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Is there a mic anywhere or if it, if it works, if it doesn't matter if you can hear me. Hello? Are you? Ok. My voice is going a little bit. So by the end of it you might be craning your head. Oh, what are we doing now? Look at that. Stop that. But is it, is it, is it going to the four quarters of the UK? It is, and there are people out there. How many people have paid money? It's free, it's free. I wanted 10% of it. Ok. Yeah. So, yeah, we've got the Yes. Ok. So from the fetus all the way up. Um, and then I'm gonna sort of finish, which is with a, a topic, a context if you like, which will make you very appropriate. All right, let's start at the beginning of surgery. Obviously in days gone by the surgeon couldn't actually do a great deal. And one of the reasons was when you started to stab people with a knife, the patients ended up screaming and moving their limbs away from you. And this sort of is a very famous painting from Rembrandt. Uh, you all knew that of the anatomy lesson of Doctor Nicholas. Th and that's sort of all that kind of surgeons anatomists could really do. They had to have their, their patients really dead and not moving before they could do any serious dissection on them. Surgeons really, er, set bones and incised abscesses. So there's, there's doctor th and this is a very typical environment for the 18th, 17th century with all the medical students wearing nice roughs and having hipster beards and goatees and all the rest of it looking intently at the master, showing them how to dissect the flexor tendons of the uh the forearm. Probably it's still like that in Lincoln, you never know. So what happened to change things to make surgeons valued members of the community and able to do things well, sadly, it was anesthesia. These are the unloved people at the top of your patient who you disregard completely, but they make it all possible. And the advent of general anesthesia started on either side of the Atlantic William um 1842 key year in the development of surgery because uh William Tg Morton experimented with the use of ether, a volatile anesthetic agent and you inhaled it as a patient and you became insensible and therefore people could do things. And that famous event was someone to remove his a jaw tumor, which is, which is pretty hardcore surgery. So that was in Boston, not Lincolnshire, Boston, Massachusetts. It's the other famous Boston in the world and this was the kind of apparatus that was being used. So there's a glass, cylindrical glass uh body and you dripped your ether down here, gathered here became volatilized and the patient inhaled it on this side. Uh not bad over on our side of the Atlantic. 1846 Sir, James Young Simpson was credited with using chloroform, another volatile agent a little bit safer than that. Neither of them. Do you want to be smoking in the presence of? Because they all, they all explode but be that as it may, he experimented with use in not only general surgery but obstetrics as well. Very famously, he administered chloroform to Queen Victoria in 1853 to allow one of her many, many Children to be born and she was at a big fat, she clearly had a hard time previously and obviously James Young Simpson became sir James Young Simpson. So now after that 18 forties, 18 fifties, 18 sixties surgeons actually started to have the wherewithal to operate on, on patients. And the late 19th century is credited as one of the golden ages of abdominal surgery. Cos you could do things inside the abdomen. Um, so here we have 1889 again, a sort of er, painting typifying what was going on at the time. Uh This is an American artist actually and there's Doctor Adn doctor Agnew, er, working in Philadelphia and his team is doing the operation. Uh you'll notice. Uh, the senior registrar is actually doing the operation, which is a mastectomy and the lowest of the low the Houseman is doing the anesthesia. You can see there's a little cone and within that will be a cotton wool ball soaked in ether or chloroform or what have you keeping the patients still. You'll notice again, the crowds of onlookers, medical students all dressed up in that irony, all looking on and all male. Uh we talk about an operating theater still in the UK. This is what it's meant by. This is a theatrical performance. Uh The only women in the room actually are the patient and the matron looking on with that steely gaze that only matrons can develop. Um and things obviously are set to change in the next century. But nonetheless, all male essentially. Ok. So pediatric surgery developed from general surgery and it developed again on either side of the Atlantic. And in Boston, again, the less famous Boston Massachusetts, uh the chief of surgery was a guy called William Ladd and he was a general surgeon working in the Massachusetts General Hospital and also in the Boston Children's Hospital and he was uh converted to pediatric surgery um because of a big