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So welcome everybody. I'm Regan and I'm 1/5 year medical student at the University of Edinburgh. And these are my colleagues, Naasia Diana and Julius. Um They're also in year five as well. So, on behalf of the Edinburgh Student Surgical Society and a and the accessibility in medicine Society will be teaching a three, the, the third part of our series and operative approach to anatomy, focusing on cardiothoracic and vascular surgery. So just some general housekeeping, housekeeping before we begin. Um I'm, I think some of you guys have attended our sessions before. So you may be familiar with this, but um just use the chat to ask any questions, the session is recorded and the recording will be sent out via medal. Um Please fill in our questionnaire at 10, 6 out of eight sessions to get a free R CS affiliate member worth 15 lbs and also follow our socials. Um Just a disclaimer that this is ap two third session by a medical student. So please bear with our uh ple please bear with us if you find any mistakes in our slides. So before we begin, um are you guys able, are you guys able to fill up some poles, um, that we have prepared just to gauge, um, done knowledge. I'll just get that back. Now. It'll be a series of a few. It's gonna be. Yeah. So I'll just give it a few seconds for you guys to get your answers other things. Yeah. And do grow up to on all five points in the chat box. I promise this is the only time that I'll send out this many questions. I won't go. Yeah. Right. I'll be closing the poll in about a few seconds. Start closing the pos I Right. So that's great. Um So let's begin. Uh We'll be covering these three cases today to learn more about the key anatomical bits in surgery. Um We have a cabbage or coronary artery bypass graft, a va or video assisted thsc surgery, lobectomy and a AAA or abdominal aortic aneurysm repair. Um All very fun acronyms. We'll just be having a quick tour through the following points here. Um The path of the pathophysiology, clinical features, investigations, management, anatomy and complications of the conditions and the surgery and we'll just be keeping everything light and interactive. So here's a quick introduction to cardiothoracic and vascular surgery. Um Cardiothoracic surgeons focus on the thoracic cavity which covers your heart and lungs and great vessels of the thorax. They are split into four categories in the UK, usually focusing on the heart lungs, congenital heart conditions and transplant surgery, vascular surgeons on the other hand, work on the blood vessels in the body and tailor their work towards the patient. So wherever the problem may be, they work on the vessels endovascularly, meaning where they puncture an artery and work with guide wires through that art artery or in an open setting to either unclog repair or remove problematic vessels in the body. So I've included a non exhaustive list of common specialty cases here done by both specialties on the cardiac surgery site. We have the cabbage or C ABG co coronary artery bypass graft which replaces blocked coronary, blocked coronary arteries with a graft from the patient and valve replacements where heart valves are replaced by either prosthetic or mechanical valve. Boho has its own differences, but I wouldn't go into too much detail regarding that. We have thoracic surgery where thoracotomies are performed where the lungs are worked on in an open approach through a direct incision or a minimally invasive approach through vats. We also have the congenital cardiac site where surgeons um work to close atrial or ventricular septal defects of the heart. And we also have heart and lung transplant surgery which is self explanatory. That's also um the aspect of um repair and trauma in the context of trauma where surgeons may work in work on organs within the thorax in cases of acute trauma regarding vascular surgery. I'm just gonna go out on a limb and quote the words of vascular surgeon who I shadow. Um So you see these pipes in the bottom right hand corner. Um So I'm just gonna quote his words and these are not mine. So they basically work as human plumbers. Whenever the pipes are vessels in the human body needs to be repaired. Often due to a burst pipe or clots, they can go in and fix the problem. So if you have something like an aneurysm, they can go in with some um with a patch of goutex or Dacron to fix it up. If an artery is blocked, they can put in stents or open up the arteries and scrape out the blockages in the case of an an arterectomy. Um They can also use various glues um or, or things like um something like superglue or um a form type of um filler substance to treat large varicose veins or fix up vessels in trauma or even amputate unsalvageable limbs of the human body. So tonight, just imagine yourself as a medical student having an 8 a.m. eight AM start in theaters. So you go in the morning introduction round and you meet the team shown here. Um You have to consult in surgeon, the ra the anesthetist, the theater nurse and the scrub nurse, you introduce yourself, but realize that the first case starts at 8:45 a.m. giving you some time to hang around while somewhat while everyone disperses. Um you're left in theater. But the nice anesthetist invites you to the anesthetic room to watch the set up. You're having a nice chat with them when the wretch brings in a long object, which is shown here. Um, so you are asked whether you know what this is by any that is, and this is the start to our interactive poll. So please answer the poll and select the most popular answer and this will take us into a unique prevent pathway. I'm just gonna put up um the polls now. Just give me a second. Yeah, sorry. This is previous, but I three months of that as well. I'm just gonna give it a few seconds. Yeah, and make sure to scroll up to answer the first um question that I put up as well. Um Regarding on how prepared are you to, to identify the relevant anatomy of the heart and associate that structures? And that's all right, if they, if you are assisting in it in the cabbage, so I'll give it 10 more seconds, right. I'll be closing the post now. And so the pain, the arms. So I think the popular consensus was the transesophageal echocardiogram probe and this is correct. So, um the wretch and anesthetist look impressed and the wretch invites you to scrub in an anesthetist gives you more teaching before the case. So at this point, um I'll just hand you over to diana anesthesia um who will be covering um the cabbage case. That sounds good. Thank you very again. Uh, let, let me know once you've shared slides, I'm just putting them on now. Um. Ok. Um. Mhm. You, I don't think the presenting view is working. Uh, oh, there you go. Oh, yeah. It's full screen actually. Yeah, it's not full screen. Sorry. I'm just gonna try to, um, present another way, I guess. Uh, um, if you need, I can share slides for you if that's ok. Yeah. Yeah, I think, I think, I'm sorry, I think it's working now. Yeah, perfect. That's all right. Yeah. Ok, great. Um So, hi, I'm Diana. Uh I'm here with occasion. We're both doing like a joint presentation on the cabbage, which is cornea artery bypass graft. Perfect. Yeah. If you would. Yeah, sounds good. Um So this is basically a procedure to treat coronary artery disease. Um I'll speak a bit more about what that is later, but the procedure itself involves like harvesting a blood vessel from somewhere else in the body and using that as a graft to like create a bridge to bypass or to like go over a blockage in the coronary artery. And I think the diagram shows that quite well, like it's got the blockage clearly marked and then they like redder lines are like a different vessel that you've gotten from somewhere else that goes over the blockage to get new, like oxygenated blood straight from the aorta or from an off branch of the aorta past that blockage. So that the further, like more distal muscle in the heart can still receive the oxygen, oxygenated blood. You do a cabbage when you've got basically any high grade blockage in any of the major coronary arteries. And what high grade means varies from center to center, but it's typically accepted that that's over 70 I'm sorry, 50 to 70% like narrowed lumen. So like nearly blocked or when someone has tried PCI. So that's um going in percutaneously like through a vessel uh to clear the blockage, but that has