Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hey guys. Good evening. Welcome to our um next weekly session, part of our con final series. Today we're gonna cover Genser by two of our lovely F ones. Um So as you guys know, we do this series every week on a Tuesday online and we cover key topics for finals following the MLA. Um There'll be a feedback form that we sent out. Once you fill that up, you get a certificate once you've finished and you guys can like pop in um whatever feedback on how we can improve what we're doing. Um And just to let you guys know the session for tomorrow, Ortho on orthopedics have been ca has been canceled because of our speaker, not, not being able to attend tomorrow's session. So we'll just reschedule it for a different day. Just keep an eye out on our socials as and meal as well and we'll let you guys know. All right. So over to you guys. Hi, guys, I'm Hannah. I'm one of the F ones. Um, currently on General Surgery at Conquest. We've got Callum as well. Do you want to introduce yourself? Yeah. Hi. I'm, I'm Callum currently on acute medicine. Um I'm at Conquest as well. So today it will be covering. So these, this is um from your MLA curriculum. So we can't, I haven't got time to co um to cover everything and some of the things have been covered, I think in other sessions. So these are just some of the things that we'll focus on today so you can look up the rest. Um So in your own time. So, so I think in general surgery, one of the most common presentations is just abdominal pain and it can be very hard to narrow down what the cause of that is because it can present quite generally. So a very good way to differentia um create differentials is based on the location of the pain. And I'm sure you guys have all heard about the four quadrants or the nine regions. This is a super easy way to sort of start thinking about differentials. So, thinking about the anatomy of each region and what could be causing the pain. So things like right upper quadrant, you're thinking your gallbladder, is there your liver? So any hepatitis or cholecystitis, important ones to point out. So you've got things like appendicitis which can start in the paraumbilical region and then over time move down into the right lower quadrant typically. Also, when you're thinking about general surgery and abdominal pain, you need to think about non, um sort of general surgery causes. So don't forget about your, um, Gyne gyne causes. So things like ovarian torsion or ectopics, very important, any sort of female childbearing age, make sure doing a pregnancy test just to rule that out. Um And also important to think about your vasculature as well. So especially uh periumbilical pain, you're thinking you want to rule out a AAA um as well. Ok. So I just wanna go through quickly the types of colorectal surgeries because I found this very confusing as a med student. But that once you like start to look at them, they're quite straightforward. So we've got a bunch of general anatomy of the colon. So you've got your ascending colon, your transverse, your descending and sigmoid and then into the rectum. So you can break this down into the areas that they remove. So, resection just means to remove basically. So you've got your low anterior resection where they'll leave the anus in place, but they'll take out the sigmoid codon and part of the rectum. And this is usually done for sort of rectal um cancers. They can do ultra low anterior resections depending on whereabouts the cancer is. And they can just do high anterior resections as well. So it all sort of just depends on what part of the bowel is affected and how much they can leave behind with your sigmoid colectomy where they just remove the sigmoid colon. Um A common surgery you might have heard of is Hartman's which is a type of sigmoid colectomy where they remove the sigmoid colon and usually leave uh a colostomy in place. Your left hemicolectomy, your right hemicolectomy. Again, quite straightforward. They're just taking away the left hemicolon, the right hemicolon. Again, usually for cancers or obstruction or anything like that. And you could have um extended versions of these where they just take a bit more of the transverse colon. You've got your other ones. So your abdominal perineal resection, that's where they take away the entirety of the anus, the rectum and the sigmoid colon and your total proctocolectomy, they take the entire um large bowel essentially. And that's usually done for things like Crohn's disease or IBD or um familial uh uh Adam, I can't pronounce it but um familial ade adenoma has poly put that one, you know what I mean? Um Yes, that's usually done for those. And then you've got other versions where they remove different extent of the bowel again, just depending on the condition and how much of the bowel is affected by it. Ok. So let's start with a case. So you've got a 50 year old female who presents to A&E with a two day history of gradual onset abdominal pain, nausea and vomiting. She not opened her bowels for four days on examination of her abdomen is extended with mild abdominal tenderness and she's got a small transverse scar, visible neurotic fossa. So how would you guys manage this patient initially or start a pole? Uh can everyone see the poll? Ok. Yes, great. I'll give you guys a moment just to answer it any last one ounces. Ok. We'll go with that. So ma majority going for D and G tube and IV fluids and some going for B, so let's start the answers. The answers. Actually DNG tube and IV fluids, which most