event at the time and that was the Halifax disaster. This is not Halifax Yorkshire. Um This is Halifax in Nova Scotia, Canada and 1917, everyone, even the Americans in 1917 were in the midst of the Great War. And in the Harbor of Halifax, uh, was a munition ship, um, and it went off, it exploded and it was supposed to have been the biggest nonnuclear explosion there had ever been. Consequently, the Harbor side was just, uh, just decimated many, many casualties, including many, many Children. And William Ladd, uh, was the American sort of, um, um, medical team which had been sent to try and do something for all these injured people. He was part of it. He led it and he was just appalled by the devastation that burns particularly had caused these Children. Therefore, he decided to devote his life to children's surgery. Gave up his other practice when he came back to Boston. So he's recognized as the father of American pediatric surgery. Our equivalent is a guy called Sir Dennis Brown. It was an Australian worked at Great Ormond Street now, Great Ormond Street at the time, it was a children's hospital. It had been in, in, um, er, going for about 4050 years or so. But what surgeons tended to do was have their main hospital as the a local hospital, Saint Mary's Hospital, University College and go to Gran or street to do their operating on Children. Uh, he decided to actually exclusively say malpractice is only Children, gave up all his attachments to the adults as well. So he is recognized as our grandfather on this side of the Atlantic. Ok. So what do we deal with, what are we, what are the kind of things that take up our time, take up our um surgical objectives? Well, as I say, we, we, we do have a practice in fetal surgery, very specialized, it has to be said, but fetal surgery is still now is now part of our repertoire. Um So we can actually repair diaphragmatic her, which is a hole in the diph, but I am gonna go into a bit more detail about that in a moment, antenatally. Um we deal with urethral valves, valves. These are only occur in male Children uh where there's a membranous occlusion to the outlet of the bladder. The bladder therefore gets big that back pressure uh is transmitted to the kidneys and that can cause kidney damage. So, if you can relieve to some extent that back pressure and maybe you can preserve some kind of kidney function and nowadays you can do that. So what happens is antenatally a a tube of needle is passed through the mother's abdominal wall, through the amniotic fluid into the baby's abdominal wall and through into the bladder. And then over the needle, a special plastic catheter with a little curly tail on both sides is left in draining the urine out into the amniotic fluid and the pressure goes down and to some extent they uh there is relief of pressure on the kidney and preservation of renal tissue. Such urethral valves, spina bifida. Almost certainly, you've heard of that. It is now possible to actually repair a spina bifida before they are actually born. Typically from about 28 weeks of gestation, 30 weeks of gestation. Remember you've got 40 weeks of your gestation available to you. So it's now possible to repair spina bifida, open max. Uh In order to try and preserve neurological function. We do that at University College Hospital. We've done it at King's College Hospital as well. A lot of the epitome of the general pediatric surgeon, however, is devoted to neonatal practice abdominal wall defects. There's an example of an abdominal wall defect. Do you know what anyone does anyone know what that's called this one? You're going to shout it uh, very good. Oh, sadly, it was the only male in the room. Oh my God. Ok. That is gastroschisis. That is gastroschisis full thickness abdominal wall defect. Always to the right of the insertion of the umbilicus, which is there and the bowel floats freely in the amniotic fluid which is not very healthy for the bowel baby are alright, but the bowel isn't. And it takes a long time for peristalsis to return very often how we can relatively straightforwardly get that bowel back in the abdomen. But it takes a long time and they're usually committed for parenteral nutrition for maybe four weeks, six weeks, sometimes two or three months as well. Gastro uh necrotizing enterocolitis. That's as the name suggests, necrosis, death, death of bowel actually but it's a particular disease of the intestines of the premature. So that's a baby that's all set up to have was having a general anesthetic, all set to have an abdominal operation and you can sort of appreciate it's a distended abdomen, but the color is clearly different. It's got a, a darkish sheen to it. And that's because the intestines have perforated, releasing its intestinal content throughout the peritoneal cavity. And that will have been due to necrotizing enterocolitis, esophageal atresia. I am going to talk a little bit more detail about later intestinal later. This is a beautiful