failed. So then you have to move on to cabbage, which is a much more invasive like open heart surgery to, to try and, and bypass that next slide, please. Great. Um The pathophysiology there, there's not much to it. You do it to treat coronary artery disease. That's um occlusion of the coronary arteries. The great majority of cases um is like quite an acute uh like thrombosis that occurs. So, a clot that occurs in the coronary arteries in someone that already has a background of chronic atherosclerotic narrowing of the lumen. So the coronary arteries which is like the vessel that supply the heart with oxygen are already narrowed um because of the atherosclerosis. So like the, like you've got like gunked up um coronary arteries and that surface is quite rough. So it is prone to clot. So that can clot and cause the a a blockage that requires a cabbage to, to bypass the um site of coronary artery occlusion, like site 1 to 3 are the most common. So you've got the anterior interventricular branch that's also called the like led your like left anterior descending artery. You've got the right coronary artery and then the proximal left circumflex. Um Those are the three main like areas that are blocked most often. Ok. So now we're gonna um go into the anatomy a bit more. So the left and right coronary arteries arise from the left and right aortic sinuses distal to the aortic valve. The left coronary arteries send off a branch called the circumflex artery. And the left marginal artery branches from the circumflex artery. The left anterior descending artery creates branches called the diagonal, the diagonal arteries and the right coronary artery runs in the groove between the right atrium and right ventricle. Right coronary art, the right coronary artery gives off the acute marginal artery. And the fun fact is 70% of patients are right coronary artery dominant and the most common cause of stenosis occurs along the left anterior descending artery and the left coronary artery. And here's some relevant anatomy of where the blood vessels for grafting are taken from. So they're usually taken from one of these three sites. The first is the left internal mama mammary artery, also known as the Lima. And it's always used first unless it's contraindicated. It's a branch of the subclavian artery and it descends along the inter internal anterior chest wall parallel to the edges of the sternum. Secondly, is the saphenous vein and these are large veins in the leg. So there's long, the long saphenous. So the short saphenous, the long saphenous ascends to the anterior medial thigh and drains into the femoral vein in the safi fe femoral junction and the short saphenous vein ascends in the posterior calf and drains into the popliteal vein. And lastly, there's a radial artery and this arises from the brachial artery and run runs along the anterior forearm and the saphenous veins and the radial art artery are interchangeable. So there's no protocol whether it's used first. It's just um up to the surgeon. Um Great, I'll introduce like our patient, which is the main case. We'll be basing our like next couple of slides on. We've got a patient. She's called Miss Anesthetic. She's 63. She's a retired secretary complaining of S ob which is short, shortness of breath, palpitations, angina. So chest pain and decreased exercise tolerance, which means that um she gets more tired when exercising or can walk a less, less distance without becoming breathless, her past medical history, um, she's got coronary heart disease. She's got hypertension, hyperlipidemia, obesity and type two diabetes, um which is um, it's a very like metabolic disease profile. So high BP, a lot of lipids in the blood. She's obese and already has narrowed arteries from the coronary heart disease and diabetes as well. She is on some helpful drugs. So, a statin to reduce the cholesterol, um, Ramipril, which is an ace inhibitor to decrease the hypertension and Metformin for the diabetes. And in terms of the social history and she's married, got a husband who's a tree surgeon, he smokes 20 a day, um, for the past 45 years. Um, she exercises little and has a poor diet and she loves pot, which is a great hobby, but quite a sedentary one as well. Um Now we're gonna move on to the investigations. So, investigations including an E CgA, full blood count and angiography are undertaken. The angiogram is done in the cath lab where contrast is injected through a fine tube straight into the heart's arteries through the radial or subclavian artery to see the flow of the blood through the vessels in situ, the patient is usually under sedation and a local anesthetic. And it has two blockages in the coronary arteries. One's in the left anterior descending artery and one is in the right coronary artery. As you can see, the blockages are pretty severe. So she'll, we need to, uh, she'll be a very strong candidate for a cabbage. She has no serious risk factors for a cabbage. So an elective cabbage is planned. So here's a content warning. So before the procedure starts, the scrub nurse lets you know that you might see some things you haven't seen before and it's ok to feel lightheaded. But if you do feel free to pop out of theater and grab a drink or snack and if you're able to or if the faint is imminent, take a seat on the floor. Um So now I'm just gonna walk you through the operation steps of a cabbage. So first general aesthetic is administered. So in the Royal Infirmary, usually propofol is used for induction um of anesthesia and then sevofluran is used for maintenance, two teams then work simultaneously. So the consultant and register work up on the chest and they work on exposing the heart and harvesting the left internal mammo mammary artery. And then the advanced nurse practitioners work on the limbs and harvest the vessels, the other vessels that are needed. Once all the vessels are harvested and the heart is fully exposed. Cardiopulmonary bypass is established by delivering cardioplegia, which is a potassium rich solution into the heart to make it stop beating. Um But a fun fact is some surgeons choose to do this off pump. So that means they actually do the cabbage on a beating heart which takes a little bit less time in the overall procedure, but it's it's quite co complex. Um So next, the um circulation is directed through the car cardiopulmonary bypass machine which oxygenates and heats up the blood. So it can circulate throughout the body and provide oxygen rich blood to the organs. Once the bypass is achieved, the distal part of the Lima is connected to the stenosed coronary artery, ensuring attachment beyond the point of stenosis. If the patient requires further bypass, the saphenous vein and or radial artery are attached to the ascending aorta to the distal portion of the stenosed artery. Patency. For all the grafts can be checked by a transesophageal echocardiogram and taking the heart off cardioplegia to see if there are any leakages. Whilst the heart actually beats. Um once there are no leakages, uh the patient is slowly taken off the bypass by gradually warning the patient up and reversing the cardioplegia. The sternum was then closed by using external wires and the chest is closed, the chest wall is closed in layers. The s the skin is closed with a tight subcuticular stitch and two drained stitches are inserted and left for several days to prevent the hematoma or bruising. So, after the operation, Anna spends less than 24 hours in intensive care unless a complication occurs. And Anna started on a li on lifelong antiplatelet antiplatelets and she continues her antihypertensives and statins as an outpatient. So after she's out of the hospital, and it goes to cardiac rehabilitation which includes exercise and education to reduce risk factors such as smoking and dealing with any emotional effects and pain management which can occur after any major surgical procedure. She'll have to attend regular cardiology outpatient appointments. I involving a series of tests including transthoracic echocardiograms to assess the success of the grafts. That was great. Very good um like summary of how to run the case. Now, I've got a bit of a fun, like, choose your own adventure where I'm just gonna talk you through um this patient anesthetics case and we can like, ask you some questions along the way. Um Great. So this is the beginning, the surgery has started and the surgeon has already located