of you got. Um, and does anyone, can anyone put in the charts of what they think the diagnosis is here? What do we think this patient's got any guesses? Ok. So essentially this patient has a bowel obstruction and we'll go through why. So bowel obstruction generally presents with abdominal pain, nausea and vomiting. She's not opened their bowels in four days. Quite often. They won't have passed um fetus either. They'll tend to present with a distended abdomen with some tenderness as well. Um And she's got a small transverse scar in the right leg fossa, which might point um at the cause of this obstruction. So, management of small bowel obstruction will come on to you in a second and I'll explain why it wouldn't be, be. So, first off, we'll talk about causes of small bowel obstruction. So a good way to differentiate this is to go small bowel, large bowel and then split it into extra mural mural and intraluminal. And when you're thinking of causes, especially on your osc and things, it's always good to categorize things. Um And it helps you not forget things as well. It's the most common cause of small bowel obstruction is adhesions. So patients might have had previous abdominal surgeries, uh they might have had a previous appendicectomy, for example, which is likely what this patient had. That's what the small transverse scar there is. Um suggesting. So it's likely she probably got adhesions from that causing a small bowel obstruction. Malignancy is the most common cause of large bowel obstruction. But again, the you can have other causes. So for small bowel ruction, um hernias as well can cause it. Uh you can have benign strictures from Crohn's also have foreign bodies. So things that patients have either swallowed or beso which like large collections of hair um for large bowel, other things to think about diverticular strictures and volvulus as well with the bowel twists on itself. So going back to this when you're taking, when you're larking in your patient, not taking a history, you might want to ask about some risk factors for these. So, thinking about your fever, weight loss, um symptoms for malignancy or previous surgeries for adhesions, for example, and you can examine them for hernias as well. So as I said, uh symptoms of bowel obstruction, not just abdominal pain, absolute constipation, which means not passing stool or uh flatus, nausea, vomiting, and bloating, which is just the symptom from the distention. They may be peritinic. So it's very important that you examine them for this. Um And we'll come on to what a periton abdomen might look like. Uh they might have tympanic bowel sounds, which typically sound like tingling bowel sounds. So, to investigate this, you'll start at the bedside. So doing your abdominal exam, apr exam, see if there's any stool in the rectum, in case there's any um impaction there, your blood. So you just need to do a sort of general screen there. You can get your full blood count. RP ES. If you think they're very unwell and they may need the, then you want to do a clotting and a grief and save. And if you're actually gonna transfuse some blood, then you'll do a cross match. And it's also, uh you can consider doing a VBG if you think they're unwell to look at their lactate imaging wise, you can do an abdominal X ray. Um In practice, uh we tend to always just do a CT scan because you can, uh they're better, um, it's more clearer than an abdominal X ray. They can be quite hard to read and it'll give you, sometimes it gives you a transition point. So you can see exactly where the bowel is obstructed. So management. So, first off, you want to do an A two E approach. So all patients that you think um are on, well, you're gonna do an A to E approach and just make sure you resuscitate them first, you can manage bowel auction in three ways. So they tend to start with conservative management, which is something called a drip and suck technique. So that's NG tube IV fluids, keep them nil by mouth and give them analgesia as well. You can then move on to a medical management where they give something called Gastrografin, which is a type of contrast. And essentially it acts like um, drain unblock and they either swallow it or put down the NG tube and it should unblock it and get the bowels moving. It doesn't always work. So they can repeat that as well. If they've done conservative management for 48 hours, it's not working or the size of ischemia, then you will go on to surgical management. And that can either be an colectomy, Hartman's or total colectomies depending on how much of the bowel is obstructed and where it's obstructed, we also talk about closed loop obstructions. So that's when there are two points of two clear points of obstruction. And it essentially creates like this pressure system which is more likely to perforate. And if there's any signs of peritonism or the patient's very unwell, then you can consider emergency surgery at any point. Ok. Any questions about small bowel obstruction before we move on. So to go back to the question, the reason you wouldn't do being an emergency laparotomy in this case is becau and I haven't given you much information, but she's generally sta stable. She's got mild abdominal tenderness. If she had very bad tenderness and had rebound tenderness and percussion tenderness. Then we'd be concerned about perforation and then they might need an emergency surgery. Ok. Next question. So case two got a 70 year old male presenting to S AU with a one day history of intense diffuse abdominal pain, nausea and vomiting. I'll