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Wonderful. Right. Well, um, hello everyone. Um I hope you've had a great day so far. Fantastic initiative by Aet to um put this together. Um I wish I'd had something like that. Uh, this when I was at your stage in my um medical career. So I hope you found it very helpful. Um I'm gonna talk to you today about a career in HPV surgery. Um I am a HPV surgeon at Royal Stoke Hospital in the West Midlands. Um I've been a consultant since July 2022 and I'm just gonna uh hopefully give you a whistle stop tour of the specialty. Uh what it entails some of the challenges and hopefully give you some, some uh advice and point you in the right direction. So, um HPV surgeons generally operate on um these organs. So liver pancreas, gallbladder, duodenum. Um and we do some small bowel surgery as well. We do some work in the retroperitoneum, um and we assist other uh um specialties in, in various operations which are involving these organs as well. Um, we uh do a number of bi procedures, liver procedures, pancreas procedures and then of course, depending on where you work and, and how your rota is structured. You may be involved in general surgery as well. So, looking at some of the, the bilary operations, um I do cholecystectomy, bile duct aspirations, um, extrahepatic bile duct resections and some bilary reconstructions and some surgeons HPV. Surgeons also do E US and E RCP. Um I currently, uh we don't work in a, um or do any liver resections in our center. Um, currently, uh but if you work in a section that, that is also a hepatic center, then you would go on to do um non liver resections or larger segmental resections and, and uh for right and left hemi hepatectomies and also hyal cholangiocarcinoma which involves um liver resection as well. Pancreas procedures. Um We do are um pylori preserving pancreatic iden or classical whipple procedures where you're removing part of the stomach. Um total pancreatectomy, depending on the pathology. You're operating on left sided pancreatectomy or distal pancreatectomies with or without splenectomy. Um I also do um isolated splenectomies in people with splenomegaly or other hematological conditions which require it. Of course, there are a number of operations on the pancreas for benign conditions like chronic pancreatitis or acute pancreatitis. So, pancreatic necrosectomy or, and some of the operations for chronic pancreatitis. And then when I'm on call, um for general surgery, emergency, general surgery, of course, emergency laparotomies um during sort of daylight hours. Uh I tend to um only be doing things like uh, small bowel resections for a, for adhesions or bowel obstruction or obstructed hernias. Um, and then upper gi emergency procedures, but overnight I cover colorectal as well. So I've done a few Hartman's procedures overnight and we do a lot of trauma surgery. We're a major trauma center at Stoke and we get a lot of trauma off at the M six and North Wales on the helicopter. This is the training pathway which has been touched on in the previous presentation. So, um core training and then you enter your specialty training and general surgery do ST three to ST six. And then the idea is that you sort of decide on some form of subspecialty pathway and all of those now involve emergency general surgery or virtually all of them apart from if you're going down the transplant route or oncoplastic breast, um or you select HPV and transplant as a suspect, um which is, which is what I did. And, and this has changed again slightly since it. Um But of course, you can select H PB and emergency general surgery as your subspecialty interest and what you're going to get your CT. In other considerations specifically for H PB are out of program periods which I'll touch on and post CT fellowships. So this is my sort of weekly uh life as a H PB surgeon Monday morning, we do a grand round of our patients. So I have a cancer clinic in the afternoon. Tuesdays are relatively flexible. I have a benign list one week in four, but most Tuesdays I do some medical teaching and some admin normally from home. Um, Wednesdays and Fridays are resection days and some weeks, like this week I operated on both Wednesday and Friday. We did a total pancreatectomy on Wednesday and I did a whipple yesterday and then some weeks, if there's, if there's a couple of us around, then one Wednesday or one Friday a week I won't be operating, but they're my main reception days. Thursday morning. I do a, um, sort of complex benign clinic in the morning and then we have our MDT in the afternoon. Uh, I'm on call for general surgery. Um, it's a one in 13 ROTA. But what that looks like is technically being on call, um, for a sort of seven day stretch every 6.5 weeks and for half of that week I'll be receiving new patients and for the latter half, I'll be post take and mopping up any operations that need doing or, uh, doing post take ward rounds, nights are relatively, relatively few and far between. Um, they're non resident. I do one