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um, hi, everyone. Thanks for joining us. Uh, this evening, first to say a big thank you to Kirsty and the S C. T s student education team for putting together such a fantastic program this week. Um, part of this is to inspire you about considering cardiothoracic surgery as a career choice. And, um, I know how much you've all enjoyed the presentation so far this week. So just a big thank you to Kirsty for putting it all together, and that's been an amazing event. So congratulations to her and the team. As Kirsty said, I'm currently one of the cardiac surgeons here in Cambridge. Um, I also teach at the university and the and that to be department. And I had the honor of being the presence of the society for cardio thoracic surgery. So if there's anything any of you want to get involved with through Kirsty and the rest of the team, please get in contact with us because there's lots of different opportunities to to talk about today. My presentation will be about just the evolution of cardiothoracic surgery and in some ways, why you would want to consider cardiothoracic surgery as a career choice. So, um um, one way to sort of help inspire you through all that. I thought I talk you through my own evolution in cardiothoracic surgery, as you'll see at the top left when I was a six. Former at King Edward's school in age, Baston actually did a project on the history and development of heart surgery and heart transplantation. And I never actually at that stage expected to be here. Um, doing the wonderful job as a cardiac surgeon. I never expected that project to actually sort of hint at what my future career would be. But, um, it was something, obviously that was interesting to me. And it's something that I've evolved and taken forward. I did my surgical training, my basic surgical training in Oxford and where I was lucky to to work with Professor Wester be and they were putting in the artificial hearts or the Jarvik 2000, as you see at the top, right? And it was a really inspiring time to be involved in cardiothoracic surgery and for me, specifically cardiac surgery. Robin. Later, we'll talk a lot more about thoracic surgery. So the bulk of my talk will be about cardiac surgery and to see what. As you can see, the device that's in the top right, which is no bigger than a thumb, can be used to support patient's with heart failure with failing hearts, where they're hardly able to walk 10 or 15 yards. And by implanting these devices, it gave them a new lease of life. These were for patient's that were not eligible for cardiac transplantation. So a really exciting era for cardio thoracic surgery and for me, what inspired me to consider it as a career choice, and obviously, 25 years later, I'm I'm still in it. So following that, um, I did my higher surgical training in cardiothoracic surgery. And then I had the opportunity to go to Philadelphia on a advanced international fellowship, where I was lucky to do some more mechanical secretary support and also heart transplantation, the joys of flying around different states in America on a Lear jet. There's me with what looks like a cooler box. It's not full of beer. It's full of somebody's heart packed around with ice, and we harvested it in one state and then flew back to another to implant it in in a patient and, um, the concept of the project that I wrote as a 17 18 year old to then be doing that 20 years later, actually, taking out X, planting somebody's heart and then putting it in a in another patient was a really exciting moment for me and made me realize that actually, I had made a good career choice. Um, and then 10 years on, I'm in. I'm consultant in Royal Papworth Hospital in Cambridge. I'm still working there, Um, and as medicine evolves from having chosen surgeries a specialty, then cardiothoracic surgery as my subspecialty, then cardiac surgery. I now actually spend most of my time operating on just one valve, the mitral valve. So medicine has meant that we all evolved to become super specialists. And I'm sure that will happen to all of you in whichever branch of medicine or surgery that you choose. But for me, it's been a great evolution from, as I said, from surgery, cardiothoracic surgery, cardiac surgery, and now spending a lot of time on the valve at the back of the heart. And for me, the reason I chose mitral valve surgery was because of the ability to reconstruct the patient's own valve. For a lot of other valves, like the aortic valve, we just replace it with a new valve. But with the mitral valve, you have the ability to, um, to be able to use the patient's own tissues some new cords that you can see coming out of the picture, the white strings coming out to the right, put in a new ring and reshape the patient's own valve to be able to allow them to live without an artificial valve. And it's a really exciting branch of cardiac surgery and something that I really enjoy. So, um, that was my evolution in cardiac surgery just to talk to you a little bit about how cardiac surgery itself has progressed over the years and the big factors that have allowed us to develop our specialty and deliver the wonderful array of operations that we do to me. I've sort of summed this up in four different categories. The biggest change that has happened in the world of card it surgery was cardiopar me bypass The picture that you see on the top left is John Gibbon and his heart lung machine. The cardio probably bypass machine, which allows us to stop the heart so not functioning, allow us to drain all the blood from the heart. So we've got a still bloodless field to do what we need to do on the heart. But during that period, the rest of the body needs to get oxygenated blood, so it needs the function of the heart, the pumping function of the heart and the oxygenating function of the lungs. So the heart lung bypass machine does that while we arrest the heart and lungs. And it was the invention of John Gibbon and sort of evolution from that in the 19 fifties that has allowed the specialty of cardiac surgery to develop and do the whole array of surgical operations that are that that I mentioned. The second big evolution is there is imaging the change in, um, technology that allows us to understand what is going on in the human body and and in particular, the specialty that I'm dealing with the human heart, what the pathologies are and exactly where the lesions are, so that we can almost decide exactly the operation we're going to do before we even open up the patient's heart. So you will see. Uh, you know the C three D reconstruction of the CT scan of the aorta on the on the left of those imaging pictures, the top right is a three D echocardiographic representation of the mitral valve. So for me, I know exactly where I need to put a new gortex cord in this