illustration of intestinal atresia, atresia. Do you know what that means? Not odd word to use in everyday life. Hannah, mm. Not formed correctly. Yeah. A bit more specifically, there's a lot of things that are not formed correctly. Is it my purse? Yes. So it's absence of a lumen. The lumen disappears to some extent and we use that word in conjunction with a lot of tubular structures. So it's congenital. This is a gal atresia. So that's the proximal geum grossly dilated because there's an obstruction. There is you can't push anything through, but the muscle doesn't know that it's continually trying to push things through. So it gets bigger. This is the distal bowel. It looks like a string of sausages, doesn't it? So this is actually multiple atresias, the bits missing there and the rest of it actually does go on to colon, but it's very small, it's, er, unused and the surgical challenge is trying to join that bit with that small bit there. Ok. Um, gastroenteral interspinal surgery. This is more children's surgery, children's adolescent surgery. And again, there's a wide spectrum for this as well. So, appendicitis, well, you know, about appendicitis, some of you may actually have had the operation of appendicectomy. Can I ask how many, one person, two people is me as well? Ok. So actually 8 to 9% of people will have appendicitis in some way in their life. But as you've just proven, it might actually get, be getting less and less as time goes by appendicitis was a disease of the 20th century. Very, very common unheard of before that everyone got it in the 20th century. And obviously, nowadays, we're the only people that seemingly have it. Um But nonetheless, appendicitis still quite common in cer where I am Crohn's disease, osteoc colitis or inflammatory bowel diseases. We tend to do this in conjunction with our adult colleagues. They tend to be teenagers and they tend to have to have other surgeries as they go on in life. So we tend to do that in tandem intususception. That is the correct spelling strange disease to try and unravel. That was a problem. Um, intersection is where one bit of the bowel, this bit of the bowel goes into the next bit of the bowel. So the bowel itself is almost engulfing itself. It thinks it's as food bolus and is taken in on itself. It's peculiar in the sense that the, the peak age is something like 11 to 14 months of age. This is the time babies are now exploring, crawling around on the carpet, sticking things in their mouth. And that might be a natural reason for it. It's believed to be something to do with lymphoid hyperplasia in the distal ilium getting bigger. And that, that lymphoid hyperplasia is perceived as a bolus by the intestine, takes it onwards into su ok. Uh Some of us decide to be urology. They're happy with wet things. Uh urethral vs, I've already mentioned um testicles, testicles, you may or may not know develop on the uh retroperitoneum really inside the abdomen at the level of the kidneys and they have to go down to the scrotum. They tend to do that in the last 10 weeks of gestation. So there's about four or 5% of boys at the time of birth where it hasn't actually happened and they usually need surgery of some sort or another. So that's quite a common operation and orchidopexy that's done by um pediatric general surgeons and also pediatric urologists. P UJ, the pelvi ureteric junction is this bit of the of the kidney and ureter. And again, you can get AAA congenital stenosis there and that can cause dilatation hydro nephrosis um of the proximal urine. And also if it's left uh unrelieved, then that could also cause kidney damage. So P UJ obstruction, some of us are more interested in things that going above the diaphragm, not the heart. No one wants to go near the heart. Thank you very much. But we are interested in diseases of the lung. Um and more so nowadays, because we can diagnose a lot of lung disease, antenatally on the antenatal maternal ultrasound. So this is a great example of that. This is cystic lung disease, not cystic fibrosis, cystic lung disease. And this is a baby. Um, who we did diagnose antenatally, didn't do a great deal about it until the time of birth. Then it became evident that these multicystic masses, you can see even a fluid level in this particular baby and that will need to be taken out typically through open thoracotomy. So chest wall deformities. This is where you either get a, a funnel chest or a pectus excavatum either way. Um And some uh pediatric surgeons, I've taken an interest in that as well. Trauma surgery. Now, trauma itself in, in the UK has in the last 10 years or so has changed in how you manage it, in the sense that major trauma centers and T CS have evolved in big cities. I doubt if you've got a major trauma center in Lincoln, to be honest, they almost certainly will be one in Nottingham. Um And that, that's, that's where you have, that's where you want to go if you've got trauma uh because they've got a whole