largely robotics? Oh, good question. Um, I think I'm going to have to learn it. Um, but I'm not really sure how much benefit is actually gonna give. So with robotics, it's more of those low anterior resections in men. Really? Narrow pelvis is, um, where the reception is very, very difficult. And they think with the robot that you might be able to make it easier. Um, but I just I'm not convinced by it, but I feel like I'm not going to be able to get away with not learning how to do it, cause I think some people are going to ask for a robotic surgeon. Um, but the benefit I'm not The outcomes are about the same for a robot and doing it lap scopic. So And I think the learning curve for it is I don't know how they'd have to have it. Every hospital for us to learn and learn it from an early stage. So from S t three. So I'm already ST start in ST six and haven't had any exposure to it at all, so they'd have to change where it become more available in order to make it a general things. Maybe it be that if someone specifically wanted robot, then they'd have to go to a certain hospital. Um, so I haven't done it, but I think I'm going to have to, Uh um what is your biggest piece of advice to medical students who want to pursue a career in surgery, I think just know you want to do it. Um, it is tough. Um, there's a lot of extras you have to do. And so I think if you're going to go into it, you really have to want it. Um, I know it's for the right reasons. Um I mean, I was a graduate entrance, so I went into med school knowing I wanted to do surgery after experiencing a bit. But it has been tough, but it's also so enjoyable, like sometimes you feel like you're getting paid for a hobby. And other times you're thinking, Wow, I need much more money for what I'm doing here. This is ridiculous. So you just have to know that you want it. I think it would be my main. My main thing. Work hard. Uh, someone's mentioned how much space within training is there to undertake Endoscopy training depends where you work. And so royal sorry is very good. So they give me, um if when I was in training, they give me a dedicated endoscopy list every week. Um, e story is very good as well, but it really depends where you work. Um, some places. Well, actually, most places I've worked, I've had to do like an add talk where you just attend and have a go at some of them. And then it gets taken over gastro, get a really good training program that's put into their thing. But for us, at the moment, it's still not great. But I think they're actually going to make it. With the new curriculum coming out, I think they're gonna make it where we have to learn it. So I think that industry units will change how they run it, and I think we're more likely to get a training list at the moment. It's quite hard to get one. It's quite rare to have a training list. Um, someone, someone's someone's Kyoko someone's mentioned, Um, are there any life surge in the future? Will there be any possibilities of life surgical conferences? Yeah, there is. Actually, we run some courses, so I'm doing my MD at the moment at the matter, which is the minimal access training unit over Royal. Sorry, that's across the road, and there is a number of training courses we run where it's got, like hernias, right? Hemi, where it's all live, linked into our theater. I think what I'll do is I'll see if I can give the link to Dashi, and then he can email it out to you. Um, they're quite cheap as well. I think it's saying, I think I want to say 25 quid for each course. Um, so we're running the first lot of them. This Allison's running some courses. Oh, yeah. So there's there's one coming up in. I think it's next month. We'll probably run a few more of them if they're successful. Um, but yeah, the live link. So it's it's good and it will be from consultants as well. So it really, really, really good. Okay, it seems that some people are having some issues with the QR code should make it bigger. No. So what I what? I'm planning a while. Do you guys is, uh, for those, uh, where the QR code is working, if you can just fill up feedback forms and you should be able to get the certificates. Um, just to mention if you want to get the certificates, you need to If you haven't done so, you need to create a quick account with metal, and then you'll get the certificate If you're still having problems with the QR code, Uh, later on this evening, I will send out an email with the feedback link. So you can just, um, uh, she is yours working. I'll send off a feedback link anyway, and you can do the feedback form through there. Um, did you say you're So what can also do is I can, uh, get the link of Claire, and I can put it also into the email, and you guys can see what, uh, Allison's doing with regards to what exactly is she doing, Claire? It's like live surgical courses. So there's a bit of didactic stuff, but then we're actually linking with theaters so that you can watch like a tip hernia repair. Open her repair, right, Hemi, Those sort of things. So, yeah. So, uh, I will send that out as well onto the email so you can get in touch with Alison and she She's very nice. And she will definitely help you guys that with regard to that, um, any more questions, guys or no. Uh, okay. Anything you'd like to say, Claire? No. No, I'm just going to say if anyone has any, like, career things they wanted to ask. And I'm happy for you to pass out my email address, and I'll try my best to respond to people's questions. Right. I will do. I'll put your N h. S account. Yeah, this one. Yeah. Yeah. Uh, well, I think everyone's no one's had said anything, so I think, uh, thank you, Claire. Thank you, Claire, for presenting this interesting talk on colorectal surgery. I thoroughly ensured, and hopefully everyone else did. Um, thank you guys for turning up turning up today. Great turnout. Please do fill in the feedback forms. Uh, very useful for us as well. But it's very useful for you as well to have the certificates in, you know, for your future. And yeah, I think. Cheers, guys. Thank you. And, uh, enjoy your evening