let you guys read the rest of the question. Just wait for a couple more responses whilst waiting. Does anyone want to write in the chat? What stands out about this guy's VB gene? What's concerning or not concerning about it? OK. So we've got majority going for e mesenteric ischemia and a couple for diverticulitis and bowel obstruction. So the answer to this one is E mesenteric ischemia. Uh and we'll come on to y so we've got a patient presenting with intense abdominal pain, nausea and vomiting, but on examination, they only have sort of mild tenderness, got no guarding or rebound. So, not peritoneal. And if we look at their medical history, they've got some cardiovascular risk factors there. They've got high BP, um high cholesterol. Um they're also a smoker as well uh with occasional cocaine use. So we've got a few risk factors there on, on their VB gene. Um We can see that they're acidotic with a Ph of 7.27 and they've got a raised lactate. So they've got a lactic acidosis and what this plus the abdominal pain, but with sort of mild tenderness on examination and the risk factors is pointing towards mesenteric ischemia. This is where you get a sudden loss of blood supply to the bowel. Um, and in general, um, in general, when you examine them, your clinical findings sort of out of proportion to um, the pain that patients say they're in. So that's why they have a really intense pain. But when you examine them, it's not too significant, uh very strong cardiovascular risk factors. So thinking about things like af hypertension, things like that. Um and again, the causes you can differentiate and categorize. So, embolic co is the most common cause. So af throwing off clots, of course, we have thrombotic causes from atherosclerosis. So this is where those cardiovascular risk factors um really uh contributing could have non occlusive ones. So any sort of some of anything that would cause a loss of blood supply. So thinking about shock. So hypovolemic shock, cardiogenic shock, other uh venous causes less common things like cirrhosis and portal hypertension and other causes as well. You can have malignancy and autoimmune, sort of vasculitic um pits as well. So, investigations again, you're gonna split into sort of bedside bloods and imaging. So do an abdominal exam, a cardiac exam just to uh examine for any AF or any of those risk factors. And do you can do an E CG for that as well? Blood. So your E BG is very important here. Um They've got sort of generalized abdominal pain doing amylase rule out pancreatitis. And again, if you think they're very unwell, then you're cutting and group and safe. It's gonna be very important. If you need to take them to the theater imaging, again, it's gonna be a CT Abdo Pelvis. Really? Um What signs you might see on uh in the reports of those would be things like bowel wall, thickening, pneumatosis, intestinalis where you get air in the bowel wall. And they also talk about loss of bowel wall enhancement management. Depending on how unwell your patient is. You want to do your a to e assessment, um, resusci them with fluids. Antibiotics is also important in mesenteric ischemia. Um, but your main stay of treatment is gonna be surgical here. So they may need a bowel resection if the, um, if the bowels dead or a necrotic or you may be able to save the bowel and revascularize it. So something like vascular might do endovascular therapies and embolectomies. But also don't forget to treat your underlying cause and um, manage your risk factors as well. Ok. Any questions about mesenteric ischemia? If not, we will move on to our third case. So we got 40 year old female uh in A&E with a five day history of diarrhea, um, and left lower abdominal pain and fever. Today, she's got worsening, diffuse abdominal pain, nausea and vomiting. But on examination, she, her abdomen is hard with rebound, tenseness and guarding. We've got some obs there as well. Do you guys want to have a go at answering this question and for anyone that answers it quickly, um, you can put in the chart what you think this patient might have or diagnosis? Lovely. Lots of people going to be that. Um, does someone want to write in the chart? What, what's your differential here? What's your top differential? Yeah, exactly. Bowel perforation. So, this is one of the surgical emergencies. So, you've got here a 40 year old female with history of diarrhea, left abdominal pain and fever. Then today she's now got diffuse abdominal pain, nausea and vomiting. So the pain's got worse and it is now, uh, more diffuse. And on examination, she's got a rigid, hard abdomen with rebound tenderness and guarding. So she's Perine, that's what we're thinking there. Um, looking at her observations, she's got high respirate, she's tachycardic. She's got temperature, she's keeping her BP at the moment. But obviously the worry is that, um, she won't. So it'll be an A two E assessment for this lady. How you diagnose, um, perforation can do a seating, but ideally this patient, she's very unwell. She's peritinic. She's already starting to, um, decompensate. She needs emergency surgery as soon as possible. All the other things are things. So, antibiotics you prob you will give, um, you might put in drains, but really you need to do an emergency surgery and you might remove some of that bowel that's perforated. So, causes loads and loads of causes of perforation. Again, just go through your anatomy can work sort of top to tail. So you've got peptic ulcers, bursting malignancies, foreign bodies. So things are solid as a