patient. And similarly, the two smaller picture of the bottom coronary angiography an MRI, help us understand, um, what is going on inside the heart and exactly what we need to do on them when we operate So that we can also explain to the patient's to give them consent about what their operation will be Because of this evolution in imaging technology. The next thing is our collaboration with our industry partners. So technology. I put one set of images on the bottom left which show the different types of aortic valves that we use. So from C, which is a ball and cage valve that was used in the 19 sixties and 19 seventies to the mechanical valves of a and B, the single tilting disc or the bileaflet valves to the tissue valves DNE that we use whether it's poor sign valves or bovine pericardium two F, which is a stentless valve, and to the more modern, uh, more recently developed valves, the transcatheter valves, which are delivered through the groin without even needing to stop the heart or open the chest. So it is our collaboration with industry that has allowed our specialty to evolve, and it will ensure that our specialty continues to evolve and that it's the collaboration with a different medical device. Companies that that that allows this to happen. And the fourth big thing I think that has allowed our specialty to evolve to the great progress that it has made is the pioneers that are attracted to cardiac surgery. Cardiac surgery attracts a certain type of person, but in particular it's the pioneers that have driven and changed our specialty to allow us to do the amazing operations that we do on patients' and change their life for the better. I put two examples of people here. One is Magdy Yakub on the right, who is probably the most famous British cardiac surgeon, and then the surgeon. On the left is Michael DeBakey, one of the most famous American cardiac surgeons, and both of them, as well as countless other cardiac surgeons, have allowed our specialty to evolve. And because of the excitement the cardiac surgery brings, it attracts these individuals that allows us to to do these amazing things on patients' hearts. Um, so, uh, Kirsty is put together this program about cardio thoracic surgery and as you'll hear from a number of the speakers over the earlier this week and even this later this evening, cardio thoracic surgery has a number of subspecialties. I myself perform adult cardiac surgery, which deals with acquired diseases of the heart so most commonly diseases of the coronary arteries or the or the valves. And I showed you some pictures of the mitral valve earlier, as well as operations on the great vessels, the aorta or the pulmonary arteries. Um, some of the cases that you'll hear from Robin later is talking about thoracic surgery, which mainly operates on the airway and lungs, but also on everything else within the thoracic cavity. That's not within the pericardium. So are there all other lesions, including of the thymus and tumor's in the in the posterior mediastinum. The third subspecialty of cardio of cardiothoracic surgery is congenital cardiac surgery. So, um, diseases that Children are born with and have to be operated on at an earlier stage than that that we deal with in an adult cardiac surgery. And for those of you bright idols spot the patient with the the image that shows transposition of the great arteries, where the pulmonary artery in the proximal aorta have been swapped across. So in this patient they'll get blue blood through their circulation rather than oxygenated blood, which goes into the lungs. And that needs an operation at an early stage to make sure the child survives. And then the fourth subspecialty on the bottom right is transplantation and the M. C s, which is mechanical circulatory support. So different devices to help patient with heart failure or transplantation to help those patients with heart failure. The transplant surgeons also deal with lung failure, so also do lung transplantation. So these are the four main subspecialties that cardiothoracic surgery has to offer, and they're all exciting in their own way and offer different opportunities and different pathologies and different operations in different ways of operating so really exciting, uh, set of subspecialties to deal with. So I've talked a little bit about the history of cardiothoracic surgery. These are some of the new things that are going on in cardiothoracic surgery. We talked about technology earlier. These are some of the newer valves that are coming in the future, this valves so we can deploy these valves, which uses similar technology to what's put in the transcatheter world. But we do these during the open operations. So and these are just one of many examples of new technologies that's allowing us to do more operations or safer operations or operations quicker or without, with less impact on the patient's in. Uh, you know, uh, as an adjunct to all of this, we are finding different ways of doing the operations through smaller and smaller scars, either through minimally invasive surgery. Also with what is coming into cardiac surgery now a lot more robotic operations, I'm sure Robyn will talk to you about robotic thoracic surgery, which is a lot more commonplace. But in cardiac surgery, more and more units are developing this as a specialty, and for most of you who end up becoming cardiac surgeons that are on the presentation today, a lot of you will be delivering your cardiac surgical operations using a robot aligned with this, we're finding different ways of understanding what is going on in the heart so you'll see on the bottom left. Three D printing, which especially for congenital cardiac surgery, allows us to completely understand what is going on within the cardiac chambers and gives us a better understanding of what we need to do. Um, as I said in particularly congenital cardiac surgery, there are 100 different, uh, abnormalities that go on in the heart. And getting a better understanding of what we need to do to the patient comes with the different technologies such as three D printing and finally on the bottom right. We're developing new technologies on how we can preserve different organs, and here this is the heart, but also with the lungs so that we can expand the organ donor pools so we can expand the number of patient's that we can offer transplantation. Currently in in our unit, we do about 100 organ transplants, and with this new technology, we're able to to deliver the transplantation to a greater population by allowing us to preserve the organs for longer and therefore bring them from further a field and put them into more patient's. I'm sure a lot of you will know more about virtual reality, and, um, the different technologies that we have that will allow us to deliver our operation and manage our patient's