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Uh Thanks for being here. So today we've got uh the lower G I med ed lecture, uh run by Johnny, former um imperial student now doctor. So, yeah, when you're ready, Johnny, I'll hand over to you. Yeah, great. Um So yeah, hi. Um I'm Johnny. I am an f one I graduated, I guess a few months ago. Um and I'll just talk through some stuff on lower G I, so I'm currently at Hilling on general surgery, so I actually do colorectal. So a lot of this stuff is actually real life now, which is, which is great, isn't it? Um, cool. So I thought I'd just start off with some more general advice because I know Fania goes very quickly and it can be a bit intimidating. Um, so I just wanted to provide some reassurance. Um Basically fan year is a really good time. You shouldn't, you should, you should enjoy it while it lasts because um it, it doesn't last very long and it's, it's really something else being a student. Like I know it feels like you can't, you're sort of ready to move on to a different phase of your life. But I think just enjoy it while it lasts because it's always different looking back. Um, I, I know that the UK FPO and stuff is really awful. Um, and that kind of sucks. You just have to get through it. But, yeah, that is what that is. Um, you guys are having a guinea pig here but that's, that's kind of a, now. Um, I would not worry. Some people have this weird thing in front of you where they feel like they have to learn how to be an F one. I would not worry about that at all this year. I would literally not even put it to the back of your mind, just eject it. Um You do not need to worry about any of that shit. Like honestly, I could teach any single one of you to be an F one in about two weeks like it is so none of like there's nothing to it. It's so it's fine like all of the writing of discharge summary, whatever you do two and you'll be fine. Um You can do this on P FA that, that's the way it is there or you know what? Just you can not even bother the P FA if you ask me is not a real thing and it's, it's kind of an insult but whatever um knowing medicine is far more important and kind of the point of all this. Um the point of medical school is not to make you an F one, it's to make you a doctor to make you someone who knows what they're doing. And, well, one thing I would say is that it's worth doing an out of hours shift because I did one on my P FA, it's like one of the few things I did do. And it was probably the worst thing I ever did in med school. But I'm glad that I did it while I was in med school because now I don't feel like much can be worse. Um, after and it's nice to have that safe opportunity to do it. Um The one thing I would say is very important when you're going to F one is to know how to do a good A to e like the only time you're really, really challenged is when someone is unwell and very few people around to help. So which is why knowing good A to e is really useful because it will really important because it will buy you time and stop someone dying. So that's the one thing I would say is really important to know in terms of preparing for an F one. And looking back, no one wishes they did more medicine in medical school. So don't stress too much and enjoy yourselves, you will be fine. Um So within this talk, I am not going to teach you all the medicine. That's not really the point of these I think at this point. Um There's a lot of overlap with third year and final year. To be honest, there's just a bit extra to it. Um So what I'll do is I'll try and focus more on high yield things like pieces or stuff, which is actually important for your life and paces, which you don't get taught so much. Um I'll try and focus more on principles and fundamentals than just going learning loads of facts because to be honest, that's not really what a good use of your or my time. Um going over kind of conditions and stuff like that in a very sort of textbook way is much quicker just doing it with notes or something like that if you want to um doing a talk on it is not, not really um an effective use of your time. And so I think I'd focus on some other stuff. So I'll just briefly run through paces because I know paces again is something people worry about in final year. I'll just talk about that. I'll talk about making differentials the principles behind how to do. Well, not even, not even OK, just like actually better than OK, doing quite well. Um I'll talk through other extensions, surgical scars, all different types because they're really, really common things to talk about in a PA station in Abdo uh types of bowel resection and different indications for all of them. Um stoma and hernias. So as a sort of first thing and I don't know. Oh yeah, I don't know if we put the mento meter code in the chat. Um It is let me get up. Oh you have nice cool. So if you just, yeah just like if you just have a look at that um just to see how everyone's kind of feeling how um I think for the general year, how you're feeling for year in particular just so I kind of know where to pitch things at and how things might be looking. Um Yeah, uh you go nice. OK, fine. Um Another thing that I'll say looking at this is you really should not worry about the PSA. I don't think anyone fails the PSA like I think literally zero people. Um It is so minor, you can, you can revise the PSA from scratch in a week and you can do it in two days if you do the E fa stuff throughout the year. So like honestly the PSA is, this should be the least of your concerns and I think this time you guys actually get some time off for the PS A um cool, nice, just a good sort of baseline. Cool. So we'll try and go from the basics up. Um But yeah, again, the PSA I know it kind of sounds like I'm saying, don't worry about anything but that's kind of because you shouldn't worry about anything like they will do almost anything to drag you over the line at this point. So you will not fail. Um, especially if you're in a lecture on a Thursday night. Cool. So I'll try and break down why you shouldn't worry about Pacers. Um, so these are the Pacers stations for your year. I think you have 12. It's basically quite similar but they put in usual difficult conversations type thing. Um, if you think about this six, so you need to, to fail paces, you need to fail six stations. 