and harvested um One end of the left internal mammary artery, that's the Lima, that's like your first line artery to use to bypass um The blockage. What do you do next? Is it a harvest the whole artery and place this in Saline until it's ready to be used and reconnected or is it B connect the free distal end directly to the coronary artery distal to the blockage? And if you just fill in the pool, uh we'll wait for a couple of seconds. Yeah. Getting some responses in already. Thank you very much. Um I'll just leave you there a bit more. Ok. Right. I'm sure I can, I can end it there for now. So I've got slightly more people saying, b connect the free distal and directly to the coronary um artery distal to the blockage. And yes, that's absolutely right. Uh Not if you just go to the next slide. Brilliant. Yeah. So that's correct. The proximal end is already attached to a branch of the aorta that, that's where we want it to be. Now, we just need to connect the distal end to bypass the obstruction. So there's no need taking the full artery out because in the end, you just want to reconnect it back to the aorta if that makes sense. So that's why the Lima is so useful. One of the end is basically already connected to the aorta or like the off branch of the aorta. So that end's already filled with oxygenated blood quite close to the heart. So you just connect the distal end to bypass the obstruction. Great well done guys. Um And that's just an image of them connecting the um distal end of the lemur to bypass the obstruction. You can see how small um the needles are and that's like very pertinent in like um cardiac surgery. It is quite difficult actually when you lose a needle that happened once when I was shadowing and it was a nightmare trying to find it. And you can see the clamp around the area where they're like reattaching the vessel back to the heart. Um It's got like a stabilizer device. Those are often seen in off pump surgeries where the heart is still beating, but you need like a stable still surface to sew up the artery back into the beating heart. So they use like a clamp type structure to stabilize the area around the like around the cut. All right. So now we've got the second bypass. The advanced nurse practitioner is looking to harvest a softness vein which is what him and the surgeon had agreed to um as like the second graft and this is what they see, what should they do. So we're looking at a picture of a leg. Um but the veins there don't look too healthy. They're the pa the person probably has some like varicose veins going on. They look torturous, not very straight. So is it a those veins would not be useful? Grafts move on to inspect the radial arteries or B harvest the Fastin veins is planned. The surgeon can prep these before grafting them onto the patient. And again, um if you just fill in the pool uh about what you think the A NP should do in this situation, that's great. I need some answers coming in already a couple more seconds, right? Ok. Let's move on. Most people went for a the veins would not be useful, move on to the radial arteries and that's absolutely correct. Um The vessels need to be of good quality to give the patient like the best chance of a healthy bypass if the veins are like varicose. So like they're not straight, they're very torturous and bendy um or stenosed. So they're quite hard and calcified, just move on to see if you can find a better vessel. So as we said, there's no preference between the saphenous veins or the radial arteries usually. So if the patient has like an obvious contraindication to one of them, move on to see if you can find a better vessel. I guess in the very unlikely situation that neither vessel is good. The surgeon can try and we'll try and try and insert in like a suboptimal graft if there is literally no other option. But given that we haven't inspected the radial arteries before, let's check those so great. Next slide, please. And that's just a photo of them harvesting the radial artery who luckily is in perfect shape. And right before closing, the consultant looks at you mischievously and asks, can you identify these three nerves? And this is quite a common question you'll get while assisting in a cabbage. Unfortunately, they love to ask you about the nerves. Um I actually have to get a cadaveric photo as I'm sure you can tell um because they're so hard to see on a living um on a living patient, they're the same color as everything else. So I've just labeled it A B and C. That should not be a pul sorry about that. Um If you just type in the chart, if you're comfortable with it, um If you can name any of the nerves A B and C, there are only three main nerves around this area that the consultants love to quiz you about. So can you guess any of them? And if you just type in the chart, the potential names for any of those, don't worry if you get it wrong at all. Yeah. Absolutely. One of them is definitely the vagus nerve. I'm all done. We can maybe move on to the next slide just in case people aren't too sure. Nerves are tricky. Yeah. Absolutely. Phrenic nerve is the other main ones. Um, no, it's OK. Move on to the next slide. Um, so we've got the two main ones which is the vagus nerve and the phrenic nerve and the recurrent laryngeal. Absolutely. That's your main three that they love to quiz you on for some reason. Um You can see the vagus nerve has the off branch of the left recurrent laryngeal nerve. That's the one that kind of tucks under that uh the aorta. So that's how you can tell it's the vagus one, if it has an off branch that tucks under the aorta, and then the phrenic nerve is quite a straight nerve that runs all the way down to innervate the diaphragm. So it has no off branches around that area. And that's quite relevant because the surgeons are really careful about not compressing or damage or cutting through the left recurrent laryngeal nerve because that creates um that innervates the larynx. So if it's damaged, it can cause things like a horse, voice or um voice box paralysis problems with chewing, you'd have to get like sot rehabilitations, that speech and language. Um Obviously, try not to damage everything of the nerves, but that's um definitely a one of the rarer complications of a cabbage that everyone's still wary of. Great. That's brilliant. Um Now we finished our case, the chest is closed up. So you use sternal wires to close them up, you put them um, yeah, below the sternum and then kind of twist them around and tuck in the twist a bit and then you sew up the tissue layers with um, yeah, you just sew them up at the end. And now finally we do our post surgical rounds and we see aesthetic three days later and she says she's doing well. She's just got a bit of a hoarse voice ever since the surgery, but she's sure that will clear up in no time. So you're a bit concerned that she does have a hoarse voice. What do you think has happened? And again, there's no point to this, just shoot out into the chat. Um There's more than one right answer as well. Yeah, someone's just said irritation damage to the left recurrent laryngeal. Definitely. Uh definitely a strong possibility. Uh Yeah, yeah, that was the main thing I was trying to get out of this question. If we move to the next slide, I've included a couple more. Um, so it could be id idiopathic. So like not sure where she's got a horse voice, it could be somewhat normal, she could have a cold, um, which could have caused this injury to the recurrent laryngeal nerve. That's one you definitely have to look out for intubation is a good one. Very well done. Um I'd consider that, yeah, you could definitely have it because of intubation. Um She might also have a postoperative infection. That's something you also should really look out for. So definitely do her s check her temperature, um check her bloods for high C RP, which is a mass um which is like an indicator of inflammation. But yeah. Um just to mention that recurrent laryngeal nerve injuries are not in any way. The most common type of uh complication to a cabbage. I think you're more likely to have um what I say, atrial fibrillation as a result of that. But yeah, a complication to look out for and otherwise that is us. Thank you very much. Thank you. So I'll just be taking over for the next case. Let me get my screen up. So, so welcome to part two where we'll be covering a vats, lobectomy. So that's basically stands for