battery. Um, the acid can cause a bowel perforation. Um, diverticulitis, that's quite a common one, which is probably what this patient has considering. She's got a five day history of diarrhea, left lower abdominal pain and a fever. She likely had a diverticulitis which is then perforated. Um, you've got appendicitis that can perforate and all sorts of other causes as well. You can also get this, um, interoperatively with, uh, I Actical. Um, it might accidentally perforate during an operation. Nonexamination. They're ge generally very unwell um, periton. So, in terms of management, you need to do at en by mouth and what is IV fluids? You're definitely gonna do your bloods again. So you're your BBg s, your cotton, your groove and say very important here cos they are gonna need to go to theater as soon as possible. Um, and then if you do emergency surgery, they'll do a, a wash out. Um, if there's sort of fecal matter in the abdomen, then that's, uh, not a very good sign. So you'll need to wash that out and then you might resect the bowel and leave them with a stoma or even try and anastomose back together, which, um, anastomosis just essentially means. So suturing the bow together. Ok. Um, any questions about gi perforation. If not, we'll move on to um Callum section of the talk. So slide to go back to the start, I will move on to case four. OK. So the 1st 1st 1 of my cases, 45 year old man presents with an episode of alcoholic pancreatitis. So he's been making some progress. He's been getting better. It's usually quite a slow recovery. He has this diffuse fullness in his upper abdomen and we can see fluid collection on act behind the stomach. Um His amylas are still elevated. What do we think is going on if I open the pole? Has anyone got any idea what might be going on with this patient? All right. So you've got some responses. So, in this case, we have a pseudocyst forming. Um So pancreatitis, although we learn a lot about the acute management and recognizing the symptoms of pancreatitis, um it can be very, very severe. Um and people can get very unwell, very, very, very quickly. Um So there's a lot of complications and it's kind of a step wise process. Um So we start with the fluid collection itself. Um This can kind of just appear on its own or it can get worse um and develop into pseudocysts and abscesses. Um But we try to leave things like this alone um because we don't want to induce any infection and sort of just make the problem worse. Um So you get a pseudocyst whenever it sort of starts um, collecting and fibrosing around and forming sort of a more visible cyst rather than just fluid sitting around the pancreas. Um And again, kind of sit on it hoping that it goes away and, um, but sometimes you do need to get rid of the pseudocyst. Um, and then that can progress again onto necrosis. Um This is very, it can start to get very serious. Um, but we try again, you try to leave it, you hope it goes away. Sometimes it does, sometimes it doesn't. And again, you might need to aspirate um sample. But when it starts to get really bad is when you have an abscess and that is when you have got an infection. Um and that's when you can drop off and get sick very, very, very quickly. Um So you can, the pseudocysts, you try to get drain and get rid of um because the infection, we need to get rid of this source of infection. Um um It can kind of progress finally into hemorrhage, um infected necrosis. It's invaded the vascular structures. So blood is now leaking. Um And that's where you get your gray turner sign, uh sign, which is quite um quite a serious looking sign. Um But people can get very unwell with this um to my next case if I start the pool. So we've got a 73 year old man, diffuse abdominal pain, vomiting, he's not had any bone lotions for five days, dehydrated, not keeping anything down. Um So we decided to do an operation um, because of the CT scan showing an obstruction. Um However, the obstruction we think is because of previous surgeries. Um, but he has also had some weight loss. But why might we consider an open procedure rather than our preferred laparoscopic approach particularly, um for this patient? Why do you think you, you want to jump in with an open procedure? Not quite any, any responses so far, even if you want to guess? Ok, so I'll give you the answer. Um It's because you've got increased risk of perforation. Um So with previous operation and adhesions, it can get very tricky. Um If you do laparoscopic surgery electively, it can be very slow. You have to take down a lot of the adhesion things are stuck together, but in something like a small, a small bile obstruction, which is more of an emergency, you don't, you might not have the time to delicately take down the adhesions. Um So we try to avoid, try to avoid laparoscopic procedures if we think it might be complicated. That's one of the um major reasons we would do open surgeries if we think it's going to be complicated. So, laparoscopic surgery itself is very, very common. Um These days, we try to do most procedures laparoscopically. Um But there are some absolute reasons why we don't do this. So if you're hemodynamically unstable part of the procedure is pumping the abdomen full of um carbon dioxide so that you can see the spaces that you're in and that puts pressure on the diaphragm. So it can often um cause changes in BP and heart rate. So you don't want to do that. If someone's unstable and again, same for it raised into cranial pressure, you don't increase BP. Um And then, and then if you've got an obstruction