range of specialist interventional radiologists, things like that available to treat you. Uh But also it's not trauma, obviously, it's not just confined to adults, Children get trauma. Um So there's almost always in a major trauma center, specific pediatric surgeons that take an interest in trauma as well. And the main um sort of organs that are injured are the solid organs, the liver, the spleen and the kidneys tumor oncology, oncology is, is a relatively specialized branch of pediatric surgery. Um So we've developed if you like specific uh ways of managing these tumors and the tumors are usually unusual tumors. Uh So a tumor of the kidney congenital tumor of the kidney is called a nephroblastoma because those are the kind of cells that they are born with and then they proliferate neoplastically. Uh the liver, the equivalent in the liver would be called a hepatoblastoma. There's one in the Prus. What's that called? Yes, sir. Very good. She is destined to be a pediatric surgeon and this is an old one. Teratoma. Teratoma. Do you know what the word means? Teratoma? It's a Greek word. Any Greek people and they classically educated people. No terato means monster, monster. So this is an antenatal ultrasound. There's the baby's head, there's the baby's chest, that's the baby's abdomen. You can see the femur, you can see the tibia. What the hell is this thing here? What is that? Do you know what it is. It's teratoma, but it's called a sacrococcygeal teratoma. So, it's arising from primitive cells located within the coccyx. Actually, God alone knows why. Um And they proliferate in, in, in uterine life to form this big solid cystic tumor. Now, at birth, it looks horrible, which is obviously why it's named a monster. Uh But nonetheless, it's actually benign. So the cells, if you can excise it, then they should be fine. if you leave it six months, no real reason why you want to leave that thing. But if they're smaller, they can go on recognize. Um But within six months, they will also turn into malignant equivalence. So, teratoma, sacroco, teratoma. Ok. So for a young told you I was going to talk about that again. It is one of our um trademark operations if you like. So how might a baby with esophageal atresia present? You know what Atresia means? Because she told you uh re like a small, small, so all small babies have got esophageal. Why do you get your nourishment in what happens if you've got an Aries of your esophagus? What can't you do? You can't feed but no one's really feeding them in 60. Um Potentially that could be a little bit down the line for, for a reason because you can't swallow your saliva and you can aspirate. Correct. So you can't even swallow your own saliva. Ok? You clearly can't swallow if you're actually fed. Um, you won't be able to swallow that, that will all come up, but you can't even swallow your own saliva. Now, antenatally that they may present actually because normal babies swallow the amniotic fluid, shrink it down, all goes through. So that may cause what's called polyhydramnios, which is an accumulation of amniotic fluid. Remember, your amniotic fluid is derived from the baby urinating. So you're drinking your own urine effectively, don't go there. Uh So these babies from the time of their birth, you can recognize them because the, the saliva is just, they're described as mucousy babies. It comes up the nostrils, the mouth and a midwife, it's just to deliver, the baby should be recognizing and if that's the case, they should be trying to diagnose them. The typical way of diagnosing them is to try and pass a nasogastric tube. Now, sometimes that seems to go in and yet the baby's still mucousy. So you take an X ray such as this one that I prepared earlier. A and you can see this is a nasogastric tube, but it's curled upon itself which is why it appeared to have gone down. Um Normally it would stop, can't get it any further. What I've used, this is to illustrate the size of the proximal esophageal pouch. So it's from there we go, it's from there to there. That's big for esophagus, that's massive. Uh So it's not going to, so this is a baby with esophageal, a trees now, they come in sort of these two essential uh types. Uh The commonest are 80% of them are, this is a blind proximal pouch. There's our tracheal bronchus and the distal bit is actually connected abnormally with the tracheal. So this is called the tracheoesophageal fistula. So, an esophageal Aries and a tracheoesophageal fistula, oh which is fine. Uh This is uh the rest of them if you like, there's our proximal your pouch, but there's no connection. So this is the distal esophagus. Now, the, now for most of these babies, we can do a thoracotomy or some kind of other access, which I'll show you in a minute um and repetitive. But this one is a real problem because the gap is just too long. So we've gotta have different strategies for that. So typically for this kind, we close off the connection with the trachea and then