video assisted thorascopic surgery. Um It is a minimally invasive procedure and performed through the use of guiding ports and long instruments or a video camera to view the procedure. So imagine a laparoscopic procedure where keyholes are cut in the abdomen. But this time it's in the thorax. The procedure is done under general anesthetic as a dual lumen or two tube, endotracheal tube is needed to deflate one of the lungs um through either the left or right main bronchus for the surgeon to get a better view of what they are going at. So, some indications for the procedures include a lobectomy which we are covering today. Um A pneumonectomy or the removal of the entire lung, um removal of lymph nodes or lung tissue for biopsy, removal of diseased lung, emb lung disease or emphysema. You could also perform a pleurodesis which involves fusing the two layers of pleura together to correct recurrent pneumothorax. And this is done through the use of TALC which is introduced into the pleural space. So, to clarify what this is the pleura is a thin double layer tissue structure that wraps around the lungs with a small amount of fluid in it to allow for protection and lubrication for movement of the lungs in respiration. That's the parietal pleura as seen a at the bottom uh right hand corner, um which is more superficial to the visceral pleura, which is shown here. And this I and this is deeper um relative to the parietal pleura and this wraps around the lungs like cling film. Um But um today, we'll just be focusing on the lobectomy part of vats, which um in essence, uses vats to remove a lobe of lung. Regarding on how it treats the condition. In the case of lung cancer, it's used in limited disease to remove a small primary cancer or palliative treatment or metastases. So, regarding bullous disease or emphysema removes that bit of poorly ventilated lung that shunts the oxygenated blood into the body, improving the ventilation to perfusion mismatch. It can also um be used to remove that lung from either um infection. So, in the case of a pe um infection or trauma. So, if you have a nasty um lung abscess or a piece of lung that's damaged through any penetrating trauma, injuries can use a vaso lobectomy to remove that part of the lung. Some contra contraindications include a patient with poor respiratory reserve. Um for example, less than 2 L of false um expiratory volume in one second. And that's because you don't want to be removing more lung from a person with um severely damaged lungs or in the case of someone with severe metastatic disease. Um If a patient has cancer cells in the brain or extensive spread within the thorax, moving the removing that one bit of lung wouldn't make too much of a difference. And all surgeries carry inherent risks. But putting a patient with, with brain Mets or extensive metastases of tumors um can be of no clear benefit. So I'm aware that this tutorial tends to cover as much anatomy and surgery as possible. So I wouldn't go into much depth regarding pathophysiology or clinical features. But lung cancer is defined as a malignant neoplasm of lung tissue and it can be split into lung metastases, which is quite common, non small cell lung cancer and small cell lung cancer. And they, they are main tests such as this is what you usually see under microscope. So, not small cell lung cancer is more common. And the top three types are adenocarcinoma which is not associated with smoking. Um, we have the squamous cell carcinomas, which is smoke, smoking associated, but has become less common since smoking has been banned in various and closed places. And large cell carcinoma, there are more, um, types of non smell cell lung cancer, but I won't go into much detail regarding that. Um, regarding the case of not of small cell lung cancer, um which is more uncommon, um, perhaps up to 15% of all lung cancers, it is more aggressive and surgery takes a backseat in the treatment of these. Um I've included a link to a scoring sheet, um, just to stage cancers um for your reference, but I wouldn't go into much detail regarding that. Now, um, general investigations for lung cancer include chest x-ray ct scan, um, bronchoscopy to take biopsies where a tube is passed down. Um, the bronchus and a needle can be used to take samples from lymph nodes or the actual tumor itself if it's invading. Um, the bronchus and pet scan where radioactive tracers introduced into the body and lights up in response to radiation which is picked up on the scanning machine. Um, treatment usually varies but for smaller tumors, a combination of surgery, radiotherapy and chemo can be effective. But today we'll just be focusing on the surgical aspect. So these two scans are not from the same person, but both of them have a tumor in the right lobe of their lung. And you can see through the images here now, for some relevant anatomy um regarding the lobes of the lung. So the left lung has um oh, I'm seeing something. Yes. Um You guys will get access to the slides. But yeah, um the left lung has two lobes and the right lung has three lobes. Usually a main bronchus leads to each lobe and these lobes are divided with fissures. So there are two fissures on the right lung simply because there are three lobes on. Um there are three lobes in the right lung. So that's the horizontal, which is the one superior between the superior and middle lobe. And that's oblique fissure between the middle and inferior lobe. Um It, the left lung only has two lobes. Um It only has one oblique fissure that separates the superior and inferior lobe going into the media aspects of the lung as seen on the right side. Um We have the hilum of the lung where pulmonary arteries, veins and the bronchus runs into. So, within the hilum, there can be multiple lymph nodes and these chains of lymph nodes run from the bronchus and extend into the lung tissue itself. So there are intrapulmonary nodes as well. And I have a clearer picture um in the in the slides down uh further into this section. So we'll talk about them. Um Later on. So let me introduce you to the patient. We have missus resection who is a 68 year old female patient. She presents with one week history of coughing up blood and general fatigue. She is usually well and has hypertension and has a normal F EV one. She's a retired accountant, um who uh she's a laundry surgeon. It's a running joke and um a small girl with a 50 pack year married and regarding her assessment, she's been through the works. She has had blood taken in the chest X ray CT scan, pet scan and bronchoscope. And she's diagnosed with non small cell lung cancer that a squamous cell carcinoma type. And there's one T one tumor in the right upper lobe of the lung and the treat after MDT discussion. Um the team has decided to put her through a vat lobectomy of the right upper lobe. So again, just a visceral content warning right here. Um Please feel free to, yeah. Uh Just take note that this is a trigger warning and we'll be going into some surgical images um in the next slide. So here we are, the team has confirmed the patient's identity and everyone's ready to go with the surgeons mark the incision sites, cleans the patient with some iodine prep and drips the patient. So missus section is shifted in the left lateral decubitus position with her right side facing up. So this is the right this is her right side that you're looking at. This is basically a fancy term for which someone is late on the left side. So the left lateral decubitus position. So while preparing to insert a guiding port in the seven length I CS um between the 7th and 8th rib, she's um the consultants asked you where the incision should be and you have two options. Um I'll get the pull up right now and I'll just leave you guys to answer the point right now. Um So option is immediately inferior to seventh R and option B is immediately superior to the eighth rib. Just give you a few seconds to answer the reports right? And I'll be closing the poll in five seconds. And yeah. So I think most of you have answered immediately superior to the eighth rib. So that's click on that and that is the correct answer. Um And this is because of the neurovascular bundle that runs um along the inferior border of each rib. So, making the incision above the rib will prevent injury to this neurovascular bundle. So I'll just pull up the explanation. So the neurovascular bundle provides innovation and