again, um and dilated bile lips, you don't want to aggravate um the bottle. Um and then sort of more relative contraindications um for the same reason. So, cardiac respiratory failure again, because you're putting strain on the heart. Um And then if you've had a recent laparotomy, uh you get formation of adhesions um especially where you've been opening the abdomen. So you don't want to go in laparoscopically. Um And then pregnancy um sort of for obvious reasons again, is a tricky delicate procedure. Um And you, it's much, it's much trickier to get in and you have to, when you go in with your scopes, you're um sorry, Callum, I think they've been saying that the, the they weren't able to see the question, I think. Oh OK. I know. And the slides weren't moving. Oh, they're showing for me. Um They're saying the slide is stuck at complication of pancreatitis. Oh I'm not sure why I mine mine are moving along. Yeah, I could see them moving. What do you guys see now, do you see laparoscopic surgery? They still see a complication of pancreatitis. Um, ok. Maybe. Should we remove it and then put it back? Yeah. Is the only thing I can think of. Yeah, cause, um, uh, we present, um, they can anyone see laparoscopic surgery now? Ok, cool. They can see it now. Good. Um, ok. All right. Sorry. Carry on. Ok. Um, definitely helps to see, um, what I'm talking about. Um, so just sort of related to what I was just saying, the complications, um, apart from the obvious risk of having an anesthetic, um, you, you can affect, um, the heart, um, and you can get surgical emphysema, which if anyone's ever seen is actually quite interesting. It's sort of like a bubbly feeling under the skin where the gas gets between the p and the skin. Um, and whenever someone, when you insert, when you've got the abdomen and you're inserting the scopes, you do have to push quite hard and it sort of rips in. So there's always a risk of puncturing something when you go in. So things like a big aortic aneurysm, abdominal aortic aneurysm of pregnancy or dil dilated bar lips because they're bigger and you're more likely to poke through them rather than them just moving out of the way of the shock object. Um, so we try to avoid that. Um, so a case on stomas and colostomies, which we've talked about. So, hopefully you'll be able to answer this question more easily. So, a 72 year old with rectal carcinoma having a lower anterior resection, they want to restore the continuity of the bile after. So essentially, it would be a defunctioning um stoma um to allow them to resect the carcinoma and then with the aim of bringing it back together again. Um after a few months of the rest of the bile, what type of stoma open the poll do we normally go for, for this type of patient? Ok. So I've got a bit of a mix of answers. OK. 5050. So the answer is loop ileostomy. And the reason it's, it's a loop ileostomy is because you're essentially defunctioning the bile, which is not something I quite used to understand. But the reason why you're doing the ileostomy, even though you're doing a lower resection is because where you have removed a part of the bile and you want it to heal. You can't you defunction it because if you've got still passing through and it's being used, um it hasn't got the chance to heal. Um So the defunctioning ileostomy allows time for that bile to heal and the anastomosis to join while the lip bit of the ileostomy makes it where you essentially have the intestine and you're kind of snapping it into but not completely separating it, which you would have on an end where you just cut right through. So it allows you to sort of bring it back together again. Um It just has a lower complication rate than putting together um, an end ileostomy. So we've got the di different types of stomas. So you've got ileostomies and colostomies. Ileostomy being from the small intestine and colostomy being from the large intestine. And just because where you, the ileostomy tends to be at the end of the small intestine, which is why it's usually in the right iliac fossa where the uh small bowel forms into the caecum. And it usually does stick out. And because it's not reached the large intestine yet, you do have quite loose stool coming out. Whereas colostomy can be sort of anywhere depending on what part of the body you're resecting. Um and it does go more flat to the skin and because it's been passing through the large intestine, it does tend to be more solid, but it depends where you do the resection. So if you do the resection in the ascending colon, and it does still tend to be quite liquid. And in this picture, you can see stomas can look lots of different ways, but you, what the average one you will see is they do tend to be protruding if it's an ileostomy and the low profile or flush tends to be what the colostomies look like. And they do come in all sorts of different shapes and sizes so that you can have them around the oval shape. The lip stoma on the right is where you can see where the sort of where they have, they've not completely separated, they sort of like snapped it in, into, but it's still help when you snap a pencil and it's still got a little arch connected. Um, and that just makes it easier to rejoin again. So lip almost always tends to be a temporary, um, operation where you would use an end ileostomy, colostomy, um for something more permanent or in an emergency. Um, they tend to be a lot more stable. So you would just do an end ileostomy in, in the case of an emergency or if you've got a bowel perforation where you might