we join the two ends together. And as I say, for most of them, we can do that at a single operation. Uh First one was done in the 19 forties by an American surgeon Cameron height. But even though he had a successful esophageal anastomosis, the kid still was in hospital for about a year before discharge. Nonetheless, uh we know from subsequent reports. Uh And if it were two thousands or so, uh the the child then became an adult and was in his forties, fifties when the last one came. So he, he didn't, he didn't mind spending a year in hospital. It has been said to anast the ends of an infant's esophagus. The surgeon must be as delicate and precise as a skilled watchmaker. No other operation offers a greater opportunity for pure technical artistry and that remains true today. Very you have to have pretty skillful surgical skill set to achieve that. Uh So why not make a difficult operation even more difficult by trying to do it thoracoscopically with instruments like this. These are narrow three millimeter instruments. So uh it can be done. And the guy that first did them, there was this guy um called, well, let's go, let's keep him anonymous at the moment. Um So he's a friend of mine from Colorado called Steve Rothenberg. I don't want to give him too much in Dora, but he did the first one in about the year 2001. And he lent me this video, not of that one but of another one. So let's see if it works. So this is operating uh with a camera through a small port inside the chest cavity without actually opening the chest cavity. So what you can see is this grasper here holding on the proximal esophageal pouch that's whitish. And what he's doing with the other side is you can see the coagulation uh and then he's sort of stripping off the tissues around it. He's mobilizing those. So we go on a little bit further once achieved mobilization. Then the next stage is really to again ligate that fistula thing and then turn your attention to the lower pouch, which is that bit and then start joining together with sutures. Now, actually, the first suture has already been placed. This is the second suture. Uh There is the proximal esophageal pouch and a disc has actually pass a nasal gastric. You can see it peeping there and that's gonna go across there into that part of the distal pouch. Once all these um, er, sutures have been er, inserted, as you can imagine, that is a little bit technically tricky to do. Er, so you have to actually tie a knot, he's trying to tie a knot um, inside this chest cavity, which is no bigger than a matchbox. So it does rely on the surgeon really knowing what they are doing and having mastery over all their instruments. So, as I say, this is an operation that makes a difficult operation even more difficult. Now, as I say, he did the 1st 1, 20 odd years ago, it's taken off some in some places but not all. So everyone had high hopes this would be the way the gold standard of repairing an esophageal atresia. But it is difficult and people have recognized that it might cause more complications and less complications. The only advantage is cosmetic. You don't get a scar on your chest. So a lot of people do not do it. I don't think they would do it at Nottingham, for instance. Um So there we go, esophagus now joined happily together. Ok. So let's uh, look at our gastroschisis correctly identified. Very good. And uh that also is a gastroschisis. What's the difference? Well, this is what we call a closed gastroschisis. Normally, the, the abdominal wall defect is open and the mid gut comes through it. Sometimes the actual defect is open, allowing the mid gut to go through it, but then it closes around the mid gut, cutting off, not only the bowel, but also its blood supply. So this is a baby and that doesn't look healthy. That black bit is dead bowel, that violent bit is almost dead bowel. So the only bits of bowel that are viable in this baby is the bits you can't see inside and there almost certainly will be a gal atresia in there where it comes to the actual abdominal wall ring, the defect where it's been pinched off. So these potentially, well, potentially they always have a short bowel and they may be on parenteral nutrition for a long time. So I'm gonna go through a story of one of our babies. So this is er, where you saw the external appearance, this is what the laparotomy looked like opening up. And here we've got a massive bit of bowel, but this is the J and it's grossly dilated. It really should not be that that long, but it only measures I think 20 centimeters. And normally your bowel length and a term, it should be approaching 250 centimeters. So, clearly, that baby has got a real problem on its hands. And what we sometimes need to do is a, uh, an operation to try and make the best of what they've got left as it's grossly dilated. It will never work as a functioning peristaltic tube. The peristaltic is to happen, the opposing sides of the bowel have to meet and then that drives things