in a much better way. So virtual reality can be used in the preoctive planning for an operation so we can get a greater three D understanding of what is going on with the patient. It can be used during the operation, either in as as virtual reality itself or an augmented fashion can be used as Telia virtual virtual medicine, where a surgeon can be in a different country and can help perform some of the operation with surgeons in the operating room. And it also can be used to help explain patient's as well as education, which we'll talk about in a minute. And this can be either as virtual reality itself augmented reality or mixed reality. Different modalities for us to help deliver our cardiac surgical operation in a better, safer, more controlled way. And as I said for a lot of you enter the field of cardiac surgery in the future, I'm sure a lot of you will be using this, um, in the future. And then the other big progression in all medicine, but in particular in cardiac surgery is artificial intelligence. We've already developed some of these different formats of art artificial intelligence into the way we deliver care for patient's. So things like machine learning in E c G echo CT scanning the computers eventually are better than our human interpretation of most of these scans. And there's been lots of studies that looked at it. When you've got experience imaging, radiologists imaging cardiologists are able to determine the lesion, the locality. The specificity and sensitivity of these computers will far outreach what the human mind can do. And this is about a lot of programming that is put in behind the scenes to allow these, um, computers to be able to help us deliver higher quality and safer surgery in the in the future artificial neural network. So using complex algorithms to determine what the safety and the outcome for a patient will be, We currently use risk assessment scores in cardiac surgery, but with newer computer technology is much more powerful than the risk assessment schools that we currently have, we will be able to predict the outcomes of patient's and therefore, hopefully prevent some of the complications that inevitably occur with all surgery and in particular, cardiac surgery. Natural language processing is another art form of artificial intelligence where their computers can understand things such as in an operation note and therefore be able to predict the likelihood of a complication. And they've done this with 100% sensitivity and bowel operations where they can predict whether the patient is going to get an anastomotic leak or not. And then finally, computer vision. So to be able to understand, to help us deliver our operation in a safer way, they've already been, um, robots. They've been able to perform simple suturing, um, techniques because of the learning that it is made. And over time, the complexity of the operations that robots will be able to do will outperform a lot of us, so they will still need surgical input. But it is, um, the use of these different technologies that will make our specialty a lot safer and a lot, uh, open to a lot wider population. This graph you may have already seen at the top explains the current pathway for those of you who choose to enter cardiothoracic surgery as a specialty. We used to have the bottom uncoupled training program, which was an eight year program, But we've recently moved to a seven year run through tray aiding program. So after going to medical school and completing your foundation years as a doctor, as a junior doctor, you will choose your specialty of choice. And if you choose cardiothoracic surgery, you'll do a seven year program and, at the end of it, become a consultant. Cardiothoracic surgery surgeon. The bottom graph shows you the different training courses that we at the Society for Cardio Thoracic Surgery in Great Britain, Ireland run for all nationally appointed trainees and what used to be the old eight year training program courses are now on the right. The seven year training program courses so that we at the society can ensure all trainees get a baseline knowledge of baseline of knowledge and skills because we have practical courses where we teach all the surgeons how to do the the whole array of cardiac and thoracic surgical operations. Um, I talked about this a little bit earlier about virtual reality in the operating room. I've, uh this is we're also trying to bring this into our educational training programs. I've had the opportunity actually to do It was not a cardiac operation, but I did a hip replacement, which is 20 years after I did one on a real patient in a virtual reality setting and the the haptic feedback and the the the ability to recreate the operation that you'll be doing in the operating room is phenomenal. And it is a true testament to how technologies evolved that we are able to. We will be able to train surgeons using computers and virtual reality without having to put them either using, um, uh, patient's, you know, learning on patient's or even some animal operations. This will be the education of the future. And so I sort of wanted to leave you with the thought that cardiothoracic surgery, despite what a lot of people talk about it is a really exciting career choice for a lot of you. And I'm sure Kirsty is present, uh, lecture series this week, and I hope mine and Robbins per presentations this evening will help inspire you to consider cardiothoracic surgery is a career choice. Please contact Kirsty all myself through the society if you're interested in the career, and we can help point you in the right direction. But please enjoy the rest of the presentation's this evening and the rest of the week, and we look forward to welcome you into cardio thoracic surgery as a career choice for the future. Thank you again, Kirsty. Thank you, Mr. Uh, Johnny, do you have time? There's a few questions in the chat. I think people are amazed by the thought of robotic surgery and all of those kind of things. Um, do you have time for a couple of questions before we hand over to Robin? Of course, if it's not impending on Robyn's time, Um, I think we've got five minutes. Is that OK? Yes, certainly. Um, so lots of people have questions about the logistics of how you use a robot in surgery and, essentially, how much control the surgeon has and what the robot just does itself. So hopefully we can debunk a few myths about that. Yeah, certainly. So often you have a console surgeon who operates, um at it with a three D vision and with two using both their hands. And it gives the surgeon a lot more angle or freedom of move movement of their joints. And you would actually in a real operation. The computers are. The robots are designed such that you get 360 degrees freedom, freedom of movement. So that's where the operating surgeon sits. There have