not be anastomise the bowel for months and months while the body and the bile have had time to heal and new stils do tend to be swollen and a lot of people don't realize is when you're putting on a stoma bag, um, it will be very swollen to start with and it will eventually settle down, but it can again, um, get some more edema later on sometimes. So the, the stoma won't always look the same way. And a prolapsing stoma, um, which I have seen a few times can be quite distressing for patients and seem quite worrying, but generally they're quite safe and don't cause much harm in the majority of cases. And they can often be, um, sort of encouraged back in so on to the the final case, I'll start the pole. So 64 year old man presents with a lump in his right groin. Um He's not sure how long it's been there. It's not been painful. Um, he's not had any changes to his bile habit. He's got high cholesterol diabetes, so it's also stable. Um, you can see a mass, um, superiorly and immediately to the pubic cubicle and it disappears when he lies down and it doesn't chance eliminate no tenderness or bruising, given the likely diagnosis. If we were to do anything, what would we do um with this man? Oh, the slides are not moving again. No. Um They say I still see K six. That's what they're saying. Ok. I'll try to stop sharing and reading, right? Do we see K seven though? Ok. Yeah. Ok. Ok. I'll go back to the pool. So what would we offer, offer this man if anything? All right, I've only got one answer, but the answer is j uh open repair with mesh. So the reason being is we know that this isn't strangulated, there's no pain discomfort. Um He's not acutely unwell. Um So it's not a, it's not one that we would be worried about a hernia. Um So we would routinely do open repair. A hernia truss is essentially sort of like an elastic band is the way to describe it that you wear around your wrist that just physically holds it in place. Um They, they can be helpful in people who wouldn't be fit for surgery. Um, but people often find that they're, they're not very helpful and they don't provide much relief. Um, so we tend to try and repair with a mesh. We wouldn't do it urgently because we're not worried about strangulation. Um Of course, you, you could discharge a safety netting advice on top of offering a routine um repair, but you would still look to do something about it, especially in someone who's 64 and is most likely to be fit. Um, for a surgery monitoring for strangulation would really be in someone who has signs of discomfort and you're worried that it might strangle it or they wouldn't be fit sort of for any intervention. Um, ok. So in terms of inguinal hernias are focused on is because they're the most common really, um, 75% of hernias, um, that we see. So there's just people tend to notice the lump in their groin. It's very tricky to determine where the hernia is exactly, especially in the groin. But if, uh you had to guess and you get asked, it's probably an inguinal hernia and that's the, um, because it's the most common one, strangulation is very rare, but people do find them uncomfortable, but generally people's biggest complaint is sort of um appearance and having the lump there and they find that people notice um, the lump. So, like we were saying, with um management, um trust generally is for when they can't have surgery, but they tend not to be very helpful for people. Um, general treatment is the mesh repair. Um, like we said, um, but we try to treat them because then we sort of eliminate the risk of strangulation further down the line. Um Does anyone have any questions? That's the end of our slides and if you fill out the feedback form, you can all get your certificate of attendance. Well, hang around for a minute in case anyone has any questions. Awesome. Yeah. II still a slide. Is it this one I think? Oh, I see. Um So this was what I was talking about how the stomas look. So, um and in the top left you attracted and flush a low profile tend to be your colostomies. The protruding tends to be what your ileostomies look like. Um And then the prolapsing one in the top, right? Um It can be very common and usually goes back in on itself. Um But you kind of treat it in the same way as you would AAA hernia. You look for signs of strangulation, pain, discomfort, color changes. Um, prolapses tend to be um self resolving a funny thing. Um If you've ever had the uh joy of watching is they do actually sometimes throw salt on it and it shrivels up back inside and that's what patients tend to do at home um to avoid coming into the hospital. Um and then in the middle left, you have, you have your neurotoma which tend to be quite swollen and can fluctuate in size. And in the middle right is the loop stoma. Um which is when they rather than completely separating the bar, they kind of snap it in, into almost. Um So it's still functioning. Um It also allows for gas to skip as well. Um in the non fun the defunction side, um and then to the bottom is just showing that stils all look a bit different. Some can be very big, some can be very small. Um, all sorts of different shapes and I would ignore the sort of the, the wound and the history of the parts. It doesn't really show you very much information there. You got any final questions? Oh, so you guys will get the slides. Um, once we've ended the chat, I mean, ended the call, I think we don't have any more questions. So I'm just gonna end the call, right. Yeah. Thank you guys for doing this and thank you guys for attending. See you all next week. Bye.