vascular supply to the surrounding muscle and bone structures. And they are tucked away in the inferior aspect of the rib. So they supply mainly the intercostal muscles. Um the three layers of intercostal muscles in between the ribs. So with this bundle, they arranged in a vein, artery, nerve arrangement from the superior to inferior aspect. I like to remember this through the acronym van or VA N and this principle um of going immediately of making your incision immediately above. Um the rib stands for all procedures, for example, a chest drain or thoracostomy. Um There are collateral branches that run above um in the superior aspect of the rib, but these are less important and smaller. So you wouldn't cause as much damage to, to the main structures in this case. So the case carries on with all devices inserted into their guiding ports and incisions. So the anesthetist is then asked to deflate Mius section's right lung. You obtain a view of the anterior hilum looking in um from inferior to superior direction. So you're looking from um so the camera comes in from the seventh intercostal space and you're looking towards the apex of her lung. So the consultant pops you another question. This white band is, is a long nerve that comes from this hycal plexus. And do you have any idea what this could be? And you narrow it down to these two options? I will put the pole. Mhm. And I'll just need a few guys to answer quite an even split. So, so I will give it about 10 more seconds so we can get ok, definitive answer. Oops 5050 right? So I'll close the pole right now. See, I don't see any more answers coming in. So it's a 5050 I might just go for the for the fun option. Um, since we have not seen the wretch in this session yet. So, um, unfortunately, the long thoracic nerve is incorrect. Um, in this case, and the wretch um, makes a snarky comment and says you are doing orthopedics and a long thoracic nerve runs superficial to the rib cage and innervates the superficial muscles. So, um regarding the phrenic nerve, an easy way to remember, it would be 345 keeps the diaphragm alive and this nerve originates from subac plexus. Um Any injury to the nerve can cause diaphragmatic and therefore respiratory failure. And these nerves runs uh bilaterally across the two high limbs and close to the mediastinum and can be identified as white incompressible strips of tissue. Regarding the long thoracic nerve, these originate from um the brachial plexus and innervates more superficial muscles like the Cerra anterior and injury will cause wing or excessive protrusion of the scapula posteriorly. Um due to the unopposed motion of other muscles. In mis section's case, we didn't see that. So I wouldn't go into too much detail as we are doing orthopedics, but this is something u useful to know and the case progresses to the dissection of the hilar structure. So, um the consultant dissects a few of these dark grape like masses from the hilum and around the bronchus, you're not too sure but come up with two possibilities, tumor masses or lymph nodes and I'll just put the pole on the, you can answer. So I'll give it a few more seconds just to let the answer come. That's pretty definitive right now. Right? And I'll close the pole right now. I think most of your onset lymph nodes, which is correct. So, um the consultant agrees happily and they're removing all the lymph nodes to be sent to the lab for evaluation and examination for metastatic disease. So, in the context of the surgery, all associated lymph nodes in the upper lobe and peribronchial and hilar region are removed and examined for uh examined by the pathologist for disease. And this is, this is really important to gauge and to gauge the stage of the disease and this is done immediately during the surgery and the tumor itself will also be biopsied. Um If there is extensive disease, surgery is unlikely to help if cancer cells are detected in the lower lobes, um lymph nodes, the operation will have to progress to a pneumonectomy. So, um if we find, let's say disease here in missus suction's case, they'll have to progress to remove the entire lung um due to extensive disease. Um So just a quick open ended question, um, feel free to put it in in the chart if you're comfortable to do so. So the closer the lymph nodes are to the pulmonary vein or the artery, the more untreatable. Um the cancer is, does anyone know why? Um just put your messages on the chat and we will see metastasis through blood. Yep, that is correct. So, it's primarily due to vascular supply where if the tumor cells are already at that region, it's a, it's really assumed that they are highly invasive and half and half already metastasized or metastasized into the circulation of the great vessels and it can really go anywhere at this point. Um However, it's good news that there is no cancer cell, there are no cancer cells found in mius sections, lymph nodes. And this prompts, the consultants start dissecting the structures of the high lung through the lobe of the lung. So the consultant then proceeds to tell you that they need to speed things up and you breath a sigh of relief as, as you no longer expect questions and she walks you through the surgery. Um Firstly, the pulmonary vein to the lobe is dissected. Um and it's used and a tool which cleaves and staplers. Um The, the the vein is used and this exposes the pulmonary artery. Um and this artery is clipped in the same way. The bronchus is then identified because um it sits directly behind the pulmonary artery and it is also identified through the presence of cartilaginous rings and it's stale and it's stapled and cleaved with the same tool. Um using a diathermy, the lobe is then dissected through the use of um dissect it upwards and into a bag to prevent any contamination of cancer cells into a thorax and it is removed through one of the guiding ports. So as you see the red closing up, you get a surprise where he decides to ask you one last question where he inserts the chest drains. So where are the landmarks bordering the triangle of safety? I can name you too, but you have to. Yeah, but you have to name the last one. So he mentions the lateral border of the pectoralis major anteriorly in the lateral border of the Latissimus dorsi posteriorly, you remember your landmarks and can't seem to decide between the second I CS or the fifth I CS. Um I'll just put the poll on the chart for you guys too, the side and I'll give it a few seconds for answers it, right. I'll give it about 1020 more seconds. My answer is to just trickle, right. So I'll start close the pole. Now, I see that most of you have answered the fifth I CS. Oops, sorry. Yeah. So the consultant here says excellent stuff. Uh excellent job. He seem to know your stuff. Sorry. Yeah. So about the triangle safety. Um This is a place where one usually inserts a chest strain typically between the fourth or fifth intercostal space as seen here within the triangle. And there's three landmarks, the lateral aspect of the pectoral as major. Um The later aspect of the latissimus dorsi posteriorly and the fifth I CS from the nipple. Um and we use the mid axillary line as one of the really one of the marking points for that as well. So, insertion of chest drains at this site, um generally reduces injury to the chest wall tissues, muscles or any breast tissue. Um This is really just route knowledge, to be honest. So, um I'll just move on to some complications of a vats procedure. So, in general, they are quite non exhaustive. Um when one opens up the chest wall, they can cause increase in inflammation or bleeding. And this can result in blood or fluid collecting within the pleural space causing either pleural effusion if it's just fluid or hemothorax of its blood. So as the lung was deflated during the surgery as well, it may not inflate as well post surgery and this can cause ACSIS or lung collapse. Um As the guiding reports are inserted through the chest wall wall, we can get some stretching or compression of the neurovascular bundles and some intercostal nerve damage can occur as well. And it can result in some transient paralysis. Infection within the chest wall from the incision can cause um a nasty pneumonia as well. A nasty hospital quite pneumonia where bacteria can get through um into the uh get through in, into the incision and when the chest cavity. So, if it spreads within the chest cavity, you can get something