been some operations where the operating surgeon isn't even in the operating room, but for the majority of cardiac. And, as I said, Robin will be able to tell you more about this. Also in the thoracic world, most of the surgeons sit at a console in the operating room. You then have a bedside surgeon, which is often a trainee surgeon or a a surgical care practitioner that is sitting there is there next to the patient where most surgeons would traditionally stand. And that is where the robot is. So they will help sometimes change some of the arms on the robot or help guide. If there's any conflict to the robot arms, help make sure that the robot is functioning the way it should do. But there's a lot of training that has to go on before you become a robotic, cardiac or thoracic surgeon to ensure that you are able to operate that machine safely within the context of the thoracic cavity or the pericardium. But it it is truly. When I did my fellowship in America, we did some of the operations using the robot. It is a truly amazing thing to watch, and I'm sure all of you are on the call today. Do a lot more video games than I did as a child, and your ability to translate that from your spatial awareness or spatial orientation into what you're doing in the operating field is just an amazing concept. I I found when I watched it for the first time. And then one more question, if that's okay, I think, um, also about what happens if if things go wrong or if the there's something happens with the robot that no one could have predicted, how how do you deal with that situation? So we've luckily had this evolution from minimally invasive surgery where things don't in all surgery. Don't always go. Go in, you know, according to plan, and you sort of have to have your own Plan B so you have to know that you can control, for example, bleeding until you're able to open the chest in a different way. So sometimes, say, for a mitral valve operation, you're not always able to do it through the small incision. But you have to understand what you'll need to do to stop that operation and then open the the chest either through the sternotomy from the front or open the thoracotomy a bit wider so you can get access to the heart. So I think it's about having planning, um, to understand what the potential complications are so that you can deal with it. I'm just gonna quickly answer one question I saw that came through on it. The uncoupled training, um, was our standard way of delivering training until about maybe 56 years ago, Um, and then we moved to what would potentially be the run through training, but with some people going through the uncoupled training. But as of last year, we have now stopped the uncoupled training, and all the people who apply for cardio thoracic training will start at ST one. We've recently introduced something for thoracic training at a later stage, but the majority of people who enter cardiothoracic training will go through the run through training, which is a seven year training program. Sorry, I lied. One final question, which was posted twice, and I think this person is really keen for an answer is about has three D printing? I know you mentioned that one of your slides ever been used to replicate functioning heart. And if so, how long has it kind of lived for? Um, I don't imagine they've ever been put in humans, but I I could be wrong. I don't believe that has happened. There is technology that is trying to use stem cells and scaffolding technology where you can use the patient's own cells to regenerate different parts of the heart. But I do not believe a three D printed heart has been used and implanted and has functioned, and the patient has survived. Thank you. OK, so I'm we'll pass over to Mr Wilson. Thank you. Thanks, Kirsty. Um, that's very kind. Well, how do you follow that? You got to follow your own presidente after a talk, which is always rather daunting. Um, I would echo his thoughts, though, and say thank you very much to Kirsty, Not only for the invitation, but for setting up these fantastic programs, which I'm very jealous of, as I got nothing of the sort, Uh, when I was looking at medicine in school. So congratulations to her and the society. Now, I will try and share my slides, um, or my screen. Mhm. Uh, if it comes out, Kirsty, you'll tell me off. If it doesn't appear, please. Um, so we can see medal at the moment. I can't see your presentation. Okay, apologies. I'm looking at it, but you're not. Not okay. He's popped up now. Hopefully, yeah. Um, if you just present your slide show now, it would be right. I've had a bit of a lag on it, because that is filling my screen. Does that work with you goes, it might just be a slight lag. Um, we still see with the slides down the side, but I think that should be fine. Uh, the spontaneity apologize. That's all right. Have to go. Well, I will go back to right. They're still there. It's just your front camera at the moment. Hmm. Yeah, we tried just dishonor, didn't you? Pdf helped. If that's any use? Uh huh. And the weather? Has it appeared now? Oh, yeah. There we go. Fantastic. Sorry. Thank you, everyone. So great. Hopefully you consider, So I can't see you, but I will try and get around that. Good. So thank you for your time. As I said, I'm local yourself. And plastic surgery at George is in London. I've been there for the last six months or so. Um, and I thought I'd just start by telling a little bit about me and how I got to where I am. Um I like you did, uh, went to school and got some a levels. I'm sure not as many as you guys will have now. And, uh, and originally wanted to go to medicine, but, uh, get the grades I wanted. So I went off to university because I was very keen to, uh, to, uh, to do that. So I went as, uh, Southampton. I did a B SC and biochemistry, and I actually worked for you in the middle of it. Um, because I wasn't quite sure what I wanted to do. Um, but I was very clear to me that I actually wanted to come back to medicine, and I applied in my final year. And again, things are never quite as smooth as you would like. And I went through the clearing process but did eventually get a face, which was great. And then I went off to Bristol, Uh, and then did the, uh, the medicine course there. So you don't have to be Well, you probably do now, but you didn't have to be when I was, uh, I was coming out of school if you didn't have to be a a three a student. But I suspect now, unfortunately, the grades are a lot higher than than than I needed. Why? Why? Thoracic surgery as opposed to anything else. I guess as time goes on and you go through medical school, you start to make decisions broadly speaking between medicine, surgery, psychiatry or general practice or suddenly were when I did it, Um, and it was very clear to me that I was sort of very practical, hands on