forward when it's too big, they just don't meet and nothing actually happens. So we've gotta do something to try and improve, er, the caliber of the bowel make it smaller so that it will function as a tube. So the operation we do is, um, er, named after this guy called Adrian Bianchi. He was in Manchester from Malta originally, but from Manchester and I worked for him during the late 19 eighties. So let's see if we can go through that. Now, it relies a, actually on an anatomical observation how you can do this. Uh, what you're trying to do is split the length of the bowel. Now, it's obvious you can split the anti mesenteric aspect cos you can see it just go across it but it's a bit more difficult to concede is splitting the mesenteric aspect. But you can, and the reason you can is because the Mesenteric blood supply to digestion comes up, but it doesn't immediately go straight into the bowel. It splits and one bit goes one way and when the other bit goes the other way, uh And therefore there is a triangle of dissection that you can do to free those blood vessels up without damaging them, er, allowing you to actually divide this mesenteric aspect of the bowel. So this is a model just to illustrate that concept. So we're splitting the anti mesenteric aspect of the bowel here. And now we're dissecting in that little triangle of dissection on the mesenteric aspect and then uh dividing them along and once you're finished, you've got two plates of perfectly vascularized small bowel, it's all small bowel uh in order to then join them together, tubularise them. And then the only real problem is determining which end of the bowel is anastomosed to the other side of the bar, which side of the bowel should you be going forward if I call this ABC and D, uh this is the top bit, which bit of bowel should you be joining together? ABC OD, ABC or D B and C, correct? That's gotta go that way. Yeah. Er, cos if you do it, the easy thing would be to do that way, but that would be there for antiperistaltic, which is not a good thing. So it's going to end up as some kind of spiral effective. So this is our baby. We're now five months of age. Uh And as I say we haven't got much bowel left. So we're dissecting in the anti mesenteric aspect. Uh This is the, we marked the mesenteric aspect to divide. We're dividing along, er, there and theres are perfectly viable but now completely split, proximal judgment and then we're tubularis. It, so there's a lot of suturing to do all the way along on either side and then we've got to join that bit to somewhere up there. Ok. So that's a, um, a bowel lengthening procedure. Diaphragmatic hernia, I mentioned that earlier on diaphragmatic hernia. Now that, that things on you've got a hole in the diaphragm going great. What's the problem with the diaphragmatic hernia? Something you're born with? But what's the problem? Oh, you know, the problem is that you get this antenatal movement of bowel from the abdomen to the chest. They usually left sided, usually left sided, occupies the space where the lung should be. So it inhibits the growth of lung. You'll see by how much in a moment on that side, it also shifts the mediastinum as well. And therefore it's got a high mortality, got a high mortality. Um, so there, we've got a very typical example of a baby just been born and, uh, we did know about it and this is actually a historical er slide. You'll see the reason for that in a moment. Um This is antenatally diagnosed. So the ultrasound can pick these up relatively straightforwardly. This was done in about 22 weeks of gestation. So normally there is a an anomaly scan about 20 weeks or so for all pregnancies in the UK. And you can diagnose these things at that stage. But in that era, nothing really could have been done. And the baby was born at King's at 38 weeks, gestation and uh delivered in on the intensive care unit. But despite all of that, all of the various things that we can throw at this baby, baby was hypoxic at birth and remained so until she died 23 hours later. And this is a post mortem specimen. Um And the pathologist has taken the chest wall off the front and it shows beautifully the pathology of a diaphragmatic hernia, left sided diaphragmatic hernia. So, what you've got is actually not only the, the uh the longer the bowel that's up, but also half the liver, half the live, there's the bowel. So all that left hemithorax is occupied by viscera that should be in the abdominal cavity. And if you look closely, you really can't see much evidence of lung. Where's the lung gone? Well, this is the lungs, the pathologist have taken, that's the larynx, that's the trachea, right bronchus, left bronchus. This is the normal lung on the right side which that baby is trying to survive on and it's tiny, it's tiny. The one on the left side is even more tinier. Uh they express things as weights. So your expected weight is 40 g, 13 plus two baby didn't stand a chance. Ok. So the question remains, should