12345 of these are examinations, you know, from third year and you should know how to do decently just from muscle memory alone. Um You don't need to pick up signs and paces. Obviously it helps, but you don't need to, I did not pick up a single correct sign in my paces as far as I know and I did better than fine. So honestly, you really don't need to. Um you need to be honest and you need to have a thorough examination and need to prove to them you probably would get it if it was real life. Um So about five of them, you can already just pass a loan if you do a good basic examination and don't find anything and presenters not find anything. You will probably pass anyway, almost suddenly sur five out of 12, you can just pass. Yeah, two more. You can just take a history. I'm assuming you guys can take a medicine or a GP history, they tend to be rather basic in the pieces as well. So more like seven out of 12, you can just do with no prep at all. So honestly, you'll be fine. Do not worry about it in terms of principles to pass or do fairly well on pas I think, always try and be systematic and categorized if you don't know the answer to something, try not to say, I don't know, or at least say, I don't know and then offer something, show them that you have a brain and you know, some stuff you need to offer, know it's ok to not know everything. Um They're not expecting you to know everything and you won't know everything as an F one. But what you should do is try to work it out, show that you have a systematic method of thinking and you, you can solve problems and you have a bit of initiative and give it a go. But obviously if you don't know, say you don't know, but then offer them something and being systematic or trying to categorize things shows that you have the right way of thinking. It shows that you think like a doctor and that's really good and really important and can show a valuable, you can use kind of a negative scenario to actually leverage it into a positive, always stick your basics be safe and you'll definitely pass and you'll probably do very well. Um by being safe generally, that means know when to escalate and don't be afraid to escalate and stick to your basics. Um, examination, a good examination, a good history will get you most of the way all the time. Even if you don't find things as long as you demonstrate, you know, how to do one and you know how to think, right? You'll do, well, it's worth looking back at the previous stations from like, back in the day when they actually there was this brief gap during COVID where they didn't really do paces. But if you look back at the stations from before, then there are a few patients who actually were repeated. So our year was the first year, last year where they had real patients again. They get some people back every year, I think. So, it's worth looking back because they do show up when you do this though. I'm just going to warn you people back in the day. Like in 2012, 2013 were pretty, they weren't like us now. Um, they, they, they were a bit unhinged, in my opinion. They, they did a lot more work. They, well, not, that's not why they're unhinged but they, they went on all these courses, you know, they had this thing called it, the Art of War course and crap like that. Like they're, it's really intimidating the accounts they give, but don't worry about it. It's nowhere near that bad. Like, I think they're just a bit over the top. Um, you don't need to pay any medicine to any, any money to do well in your exams. And please don't, I really don't think that's, I really don't believe in that. I don't like people who exploit that. Um, he is all about confidence, being a doctor, all about confidence as well. So just conduct yourself well and speak properly. Um, be a real human being, talk to people like people, you are a person for your doctor. And honestly, like that's 11 bit of feedback I get from people at Hilly Dunn is that if her students kind of are a bit too systematic and not systematic but too robotic, they kind of focus on things, they want to get out of a consultation rather than actually talking to a patient like a human being. Um So if you do that, you can stand out a bit as well and never lie in a police station because that's a, that's a way to fail. Never lie. If you, if you can't hear something, you can't hear something and they will guide you towards what you're meant to hear, do not lie. Cool. Um In terms of making a differential when you're at the door of a station, when you're about to see a patient and you have a two sentence summary, um You can always get a good idea of what you think might be going on So you'll get two sentences. Think about, for example, the anatomy. If it's an abdominal problem in, let's say the right inferior quadrant, there's, there's not actually very much stuff in an abdomen. There's your bowel, there's your small intestine. Um, if you go up, there's your liver, your biliary tree, if you go to the left, you have your spleen, you have kidneys lowered down. You know, if you're a woman, you have ovaries there, there's not actually that