the kind of person, like doing things and getting an immediate result, which is what surgeons do. I couldn't give people tablets for three months and then see if there was an effect. Uh, later on, I needed to do stuff there and then and you can see the result myself. And I think, um, as it's been alluded to, you get inspiration from people that you meet along the way, and I was lucky enough to work any for a two or three very key people who inspired me. Um, and that's a bit of a cliche that those mentors are so important, um, to help get your career off the ground. And as time went on, it became very clear that thoracic surgery had a wide variety of different angles and different facets a bit like rains talked about the facets of cardiac surgery and also, similarly lots to do in thoracic surgery, which will cover in a bit. And I'll highlight some of them. And I think that variety is the last thoracic surgery, the last real general surgical specialty where a lot of surgical specialties have got smaller and smaller and thoracic surgery has remained quite wide. I think also you can't work in any medical profession without being involved in a team or many teams, and I think that also helps drive before and being part of the team's very rewarding. It can be challenging, but it can be very rewarding, and that also appealed. But just because you're a surgeon doesn't mean that you are the top of the pyramid and you are a cog, and it can be a very small cog. It might be a very vital cog for the patient needing an operation, But I've just as I thought about this talk today for that. All the people that I come across with day to day, and I'm sure I'm afraid I've forgotten half of them of all the people that you have to, uh, get on board with get onside with and work with in your day to day job. So you know all the people who don't think about so important to the running of your service. Um, but as I put colleagues at the bottom twice, it's actually very, very important that you find good collaborative colleagues that you can work well with. So my path is outlined below. I did medical school, and then I did the foundations. Years one and two, which I think are still, uh, will still still be what you have to do. Um, they were pretty originally called P R H O and S h o years when I did them, but, uh, foundation years and then I did a sort of old star. I said, Joe, job for a year where I wasn't sure what I wanted to do. And this time and time. And as I've said before, you get inspired by the people that you need to on the way and you cross off the specialties that you don't want to do and you can end up where you where you're aiming and then did a clinical fellow registrar job. I did a bit of research and then I got my national training number, which I did for six years and then after the completion of training, Uh, I've been a local muscle now since April 2021 in a couple of units, so you can see that it's a It's the quite a long path. And most surgical specialties are like that. And I think once you start and embark on this exciting career, then you've got to You can sub specialize in the way you feel, and I think I can skip most of the slide as we've done it before, but essentially cardiac surgery is the heart. The aorta and the major branches of this, uh, the Communist operations are replacing Navid arteries, valves and the, uh, the larger arteries as they leave the heart. Thoracic surgery, consequently, is everything in the chest, really, except for the heart and the esophagus. So it's the lungs, airway, chest wall, soft tissues, diaphragm. Uh, it offers such a wide variety of options. There are some gray areas and crossovers between other specialties. For example, orthopedics with the upper limbs clavicles off in the fight about who's doing what to to when, when there's problems with that. And then there's the head and neck crew as the, uh, for the thoracic outlet below below us, as it were below the diagram. Uh, the general surgeries have their domain. Well, I did want to just highlight before you moved on with the history, and you can see the thoracic surgery is a much older specialty, beginning in the late 18 hundreds, with the first surgery for tuberculosis clearing the chest of infection. Um, it's really the first board of corn. And then there's the developments went on with anesthesia in particular. So we've gotten on all the way through too much more modern days whereby we can isolate one lung from the other, uh, and then perform, uh, an operation on one side while keeping the patient alive with with the other lung and cardiac surgery and comparisons. We talked about it as much younger specialty because it was really the invention of the cardiopulmonary bypass machine, heart, lung machine, or CBP in the in the 19 fifties. Um, that permitted them to go on to perform the fantastic operations they do today. So I've put together a few of the things that give thoracic surgery some of its variety. I make no bones about being a surgeon, so there'll be some glory pictures coming up, I'm afraid. And the and the video at the end. Um, but I just want to highlight some of the areas in the talk today to show you what the breadth of what we do for this end of bronchial airway intervention work on the diaphragm, the airway, The work might be cancer. It might be infection. Um, and it's such a wide drive to keep you interested in keep every day at very different from the last. So I wanted to just tell you a little little bit about in the bronchial work. So, um, there's looking down the airway with the camera and this is obviously introduced with a rigid broncos, Uh, bronchoscope, which is, uh, put through the mouth through the larynx and down into the trachea with the patient passed the sleep. However, it won't surprise you to know that before the invention of good quality anesthesia, this was done with the patient awake. And we can use this for diagnosing things, uh, taking biopsies, two examples. And then there's the therapy we can offer. So the removing things that shouldn't be there overgrowth of tumor's stenting of the airway to opening up as the bottom right picture just to try and give a good passage of airway Good passage of air I/O. The patient to breathe better. Yeah, the diaphragm, obviously the main breathing muscle. Um, there can be many different pathologies here, but often they can be malignant and the tumor's arise employee, uh, brilliantly tumors arise with the diaphragm. We might need to operate on that, and then it's a collaborative procedure. Often, uh, conducted uh, with our general surgical colleagues as it has. Sometimes these, uh, abnormalities are better approach from the bottom. Or are they under side through the through the abdominal cavity. And sometimes it's best approach from above, uh, through the chest. And that's often why