this not be your patient? These are Mr scans antenatally. So they show a fetus with a diaphragmatic hernia, with diaphragmatic hernia. Should you not be trying to do something at this stage when the baby doesn't have to breathe? Because the mother is doing all the breathing and oxygen exchanges for it to try and correct the whole in some way, allowing the lungs to restore normal growth. That's the idea. So, ok, that was first, er, enunciated as a strategy uh by this guy called Michael Harrison. Uh, and he um uh set up the fetal treatment center er in San Francisco in the 19 eighties. And his sole task, he gave up real pediatric surgery, devoted his life to fetuses and his task was really to try and investigate and do surgery in fetuses. And the idea is you do whatever surgical thing you usually second trimester and then the baby goes back in the, in the uterus, uh to await a normal delivery at some months later. Um, and in diaphragmatic terms, then he did try a series of fetal operations for diaphragmatic hernia stand repair the way we normally do it in neonatal surgery, which is to do a laparotomy, bring the bowel down, close the hole up clo and uh, well, leave the baby. Um, and he did a series of complete disaster, complete disaster babies babies, fetuses do not tolerate that amount of trauma during that and they almost always never survived after the operation or uh they delivered prematurely or something like that. So, we have to think a bit outside of the box for a solution. And the thing he came up with, er, was this thing that he termed plugging tracheal plugging plugs acronym, uh plug the lung until it grows. And it relies upon uh an observation that was made in, in clinical practice, there is a rare condition where you get atresia of the larynx. And if you get atresia in the larynx, you're born and your lungs are huge because the lungs throughout the intrusion in life produce fluid and that fluid, if it can't escape through the trachea builds up and the lungs become hypertrophy bigger than normal, they don't work as well. But nonetheless, he thought, well, could we not try and do that with babies with small lungs? So, uh they initiated a program of tracheal plugging and that seemed to be a, a good way of achieving what they wanted to do. And the first patient whose name we know Kristen um got a fetoscopic. So that's a telescope down into the amniotic cavity and uh they clipped the trachea so pretty gross way of achieving er tracheal occlusion. Um and the, the, the baby was born and they did then a, a standard repair of the diaphragmatic hernia and she has become an adult now. So, yeah, she having a problem now for one reason or another, however, they tried to do it subjected to a trial and it didn't, the trial didn't go too well in the sense that, um, those that had the plug had the same, er, survival as those they didn't offer it to, they couldn't select out the babies that really had a terrible outcome. So they tended to abandon it on America in America. Uh And we put, picked it up on this side of the Atlantic and we developed a procedure called fal fetal endoscopic tracheal occlusion using much more subtle ways of doing it. And the guy that invented, this was a guy called Jan Dere from Belgium and our chief of fetal medicine and kings called calliades. And what they were doing was a much more minimally invasive approach to try and achieve occlusion of the uh minimally invasive using very small ports, the Americans who use fairly big ports. And the idea was to place an obstructive balloon in the trick here rather than actually clipping it. So what's done? Um is this is this is fetoscopy and the operator puts the tip of the ethos cope into the mouth, advances a catheter through the pharynx into the larynx. Here it is in the larynx and then a special tube with a balloon on the inflated balloon is passed through a working channel and then inflated and then left detached and that achieves occlusion of the trachea and then everything is removed. This is done at about 28 weeks or so. And then typically, obviously, we've got a problem with a balloon in the trachea. How do you, how do you deliver a baby with a balloon in the trick? Well, that was a problem in the early days. Uh, because what you had to do was do what was called an exit procedure. You can't intubate these babies cos they've got a balloon in there to you. So you had to get, you had to actually deliver the baby but not cut the cord. So if you keep the placental circulation intact, you've got a baby that's, that's there and you can do whatever you want with for about 1520 minutes. Uh So what they, you then do is call in an ent surgeon to do uh put their own little telescope down and extract the balloon and then you can put your et tube in. But it's a big performance to exit procedures. So, what we now do is a second, either fetoscopy or even more simply just puncture the balloon from the outside. And therefore these babies