called an empyema where you can get a massive collection of pus and infection within the chest. And this is a really nasty infection that needs to be washed out. Um again by the cardiothoracic surgeons. Some other complications can include simple normal site infection or incomplete excision of the diseased parts of the lung, requiring repeat surgery. So, Mius section is off to recovery and you turn up at 8 a.m. the next day. But due to some problems with X ray with, with the trace and limited theatric uh capacity or cardiothoracic theaters are unavailable for you to observe unfortunately, but um you get invited by a nice vascular consultant who catches you looking lost in the hallway. And um you are and you are invited to watch your surgery at 9 a.m. And that's the illusion of choice here because you hit the books and you learn more about vascular surgery who I'll let Julius cover. Perfect. Thank you very much for that introduction and good evening everyone. Thank you for your engagement so far. Uh While I get set up, you'll be happy to learn that we're running on time. And so I'll be sure not to cause any delays. Ok. And can everyone see those sides? Ok. Would you want to do that? Perfect. Ok. So let's begin with abdominal aortic aneurysm repair. So first off, let's just quickly run through some uh relevant anatomy. So the abdominal aorta begins at the T 12 level when it passes the um for the aortic of the diaphragm and then runs to L4 where it bifurcates into the common iliac. And along its course, it gives off nine branches. And then at the L4 level, uh we have to call the iliacs, which then give rise to the internal iliacs which then give rise to the external iliacs. And the internal iliacs supply the pelvis and the external iliacs give rise to the common femoral arteries. So I know this is a quite a horrible slide and, but I think it might be you, some of you might find it useful for your, for your revision just to cover some things quickly cause I don't want to, to look at it for, for too long. Um Things to know are um the fact that the renal arteries, um the right one will run posterior to the inferior vena cava, which sits quite snug on the, on the right side of the abdominal aorta. And the second thing I'd like to draw your attention to is the uh or the uh uh suprarenal arteries. Uh Only one of them is an independent artery of the abdominal aorta. That's the middle suprarenal. The other ones, as you can see, we have the superior suprarenal coming off the inferior remic and renal. Um But let's move on from the turbo slide. So looking at the, the bifurcation of the bone or the specific the femoral arteries, it's important to spend a minute on them uh because of their importance in other, in some key surgical procedures. So they originate from the external iliacs uh upon their passing under the inguinal ligament and then they give off rise to the deep femoral and the superficial femoral arteries. And let's just take a moment to look at the, at the femoral triangle which you can see here which consists uh or rather contains within it or free structures. Uh The femoral nerve artery and vein in that order from um natural to me. And the mid inguinal point is a key point which is halfway between the uh anti superior iliac spine and the pubic symphysis where the femoral artery is palpable. And that is a key site for many surgical procedures, but notably coronary angiograms. So, moving on um to our patient which we'll be concentrating on. So he's a 64 year old male. He's got a, an history of an incidental finding of a dilated abdominal aorta. And despite the fact that in the UK, we have a screening program for uh AAA S, um a substantial amount of them are still found incidentally and this is what we might see on an ultrasound with the still patent lumen surrounded by the thrombus, uh all within a clearly dilated uh aorta. And at the bottom here, we have to scan a ct scan of a of a measurement which says it's uh roughly six centimeters in diameter. And key information at this point is that it's infrarenal and we'll, we'll come back to when that's significant. Uh His past medical history is hypertension. Uh He's got, he's got some basic meds for that and he's a smoker. So both of these things, hypertension and smoking are key risk factors uh as we'll just learn. Um But, but first before we cover those ri risk factors, more details. Let's define some basic physiology specifically a true aneurysm versus a pseudoaneurysm. So, we have our three basic levels of of the arterial wall, uh intima media adventitia um from deep to superficial. So, and in the center here we see a true aneurysm and this bulging, this swelling is bounded by all three of those layers. And this is caused by a breakdown of the proteins. How that happens isn't fully understood. But we do know that things like atherosclerosis and hypertension and connective tissue disorders do contribute to this process. So our patient who's who's smoking and does have hypertension takes, takes up the majority of these boxes. Whereas a pseudoaneurysm which we see on the on the right here is bounded only by the tunic adventitia and that's caused by damage to the vessel wall. So that could be iatrogenic uh for example, during catheterization or it could be um due to the uh patient's habits such as IV drug use. Um and also in the case of acute pancreatitis, the hispanic artery um can form a pseudoaneurysm also for both true aneurysms and pseudoaneurysms. Um vasculitis is a risk factor as well. So, um, moving back to our patient, what can we do for him? Well, first of all, do we need to do anything for him? And the current guidance is that if it's a small aneurysm, um, so less than, um, 5.5 centimeters in diameter, then there's a few percent, uh, risk per annum of cardiovascular death. And the current guideline is that, that risk is, um, accepted in that we, the risk of an operation will be greater than, than 3%. So we only intervene if the aneurysm is greater than uh 5.5 centimeters and is asymptomatic because if it's symptomatic or is growing quite rapidly, then we want to intervene sooner rather than let it grow. But for our patient who's got a six centimeter diameter, we definitely want to do something for you. And there are two options. So you could either do an endovascular uh aneurysm repair where the graft is inserted uh via the femoral arteries. So again, that femoral triangle, very important for a lot of vascular and cardiac procedures or we could do open repair. Uh There are similar long term outcomes with both procedures. Um in a few um younger patients um are more likely to benefit from the er um but our patient, for the sake of this case, uh got an repair. So we begin here with the patient um already obviously on the G A, uh the patient will be supine uh for your orientation. The, the head will always be to the left and the feet to the right. And we begin with a midline laparotomy. So I have a first question for you. It's uh hopefully easy. 5050. So the consultant is uh di dissecting through uh fibrous midline structure that runs from the xiphoid to the pubic symphysis. And they turn to you and ask you what is the name of this connective tissue? OK. We have a clear winner so far, I'll just wait a little, a little longer for some more answers to come in. OK. And I think we'll move on to the answer and it is in the linear elbow, uh which is a kind of connective tissue in between the rectus abdominis muscles. And it's uh quite a common uh uh common surgical landmark used for approaches of uh laparotomies as there is only connective tissue there, it's quite safe to, to gain access. So, uh moving on, we have the bowels here exposed and immobilized. Um So the transverse colon would be retracted severely with the small bowel retracted to the patient's right. And this will expose the retroperitoneum. And next up, the uh Vrain asks you, what is the name of the structure that we are dividing here in order to mobilize the duodenum and better visualize the abdominal aorta. And um you got some ligaments from the back of your mind, ligament of traits, ligament, arteriosum or the inguinal ligament and it's very faintly highlighted here in blue, just waiting on a couple more answers to come through. Ok. And most of you got this one correct. Although there, that's, there is a bit of a split. Let's start with the least popular one. I think this one would have, uh, gotten