having a good general surgery of colleague is so important. But Airways, they maybe, uh, in the bronchial, as we've discussed so camera down the airway and intervention that way. But often, uh, that's not possible. And there's a select number of patients that need surgery on the airway itself. Um, and obviously, if you disconnect the airway, as in the pictures of the bottom right, you need to be able to keep the patient alive by ventilating them while you're operating. That's where your anesthetic colleagues yourself have that extremely good relationship so that you can take control of the airway, uh, and manage that, which is obviously what the anus this is used to. But you may not be quite so familiar with it, but obviously good, good communication is absolutely vital. That's slightly more con, uh, controversial topic at the moment is aesthetics. Um, there are often, uh, there is currently, uh, no NHS funding for this, uh, this kind of this kind of work. But I put it in here because obviously there are deformities of the chest wall. Um uh, some of these are extreme. And the correction, um, and the diagram of the the top rioters and unification defective excavatum really got a a depression of the sternum and the chest wall and that needs correcting by pushing it out from underneath. And that's done with the metal bar that's usually in place for 2 to 3 years. And the bottom right picture is the reduction with the patient of the pictures, Karen Autumn, which is a Tuesday of the chest, and that's operated on to put it into a more normal position. So the pleura, these are the lining of the chest wall on the inside and the lining of the lung itself. And there are many pathologies here of communist being simple infection, uh, and the collection of fluid in the chest, such as the middle chest X ray, which shows a large left sided pleural effusion. And, uh, again, we often, uh, quite to help expand the lung with operative, uh, operations, Whether they be minimally invasive or maximally invasive. Um, but again, some of these pathologies are malignant or cancerous, and again, uh, patient's need diagnoses. And we often use quite commonly perform operations to try and work out whether for the pathology is a malignant pathology or cancer or not so infection in the chest is called Empire Empyema, which is a collection of fluid and often debris. And as time goes on, the lung gets a cortex on it like the grind of an orange, and it becomes thickened and doesn't allow the lung to expand. And, uh, makes patient breathless because the liver is not functioning correctly. And traditionally we used to do what's called the thoracotomy. So the large incision that with the 24 centimeter mark, um, to help, uh, scoop out all the rubbish inside and then remove the lining the lining of the lungs without to expand. But as time has gone on, we've got more minimally invasive, and the picture on the far right, uh, shows three of the small cuts we use for video assisted thoracoscopic surgery or that surgery, Um, when it's appropriate. So another interesting facet of our job is chest walls. Um, um Um and they are usually a malignant growth, although not always, um, and they can arise from the muscle of the bone, uh, soft tissues. And, uh, we can perform quite extensive operations to remove these large, often quite large abnormalities. Again, we have good collaborative colleagues and the plastic surgery department because they often need to be involved to cover the defect left by the by the often large reception that we've had to perform. But what the majority of our work is, about 80% of it is lung because of, uh, primary functions charge here people with lung cancer which performed, which is the majority of our work. So the chest X ray in the middle of the shows a mass in the left chest. Traditionally, we've would perform a thoracotomy. The picture on the top right, um, to remove this. But as technology has advanced with our incision's have got smaller. So the picture on the bottom right is, uh, three port bats surgery. So video assisted. And then, as Mister McCIane has already said, um, the growth of robotic assisted so rats surgery has again lend itself to certain cases that the smaller cuts we can do. Obviously, the recovery is quicker in in the right, in the correct selective patient. There's a picture at the end, which I hope will show what, uh, what the sort of robotic, um, theater or set up looks like There were some questions earlier, so hopefully the picture will answer that. There's a lot of work out we do for these patient's. They have CT scans and PET scans and then function tests, which will come on to, um, to ensure that these were selecting the right patient with early state lung cancer to operate on to try and cure. There's just a memory issue with with some, um, lung cancer is in the CT scan. The black and white pictures is used for anatomy to find out where it is, how large it is. And the pet scan, which is a functional scan, is there to look not just at the lesion itself, but also has it spread anywhere else. Are there any lymph nodes involved and then again, all to do with staging the disease correctly so that we offer operations to the right patient? As you can imagine, we're taking out pieces of lungs so we need to know what the pulmonary function tests are for the patient's before and after. And when I say after we work out how much lung we're taking away in this, uh, I'll show you the second that we use the rule of nineteen's, um so anyone good at 19 times table is, uh, obviously an advantage to be for a thoracic surgeon. And we use various lung function test to predict their postoperative PPO values to show that to, uh, ensure that we don't take out too much loving to make the patient significantly breathless. But for obvious reasons, if we're taking out some lung issue, then, uh, the patient will be more breathless than they are before before surgery. And that's the trade off. We have to work out, um, to offer them hopefully curative lung cancer surgery. So the picture just demonstrates what what we have. What how were built and how we put together. We've got to lungs. We've got five lobes, three on the right and two on the left. But actually, uh, in more detail again, we've we've got several segments per lobe unsurprising. This is what the rule of 19 comes into and we have 19 segments, uh, and therefore working out how much lung tissue we can remove safely. Um, it's part of the preoperative work out, and then, depending on the pathology, is it a simple slice of the lung or wedge resection, which is a non anatomical reception? Or is it an anatomical reception whereby we're taking out the other segment, or lobe, or a pneumonectomy either whole lung on one side? Um, and we do that in an anatomical way. The difference between the non anatomical