night a month and roughly 2 to 3 weekends of nights per year. Um, this is my current activity over the past 2.5 years. Um, and, and as I'll touch on, um, and as a HPV surgeon you do get involved in other cases that you might not necessarily either have started or then patients might not be under your care. But, um, over that 2.5 year period, I've been involved with about 350 cases, obviously done a lot of lap Colli, I've done about 50 whipple, about 10 total pancreatectomies, about 10 distal pancreatin and a few other bits and Bobs. So, what are the positives of a career in HPV surgery? And of course, I'm going to be a bit biased here. But my feeling is that HPV surgeons generally and the people I've worked for and with, in the past, I've always seen them as the most complete general surgeon. If you know, general surgeons don't really exist anymore in the way that they used to where they did a bit of everything. But as a HPV surgeon, you are, you know, in solid organ surgery, bowel surgery and you're effectively a bit of a vascular surgeon as well. Uh You're comfortable working in places that other surgeons aren't um in the retroperitoneum in the sole, so called sort of surgical sole, um, behind the head of the pancreas, we, we often get called in to other theaters when things aren't going very well. Or certains have run into difficulty and, and need a hand, the anatomy of, of the sort of liver pancreas and gallbladder. And again, this is me just being biased because I, you know, I enjoy what I do, but I think the anatomy is just amazing. The conditions we operate on are really fascinating. And I think the indications for HPV surgery are really only going to increase, you know, bilary disease, gallstone disease. Um You know, assuming we can try and get a handle on getting the pancreas cancer diagnosed more early. Um earlier, you know, our, the number of patients we'll get to operate on will increase chemotherapies will become more effective. Um The number of indications for liver surgery are increasing as well. It's a fantastic community. Um We have great interactions with links with critical care, anesthesia, nurse specialists and other medical specialties. I actually for many years, as a med student wanted to do orthopedic surgery and when I started doing general surgery in particular HP surgery when I was in F two, I just felt that, you know, the links with teams really sold it for me and the fact that you just still, you know, orthopedics is a great specialty, but you are quite detached from medicine as a, as a, as a topic or a subject. Private work is feasible. Um Depends where you work in the country. Um There's not a huge amount of H PB private work in, in the West Midlands. There's some in Birmingham um in the big cities in London, of course, depending on how hard you want to work. Um and how often you want to see your family there is um you know, significant amounts of money that can be made in, in the larger cities. But it's all about work life balance. What are the challenges? Well, it's a long training program. Um, the surgery is challenging and very stressful. Um, I'm now on Ramipril because my BP was uh quite high when I started becoming a consultant. Um, they are long demanding cases, you know, between five and eight hours is not un er, unusual. Um, we do have a high degree of morbidity and mortality compared to other specialties. Um for example, if you, if you do benign work, um and you do lose patience and this is very distressing. Um And you don't always cure people. And our long term outcomes for HPV, malignancies are not that of other specialties like colorectal surgery, breast surgery. Um but as um Y said in her hit song, the only wears up and I'm hopeful that that improves over time, subspecialty options. Well, you can do liver and pancreas depending on where you're working, liver or pancreas. You know, in, in Liverpool, there are liver surgeons, there are pancreas surgeons. Similarly in Cardiff and Swansea, um uh you can do complex benign HPV, like the team in Derby and Burton who have, have an absolutely superb, minimally invasive, complex benign H PB service ALFA one and in Raba In Derby who are dear friends of mine. Um You could specialize in liver transplant, which I think there's a transplant session later on. I saw on the schedule and I'm sure they'll touch on that. I think that the number of consultants around the UK who are both combined in HPV and liver transplant has reduced over the years. And I think there is a move towards those specialties diverging. Um You could do HPV with organ retrieval again, depending on what center you work in, you can choose lap and robotic surgery as well as open surgery. And of course, the E RCP in the US is a really valuable skill to have if you're a HPV surgeon wearing the bottlenecks. Well, um an out of program period is probably essential if you want to be a, a resectional surgeon in a, in a big center. And that's either an MD or a phd, you're probably going to need to consider a post CCT fellowship