or your, uh, the cheeky comment from the reg for sure. So it's not the inguinal ligament. So that's, that's what we covered before. And it's the aponeurosis of the external oblique muscle. And it's the superior boundary of that thermal triangle we we saw before and again, that would be the point of the decision for procedures requiring f access like endovascular repair, which is not what we're doing here, we're doing an open repair. Um But the, the sort of tricky answer cause it's got arteriosum in it, it might be related to, to vascular, which is what we're doing here. But no. So the ligament arteriosum is quite interesting. So it's, it's a vestigial structure. It's a remnant of the ductus arteriosus. So we can see it just, just here between the inferior aortic arch and the left p uh pulmonary artery. And, and again, I know this is uh come up but not, not, it's close relation to the left recurrent laryngeal nerve. Um So again, there's potential for that to, to get injured if we're working on this area. And why might we be working on this area? Well, it's most likely because of the uh patent ductus arteriosis and the ductus arteriosis functions as a shunt to bypass the fetal lungs. But then it's meant to close uh about a month or two after birth. And if there is uh if it's uh left un untreated and remains patent, then there's a risk of pulmonary hypertension. And um a key clinical sign is if you're ever auscultating a patent doctor's arteriosis, it would be like a constant um machinery murmur. So, moving on to the correct answer, which will get the consultant impressed is the ligament of trites and it is the suspensory muscle of the duodenum um which uh runs from diaphragm to the duodenal uh Jejunal flexure. It is uh classically the boundary point between upper and lower gi tracts um which is of course significant for uh gi and describing bleeds and whatnot. But in this case, we use it to get a better view of the aorta. And um here we can see entering the retroperitoneum by incising the posterior peral uh peritoneum. And we can just uh see the, the bulging of the aneurysm there. And now that the surgeons have gotten a better view. Uh So here's the aneurysm sac. And what I'm highlighting here is the surgeons uh visualizing the aortic aortic neck and dissecting it free to establish proximal control. And they do this by interlooping the um proximal aorta. And at the distal ends here, the surgeons then acquired distal control by uh interlooping the common iliacs. So we're just working our way from up to down to ensure we have control over the aneurysm. And finally the surgeons get control of this structure and I just want to open up the chat. Does anyone know what this could be? So this is the um posterior and this is towards the feet. We have the common iliacs here. That's the aneurysm. And does anyone know what this branch coming off? The aorta here would be, I'll just give you a, a second and chat to think. But it is quite tricky. Ok. That would be the I ma the inferior mesenteric artery, um, which would be, yeah. Oh, someone got it perfect. Um Well done. So, yes, that would be coming off here and it's, it's important that the uh surgeons get control of this uh uh branch and we'll come back to it, uh, cause it's quite important. So, um, next up, um, while we were establishing distal control here, uh, the consultant turns to you and asks what structures must we be careful of when acquiring distal control by looping, looping the common iliac arteries. Is it the ureters? Is it the common iliac vein or is it both? And most of you have got it. It's a nasty tricky question. It's, it's both. So I just like to draw to your attention to the fact that we have the ureter which passes superior to the artery and we have the vein which passes uh deep behind it. So it's just um obviously, this is, this is quite a major surgery and there is always um collateral structures to reach out for. But this area in particular, we have, we have those two structures which we definitely don't want to mess with. So, moving on, um at this stage, um the patient would have been heparinized and now we see circled uh clamps and actually the distal clamp would have been applied first to prevent any embolization, traveling from the, um from the proximal end down to the feet and causing any damage uh in the uh peripheries. So, next up, we see here that the um, aneurysm sac has already been opened. So the surgeons would first depressurize it by uh poking a needle through it and then uh draining some blood and then incise it uh properly. And then here I can tell you that even despite emptying the thrombus that was inside and draining any blood, uh, as you can see, you see, there is still blood within the sac and, but we have the ureter clamped. So, does anyone have any ideas why we're still getting bleeding within the aneurysm sac? Does anyone know where this blood can be coming from? Just put your ideas in the chat if you have any. So, um, it could be, um, well, I suppose um, both leak and collaterals are correct and, um, I won't be harsh and say that you're not wrong. But let me tell you exactly where it's leaking from from and which collaterals that is. So you, you're both right and it's the, the lumbar lumbar arteries. Um So we've got four pairs of these branching off the abdominal aorta and the reason why they back bleed or why they leak back into the aneurysmal sac despite it being clamped, uh at both ends is because the anastomose with um many ipsilateral arteries from the thoracic wall. Uh but to give you some background, so they supply the lumbar segments of the spinal cord, post the posterior abdominal wall and also the lumbar structures of the back. And again, each lumbar artery sends collaterals to anastos with other lumbar arteries one level below. So again, even though, because we've, even though despite the fact that we've clamped aorta approximately and distally, that's where the back bleed is coming from. It's from the lumbar lumbar arteries. Ok. So the next step, uh here we see that the graft has already been connected to the proximal aorta. Um Now, the order of steps in which the surgeons would do this is they would um fit the grasp and then they would uh for a very short period of time release this cramp to check the integrity of the suturing there of the anastomosis with the graft to make sure there's no no leaks. And that would also allow the graft to be fully pressurized which would allow it to be nicely measured and then allow it to be snug with the distal end here. And just before they connect the distal end as well, they flush it. So they, they let go of the, of the proximal clamp and then the that allows any debris or uh clots to be flushed out without again going to the extremities and causing havoc in the, in the legs and feet. Um So after that, just before closing the sac and uh the peritoneum over it, the surgeons take a Doppler probe and uh apply it to uh the um a colon. And I was wondering if anyone has any ideas, why do we do this? Why might we check or why might we Doppler the me entry before we close up? Um Why, why would be worried about the blood supply to this area after such an operation? Very good spot on? And I, like these said, uh S MA and I MA, um because this brings us to the um number one complication, even though it appears in only um 1 to 2% of cases, it's quite severe. So the colon relies on the I MA, but it also uh uh gets its supply from the um internal iliacs as well as the S MA like, like someone mentioned, uh but also the circumflex several vessels. So usually, um after we uh gain control of the I MA, it's just suture ligated. However, if we then check with the Doppler probe and um the colon isn't getting an adequate blood supply, then we can ligate the I MA onto the graft and ensure that it gets uh supply. And, and that way we avoid colonic ischemia. So that's why the probe is applied before everything is closed up because obviously, you don't want to go back and, and reopen after you discover that the patient's bowels are uh not getting a blood supply and also how it's the, the usefulness of, of, of uh memorizing parts of this graph as, as we can be aware of the potential side effects. And at the beginning, I not, um I noted that the aneurysm was infrarenal because obviously, if it, if we had to perform the repair at the renal level, we would have to think about the kidneys and the