anatomical reception is that an anatomical reflections dividing the blood vessels that go what the arteries that go to that part of the lung, the venous drainage from that part of the lung and obviously, airway to that part of the lungs as well. Whereas the non analytical wedge resection is simply a a sliver of lung tissue can be quite large, but it's not dissecting out. All those vessels individually have been dividing them, and these are some still shots before we get to the video of division of some of those structures. Uh, all I really wanted to illustrate here was the fact that we often use, um, staplers to uh, to divide these structures that leave three rows of staples inside the patient, three rows of staples on on the specimen, and then it divides in the middle to seal, whether it be a blood vessel or or a an airway, all the lung tissue itself if we're dividing off other parts. And if I move on to the video, I think we've come for a couple of minutes and this is just showing. Hopefully, this is playing. Um, uh, this is just showing some of the steps. It's a little speeded up, so the movement can be a little bit jerky, But what I'm all their paws at various points. This is just let you know what's going on is this. This is a left sided operation and there are two lobes here and upper and lower, and we're looking from the back of the patient. So the the the part of the lung that the finger is finding the lump in is the left lower lobe and the to the right. It would be the less oculogyric if I move this on. So this is how we dissect, and this is a kind of kind of picture you'll get when you're doing a video assisted, uh, operation. And what we're doing here is just dividing the lung, the fissure, the divide, the anatomical division between the upper and lower lobes, the upper lobe being on the right here and the lower lobe being on the left. And the white structure is coming into view as the coronary artery. And here we're just taking off the mayor's to safely divide one from the other. If I just pause the video there again, I beg your pardon. That's my castle. A large structure that came into view briefly was the was the aorta, which I'm just back. Probably a little bit. They're so that large tubular structure does a you bend as it comes out. The heart goes back down the chest and into the abdomen. Um, thank you. So once we've divided out the structures, you come down them safely. We can use the stapler. Two. The two divide structures. That's the bit of the lung fissure. It's divided the back, and these are the hand hand cranked as it's wobbling a little bit or they can be motorized. Now we're looking at getting the layers right off the artery to make it safe as possible. There's the good old question. Purses is to cut those, uh, sort of non vascular tissue. And this white structure that's coming into view is the pulmonary artery. So in the background, just there at the very top of the pitch, you can see the beating heart inside the pericardium, the top left of the picture again. Here we're just dissecting out all the layers with what's called peanuts. They're small goals, pieces of goals used to gently retract tissue. And this is now going around the artery. So these are This is a fats operation video. So this is one of your assistants using the camera to show the surgeon who's operating for using too long instruments, um, inside the chest and here we go. So we're going to divide part of the artery with the state color, and the aorta is getting in the way at the bottom of the picture. Uh, you go crank it shut and then pull it back, and then that will divide the tissue, and then you can see the sealed artery, and that's the other part of the arteries of the lower lobe. Again safely going around before the state that is applied. It might look like a very bloody operation, but I can say that actually, it's probably any sort of 20 mils of blood floating around at the moment. It always looks much more magnified. Uh, his coming through the front part of the fissure safely, now that the arteries divided and is out of the way. And again, you can see the heart beating way at the top of the screen, in the background. Inside the pericardium again, it's a different type of staple, but the same principle to put lines of staple sealing things on both sides before cutting in the middle. Let's see, I moved on now. Very so. The structures have now been divided, and this is now looking down at the diaphragm to the diaphragm is on the left of the picture, and the aorta is at the bottom of the pictures or six o'clock. And this is the vein that drains the lower lobe back to the heart. And again, this you stay cold. In the last structures we've already discussed, we divided the artery. Arterial supply divided the venous drainage. Now we're dividing the bonkers But first we clamp the bunker shut and check that the other part of the lung we're going to leave behind inflates. And then, once the last few bits of tissue have been divided, put inside the bag inside the chest, and then the Vegas retrieved through one of the ports. In this case, it's done to the picture. So I put the last slide. Um, is what's happening next, and there are 22 main main developments. Firstly, is the on the left. It's the or the application of technology in the form of robotic surgery. And although this is a picture from A from a company, it's sort of illustrates the point Mr More Johnny was making earlier. You've got the surgeon with his head in three D, Consul on the Left. Uh, he's operating away, and what it is is robotically assisted. So there are set of arms that you can see going down into the operating table and the patient, and then the surgeon's assistant with the back to us is at the table side. And there's another unit, which, on while pictures on the far right, which has a picture for the assistant and all the all the electronics, but you can see it's not in. The surgeon does all the operating and does all the movements. But the robot is a set of very exquisitely made arms with, uh, Mr Charlie would say it was fantastic movement, uh, almost risk or better than risk type quality whereby you can get all the way back on yourself. And you you're afforded fantastic vision because one of those arms has a has a exceptionally good camera on it. So if you get the quality of the picture is fantastic. So one of the next steps and thoracic surgery is how we're going to use this technology to the maximum benefit, which is very exciting. Uh, and then the other picture shows the other gods that's coming into into plastic surgery, which looks a bit dull, actually, isn't it because it's a scan er and what that's illustrating with the fact that none cancer screening, which is already piloted in several areas, this one being one of the first in Manchester is now hopefully being rolled out. We've