again, in order to remain competitive, I have very strong feelings about post CT fellowships. I would love them not to be required for people coming through the system who've committed a huge number of years and sacrifices to, to go down the route of H BB. Um And um I'll touch on what I did and, and my pathway consultant jobs are often one in one out. So you are sometimes waiting on a retirement of, of, of someone in the center, but there is movement within the HPV community. And um uh and you know, you do have to serve your time a bit sometimes. Um and there are of course, always opportunities to, to train and work abroad. My training, I did eight years of med school. Um I went to Saint Andrews doing physiology and biochemistry, did two years of that PSE degree and then transferred into medicine further three years at ST Andrews and then three years down at Manchester and actually got moved to what was North Staff Hospital, which is where I'm now a consultant as a Manchester student at Kiel University. So I was eight years at med school, went into my foundation training, um two years of core training. And then I was fortunate enough to go straight into ST three, halfway through ST four, I came out and did a period of research at the University of Birmingham in the Queen Elizabeth Hospital. And that turned into a four year phd. And during that time, I did four years of organ retrieval on the organ retrieval rotor um and quite a bit of transplant work and um some elective HPV work as well, went back into training um did ST five to SD eight. So a total of 21 years after leaving school. So a long role. And then I actually t six months early in order to take up a local consultant HPV at Royal Stoke and then took up my substantive post um in the November almost two years ago. Exactly. Um So the future especially I think is strong the outcomes for HPV. Malignancies I think will only improve volume is likely to increase. There's 36 of us now in the UK, out of about 100 and 50 HPV consultants who are now on the robots E US is being increasingly used for some bir and pancreatic intervention and for tissue diagnosis. And of course, A I is just an absolute um you know, it's just going to explode. I think in your time in, in surgical training, what would I do differently? Well, I would not change my decision to pursue a career in H PB. I'm very fortunate to have found a career which I'm very passionate about and really enjoy. I think for me, it's the most fulfilling, exciting and challenging specialty there is. Um but looking back, I probably would have tried to get my endoscopy. I made a decision quite early not to try and get trained in endoscopy partly because I just don't know where I would have found the time. But I think looking back, I would have tried to make the time and made it a priority to try and get my jag accreditation so that I could have gone on to get trained in the US and E RCP because I think it's really valuable um not very good picture but just a real note on sort of EDI within HP BHP B has not always had the best reputation for equality and diversity and inclusion. I like to think that that's changing uh and we have a really diverse and very, very friendly community in the UK. And um this is a robotic meeting that took place in, in Coventry in 2022. So I think that is improving. Um This is just a quick uh video. This is a robotic gallbladder. These are the sorts of gallbladders. We, we end up getting involved with the more complex ones, really. Um Big ste and Hartmann's pouch, um, very difficult to dissect. Um, so made a decision to uh, open the gallbladder and drain it. She had an empyema. This lady, she was actually on my, this is one of my elective lists. One of my, this was my sixth robotic case. Um And despite this, she was quite well in herself, massive stone and Hartman's pouch, um, which we, which I removed and then, um, it was becoming clear that, uh, it, it was going to be very difficult for me to get my critical view of safety here. Um, started to do a bit of dissection, but her common hepatic duct was sort of coursing fairly close to Hartmann's pouch. And you can see on the ICG here, we give ICG induction. So after about 45 minutes or half an hour, it starts to get taken up into the bile. So you can see cystic duct clearly here, but I didn't know where the right hepatic duct was going or where the left was going up here. So I tried a little bit of dissection of the to get the posterior window. But, um, I decided in the end to, uh transect the gallbladder and um, do a sort of top down approach around down the back of cystic plate, a little bit of bleeding at the back there, which is not unusual, but with the robot, it's nice and easy to control these things. So, um, got a clip on that and then just continued to peel Hartmann's pouch um off the back here of common hepatic duct. This was sort of an evolving early Moritzi syndrome, but we were able to get it back and eventually get a clip on the cystic duct and do a total cholecystectomy. So, some