operation will become a lot more complicated and it would require a more careful approach. Um But that's quite specialist. So, moving on to other complications, uh M I uh is obviously uh a major risk of any aortic surgery and particularly due to the sudden hypo when unclamping. Um So, um as as we saw, there were multiple moments where the aorta or the graft to be unclamped and obviously, at the end of the operation will have to be unclamped. Um So those are the key moments um for the anesthetist and they need to be aware of that. Um Other early signs could be obviously bleeding with such a major operation, trash through if uh any emboli made it through uh to the lower extremities. And again, uh urinary damage, as you pointed out, that's a key structure that's quite close late signs. Um The graft could be infected and although our patient was uh picked up on a, on a scan and the operation was uh routine and scheduled. If uh the patient presents an emergency, particularly a ruptured abdominal uh aneurysm, then the mortality is still very high for this type of procedure. Now, although we haven't covered endovascular repair, um I find it quite interesting although it is quite advanced knowledge. So if we put in graphs through um the R approach, um then there's five different types of leaks that may occur. Um So type one would be if that we have leaks at um proximal distal attachment sites of the grafts. Uh Type two would be if we have flow from side branches to those um uh collaterals that we mentioned that can also happen in uh in vascular repair. Type three is a defect in the graft which causes leakiness and type four is um porosity within the graft wall that again could be due to the uh the graft being faulty and five is just unknown causes. So, despite uh what appeared to be like a successful operation, the uh aneurysm keeps growing and of course, we're going to keep an eye on these patients after the operation. So they are uh frequently recalled for ultrasound imaging to make sure that the the graft uh so the aneurysm is not growing anymore or in the case of open repair that the graft um is nice and uh stable and also not likely thing. So uh a picture summary for the end. So uh starting with the biggest picture, it it's complicated, but it's important to have an awareness of these 99 branches. Um It come in handy um for your surgical placement. And second, um this is obviously a big operation, but there are some collateral structures to keep in mind that can cause um complications. And thirdly, it's very important for this operation to keep the anesthetist aware of what's happening because as we mentioned, there can be severe drops in pressure with the cramping and clamping of the aorta. So communication and team play is key and that brings me to the last picture which is that these are very complex operations and complex cases that we have involvement from uh interventional radiology which often lead these operations, obviously vascular cardiology and radiologist. So it's, it's a full team approach and that brings me to the end of, of my bit. I will now let re can share the slides as we move on to the multiple choice questions. Thank you. So, so we have some Mc Qs for you to go through now. Perfect. So for this first one, we have a pseudoaneurysm is defined as a breach of the arterial wall resulting in an accumulation of blood between which two layers. Yeah, I think most people answering the perfect and that is the correct answer. And this question is quite tricky because it's a bit of a mouthful of all the different layers. But yes, it is B and um I've included some pictures here which I think might be helpful to, to visualize what's going on. So it's, it's blood that's entrapped by or contained by the only by the most external layered, the adventitia. And so it will be between the adventitia and tunica media. Um So yes, I think the, the pictures are quite helpful, at least for me to wrap them around, around this concert, wrap my brain around this concert. And here we have the second question. So at which vertebral level does die go to pass behind the diaphragm. I think most people it answered. Perfect. Yeah. And that is the correct answer. And just if you're interested, t four is the level which the uh aortic arch ends. And T 10 is the level of the esophageal here. This is where the esophagus passes through the neck. All right. So I'll move on to the next question. Great. So we've got some questions on cabbage. Um This question is asking you what vessel is used first line for grafts unless it's contraindicated. So we want the first line graft vessel. So we'll just wait a couple more seconds. Ok. We're getting, we're getting quite spread. Um So the correct answer is actually see the left internal mammary artery, the Lima, that's the one already connected to the off branch of the aorta. So you only need to connect the distal end after that for like a second graft, you can use this with the radial artery. Um The right internal mammary has been used and has been described in some like case reports. Um Apparently it's equally as useful, but it's not used as often because of its like perceived operative risks. It's all down to surgeon preference. But the general first line graft is the lemur so well done to those that got it and question two or question four rather. Um Which of the following is the most common postop complication uh for the cabbage surgeries. I'm getting some answers. That's good. Yeah, I've got a few who can probably move on. So most people answer d atrial fibrillation and that's absolutely correct. That's the most common complication. Hold on guys. All right. So I'll move on to the next question on vat. Uh 45 year old man is recovering after thoracic washout. He is immediately found to have poor respiratory effort on the right side, profound hypoxia, but no evidence of extensive hemorrhage and present heart sounds what is most likely to have caused this presentation. Just put your answers in the polls. All right, I'll give it five more seconds since we have forgot quite a few responses. No, I suppose. But, um, I think most of you answer for uh, the phrenic nerve, which is correct. Um, snipping, uh cardiothoracic surgery can sometimes cause damage to the phrenic nerve through um various forms of injury, like compression, stretching or sometimes outright transection of the nerve. Um, this person has respiratory um just on the right side and has no extensive hemorrhage and present heart sounds that's indicating possible damage of the nerve. I don't think that would be that profound hypoxia in the case of um damaged nerve bundles um in the intercostal nerves, uh intercostal th there wouldn't be that much of, of a profound hypoxia if only intercostal nerve bundles are damaged. So, moving on to the next question, this is a could be a bit long but which of the following patient with net S is eligible to undergo a va lobectomy procedure. Assuming all tumors are squamous cell carcinomas, feel free to put your answers in the chat. No, sorry. In the p sorry. This is the last question for this. See if we put you on something. OK, right now, close the pole in 10 seconds, right? So quite an even spread of answers. Um but D is correct and the explanation is as follows. So um the answer is d due to due to localized disease with little lymph node involvement, apart from the ones within the lung tissue, the intrapulmonary nodes. The patient has good respiratory fitness as well. So let's break down the other options. Option. A needs a pneumonectomy as the tumor has caused, has crossed the oblique fissure and the two lobes of the, of the left lung are affected. So, this patient requires a pneumonectomy. Instead of a simple lobectomy. Option B will receive little benefit as the tumors are too extensive to be resected with two with extensive lymph node involvement for option C brain mets are a contraindication for vets as there is no benefit or little benefit where cancer has metastases to the brain. At this point, we would consider p palliative care for the patient and option. You will not be eligible for surgery as she has two limited of a pulmonary reserve as her F EV one is less than two. So just to cap it all off. Um Here is just a quick summary of our cases. Um You guys can have a read as the slides will be available after the tutorial, but thanks so much for listening. Today, we have another session.