been delayed by covid, but the advantage of screenings that will detect lesion's and advance, uh, potentially cancer at a much earlier stage and then offer more people hopefully, uh, radical treatment in the form of surgery. Or if not, then there are lots of other things that can be used radiotherapy, chemotherapy and immunotherapy For those, uh, for those cancers that are not amenable to surgery, I think I'll stop there, if that's okay, and I will stop share ing. Uh, thank you very much. Thank you. So we have a few more questions in the chat if you've got a couple of minutes to All right. Uh, mainly because my I'm not sure I know anything about the long term effects of a pneumonectomy. I was I think you might be able to help with that one. Sure. Uh, so, yeah, as you can imagine, you're effectively dividing your lung function in half. Um, and that's unfortunately what sometimes we need to do. So you obviously have to be quite fit to start with with good lung function, so that when you have it afterwards, um, you can still have a reasonable quality of life. It has its own specific set of problems, and dyspnea, or breathlessness afterwards is clearly one of one of them. Um, but you can quite happily function with one lung. Um, you may not be running your four minute mile or doing your, uh, 12th 100 m anymore, but it's perfectly possible to function on only one lung. Uh, and thankfully, we're doing less and less of them in terms of the number of these operations, because our techniques have got better in terms of minimizing the amount of, uh, lung parent time or or lung that needs to be removed. So there are several more complicated operations that we can do to try and preserve more lung, Um, and not performing pneumonectomy because it does carry such a potential, significant, significant morbidity with it. Thank you. And then the next question is about basically how the staples work. So do they stay in forever? And what happens if they fall out? Okay, so they do stay in forever. They're tiny, they're millimeters inside, so the larger ones are sort of 2 to 3 millimeters. Uh, and they are in graduated. So the line, the line of staples that is closest to the patient is smaller, and then they get bigger and bigger will look as you get to be outside Um, and of those three layers, they don't usually fall out. I think I'm sure somebody somewhere it's been a problem because that's in medicine. There's always, you know, someone's already always recorded one such event, but no 99.999% of them stay in, stay in forever and don't cause the problem. And I think probably the last question is one for both of you, if that's all right. Um, I guess it's what is the most exciting operation you seen or what is your favorite one to perform, which is probably quite a difficult question. Um, it'd be great to hear from you both. Robyn, you go first. I I love airway surgery. Um, I think that's my my thing. So I've been fortunate to see and do a couple. It's not very common a couple of airway procedures. So tricky receptions, uh, pretty exciting, because you need to have a very good plan with your any cyst about how you as a surgeon are in charge of the airway, which they don't like giving up. That's for obvious reasons that some some idiot surgeon look after the breathing tube and how to look after the lungs. But I think and having watched several, um, of those with a very, uh for the previous Presidente and was watched up to work for a typical and also seen one of the professors in France do it. I think that's, uh, that's the most exciting operation. And when you say exciting everyone you want boring, you want boring and no, no excitement, because that means obviously, things may not be going as planned. If you plan it properly and it goes smoothly, it's boring. But it's exciting if that makes any sense. I think I was very diplomatically answer, Johnny. I think I share some of your last comments. I think the question had two bits. It said exciting. And I think I alluded to actually some of the exciting operations that was involved with probably one of the It's like the first time you go skiing the first heart transplant I did. I didn't think I would ever forget. And even the prior to that when we put in that, uh, left ventricle assistant device, the artificial heart pumping artificial pump inside the ventricle, it's, uh, you know, especially at the stage that I was at was truly mind blowing. It's a crazy concept to think you can put in a you know, something that's big as a whatever double C battery or whatever those batteries are that you can put it inside the heart and it will do the pumping because the patient's got heart failure. But and then the last bit was the What's the favorite operation, I think, is probably what I do, which is why I've chosen to do that is reconstructed mitral valve surgery. Just the ability to recreate someone's own valve that is failing to fix it and it works again, is different. A lot of what we do in card it surgery otherwise, just to replace valves or replace tubes or put bypass tubes around the blockage. I think that is why I've chosen mitral valve surgery. But just to inspire you all, I think all branches, a cardiac and thoracic surgery is really exciting, and I would encourage you all to at least consider it as a career choice. I think that's a really nice note to end on. I think it's the thought that surgery, I guess in itself is a bit of an art and so we'll differ depending on which patient's you see. Um, and hopefully that's what we've shown this week is all the different aspects you can go into. Um, so I think probably will end there. I'm very conscious of time. I'm just going to put my final slide, um, for feedback, which I will stop going on about. Uh, So the question is there just now, um, it's the same one as every night. So if you've already got that, um, you can use the previous, uh, code and just put in a different lecture title. Um, I think based on some feedback that we've already had this week, I've changed the format of tomorrow night, and I'm hoping to do it as a bit of a C b L slash PBL based session. I know that a few of you are keen to do something like that. So it's going to be a bit of investigative work from from all of the audience. Uh um with a patient coming in with a problem that by the end of the night, hopefully we'll have solved and treated them and gotten better. Um, so if you're around tomorrow night, that's the plan for tomorrow. Um, and other than that, I think we'll let you go. Thank you very much for both of us speakers this evening. I hope you all really enjoyed it. And thanks again for all of your questions in the chat, because I think that helps make it really exciting. Um, so I'll let you all go. Thanks, Kirsty, for a fantastic program again. Thank you. Thanks, Kirsty. Well done. Thanks.