recommended resources. Um We've got some great organizations in the UK. The first group I'd like to highlight to you is the RU group that's the training association for or, and they're an absolutely superb organization and great community. So, if you're interested in upper gi surgery, any specialty, please contact the RO group and join as a member. And we've got the G BHP B which is sort of a branch of ors which and we've also got Pancreatic Society of Great Britain and Ireland. And then you've got the European and African H PB Association and you've got the American HPV Association and their annual meeting is always in Miami in March and it's always a good meeting to target for abstracts if you can get some funding to go. Um I use X quite a lot. Um Previously Twitter, I'm also on linkedin. Um So please contact me if you want any advice, you can contact me on Twitter or find me on linkedin. I'd be more than welcome. More than happy to provide any advice I can and point you in the right direction. So engage with the department early in your career, maintain your log book, get involved with audit and straps case reports, collaborative research. We've got a good H PB collaborative research group, which is chaired by Danny Gomez at Nottingham. And you can email him at that email address and I'm sure he'd be happy for you to get involved in any way. Enjoy the experience, take every opportunity you can and look after yourself is um training has is stressful and you've got to enjoy life. So please take time for down time and you know, this is my wonderful support group and family, William and Beatrix and my wife, Susan. And I really wouldn't have been able to get to where I am now without their support and without Susan's support. And that's my mad dog Arlo who is always happy to see me. So, thank you very much. And if you have any questions, I'd be delighted to. Uh No, great. Thank you so much for presenting today. Taking the time again out of your busy schedule. No problem at all. Um There's no current questions at this moment in time. Right. But is there any significant kind of moments in your life that were, like, I know you mentioned earlier you wanted to do orthopedics and you saw the MDT work a bit in general surgery. Is there any particular favorite part of your job that makes you wake up? And you're like, you know what, I'm actually excited to go into work today. Yeah, I mean, I think it's, the operations are challenging and stressful, but they're incredibly rewarding. And um I think when you've, you've seen a patient who's, who's got a nasty malignancy. Um And, you know, you, you, you put them through what is a pretty morbid operation? I had a guy who came to clinic just last Thursday in his mid seventies and he presented with jaundice in April of this year. We did him as a fast track whipple procedure. He ended up having a relatively small. He was very lucky where this tumor was because it, it presented early and he had at one tumor, no nodes margins clear. And, you know, he, he came back to clinic on Thursday. He's absolutely fantastic. He's back to his effectively a normal life, even though he's had a whipple procedure. He's, um, you know, nothing's really changed for him and he'd written a book in that time actually, since he'd been there since he'd gone home and he actually brought a copy of his book with me as a gift. And it's just little moments like that, that sort of, it genuinely made me feel that surgery, um, any specialty you do, depending on the important thing is you find you're passionate about it and you enjoy it and because it's a long career consultancy is long and you've got to want to get up in the morning to go and do it. And I know that I often speak to medical students who, when I ask them what they want to do, they say I'm put off by surgery because of the length of the training and da da, da, da da. But, you know, I tried to, the first thing I did, I think when I embarked on that was, um, I didn't look at consultancy as the start of my job. And I think if you're constantly only assuming that you're becoming a surgeon, when you become a consultant, then it's absolutely draining and demoralizing because you think it's just so far away. So I think just look at your, anyone on here who is in surgical training, you are a surgeon and you are operating and, and you've started your career and the way I looked at it was just a bit of a promotion every year. Um So, uh yeah, it's, it, you, you've just got to find the, find the specialty that you're passionate about and that might be breast surgery. It might be orthopedics, it might be plastics. Um But as long as you've found that then you should be able to um uh get up in the morning and, and drag yourself into work. Yeah, definitely about enjoying the journey. Thank you very much for your time today. Uh We really appreciate it. Um We don't have any questions at this moment in time, but if you have to stick around for a couple of minutes just in case I post anything in the chat. Yeah, great.