are not born with an occluded trachea and they can be managed uh in a conventional way. So FTO these are the kind of instruments three millimeters that's really quite small, that's the balloon when it is inflated. And uh this is what it looks like. There's a little gold board, you can see this on an X ray. OK. I'm gonna show you this as a, as an example of uh trials and things like that and statistics. So we started our program in 2002. Um 1 of the first big centers to actually do it. And we were clear in that it was a, it is a great thing to do, but it had never been subjected to a trial, a randomized trial. Um And there's lots of European centers that did it. A few South American Centers and they were pushed into doing a trial as it happened, a randomized trial and the results were, were issued a couple of years ago in the New England Journal of Medicine. So this is, this is the schematic of what was was done. These are all severely um severe left with a predicted survival. 10% or so. Uh So what happened in the o group while they did survive it 40%? And if they didn't have veto, they uh only 50% survive. So there was clearly value in doing this procedure with an expectation of improvement in survival. And once you do survive with this, you don't really have any long term issues. So, uh we are still doing that and many, all the centers are now thinking about doing it as enormous routine intervention for severe diaphragmatic hernias. OK. Now, let's try and finish off with a, a very obvious issue around here. Um it's notable, I got this from the B MJ in 2022 of the last 2225 years, female medical students have made more than 50%. In this case, about 95%. It seems uh medical students, why is that? Why is that, what it is obvious? Actually, girls are usually cleverer than boys. Sorry about that. Um But it's an observable fact, but does that translate into the choice of surgical specialty? So, you know, do all girls just want to be GPS? Who do I know? Um So this is a study that looked at the surgical, the choices made of those wanted to do surgery. I will get to that in a moment, but don't worry about it. You, you're ahead of me though. Uh So these are, these are the two things that from 2011 to 2020. Uh And it's two sets of people registrars, um and consultants. So these are specialist registrars. They're not core trainees or foundation specialist registrars chosen already. So what you can clearly see if you look at the top scale is the proportion already quite high actually for os in pediatric surgery, which is the green line. Um And it's going up still to the present day. So from 40 to 50% of our trainees are women. The only thing that really can compare is the ophthalmologist, but who wants to have a surgical career where you have to sit down all the time just doing one operation to remove cataracts. Um The consultants and even greater expansion of our consultant cadre starting at about 20% in 2011 hitting about 30%. I think I put 35% in the next slide. Give it three or four more years and it will be parity, 5050 in our specialty. So it's a very female friendly um environment for women in surgery if you choose to become surgeons, obviously. Uh, so, ok. Yes, trauma or orthopedics. That one goes into that. Um, so what do we conclude? Well, pediatric surgery is clearly an active specialty. There's lots of interesting stuff going on, but it is challenging. You've got a downside, you've gotta do things that are challenging you, you are an intellectually capable community, so you gotta have things that stimulate you. So not orthopedics, obviously, that's just carpentry, isn't it? We do work in big cities, not Lincoln. So all our, er, there's about 2627 neonatal surgical units in the country. Uh, and pediatric surgeons cluster in those things. Typically I work in a small unit and there's five of us, 56 of us, er, but bigger units, Manchester Glasgow will have 1011 consultants, obviously, about half of them now will be women and with a full active work life balance and Children. So as a, as a, as a woman, if you aspire to have Children why you would want to have Children? I do not know. But if that's your aspiration, clearly, it can be accommodated in pediatric surgery. But as I say, you have to work in big cities. So you cannot work in, in smaller cities, you can't work in seaside cabins. Apart from Brighton, Brighton's got a pediatric surgical unit. And more importantly, patients that we operate on don't usually complain. And if they do complain, we anesthetize them. So if there are any comments or queries, I would be more than happy to answer them. And while we're talking, you can just consider this. I stole this from a colleague of mine. I suggest we just running a little late. Um Is it ok if we bring lunch and then people can bring it here, we can have an open discussion. So we continue the conversation. Absolutely. No questions. Thank you again. I was not a problem. I do apologize. I so that they can