much and there's not that much stuff that can go wrong if you see what I mean. So you can always start to narrow it down. You just think about what's in that area. Think about the chronology. I think this is one of the most important things. Is this a problem that's been building up over time. Has this come on very, very suddenly because sudden issues. First of all you're more worried about. But second of all, there are very characteristic things that happen very suddenly. For example, someone's quite unlikely to be obstructed if they just suddenly got bowel like pain in the abdomen. That wasn't there the day before. Um, someone's unlikely to have ovarian torsion if they have a pain that has been building up over weeks. So Theochron can give you a good idea of how severe of how worried you need to be, but also the types of problems. So, for example, classically, vascular problems are almost always very, very sudden onset severity how worried are you? How quickly do you need to speak to your senior and who do you need to speak to? Do you need to get ICU involved? Do you just need, can you handle this by yourself? How worried do you need to be? And how urgently do you need to get things done? Chronicity? So, is this a new problem or is it an old problem? So this, I ask a few questions to almost everyone whenever I ask anything. So it's, has this happened before? Um And then if it's pain, you do Socrates and um and that covers basically everything to be honest and think about the context and think about their past medical history, think about their drug history if you're having new onset pain in the background of a chronic condition, that's often. So for example, chest pain on the background of having a previous mi of having stents very, very different to a random chest pain in a 20 year old like guy or girl coming into Ed, you have very, very different thoughts based on those contexts. So whenever you're at the door, think about one or two or three differentials that you might have in your head that you might sort of be guiding towards just to show the examiner, you, you are, you are actively ruling things out and you are actively trying to rule things in and you're not just asking a standard form of questions because at the end of the day. That's what sets you aside from a PA or something like that. You don't, you shouldn't operate by protocol, you should operate by sort of using your diagnostic process and your principles. Usually all of this stuff can get you most of the way there or at least get you fairly close or on the right track, which is the most important thing in finals. Um And as a general principle as well, if all else fails, just rule out common things and rule out worst case scenarios, rule out an emergency, even if you don't think it's likely because again, it shows you're safe and common things are common and bad things are bad. So that's, this is like, that's like the number one piece of advice I would have if all else fails. Um And you don't necessarily need to exit a station with a diagnosis because they recognize that 10 minutes is not a lot of time. Eight minutes, seven minutes, how long you have a history or examination is not a lot of time. Real life is not like that. You just need to show you need to give them the confidence that you know, the examination, you know, the history and you would get it in, in real life and always be prepared to explain yourself any investigation or differential that you give. Um So we'll talk a bit about abdominal distension. So there's this thing called the five si don't know if you heard about that. So it's fat, fluid, flatus fetus and feces and just taking that a step further, you can think about tests that you would do and possible differentials for each one. So fat is really something you rule that out. Um, fluid. What are you worried about? You're worried about ascites. You're worried about a liver pathology or some kind of basically a liver pathology usually with fluid. Um, how would you rule that out? You can do an ultrasound, you can of the liver, you can do the, what do they call it? You can do the shifting dullness test. Um That's an easy way to rule that out fetus and feces kind of go together. You're worried about bowel obstruction, you're worried about impaction. Um which is again, something I'll talk about in a second and fetus basically, never forget about pregnancy. Um Always rule out pregnancy in appropriate presentations. So, um I'll just move on to one question. This is something that comes up really, really commonly. So what is the most common cause of small bowel obstruction to something they love to ask you in paces when you are on firms in finals anything. And it also is just a really good piece of knowledge to know. So just wait until we get a few results. And I guess this will also be a good benchmark of, of, of if I pitched this at the right level or if it's a bit too basic. Ok. So, one more second. Cool. Let's see what we got. Ok. Good. Yes, it is adhesions. That is the number one cause of bowel obstruction. That is the most common cause of small bowel obstruction by a long way. And it is what you should be thinking of if someone has signs of small bowel obstruction. Good. Um, so we'll do this one very, very quickly then, as you probably know it's large bowel obstruction. Uh, I would describe this as a high, too high your fats. Mhm. I reckon we can just see where we're at. Ok. Interesting. Let us run on then. Ok. So split, split between volvulus and malignancy. Um, is malignancy. Malignancy is the most common cause of large bowel obstruction. Volvulus is not actually that common. Um, I've only seen a few cases of it so far, but I've seen a lot of cancer causing a lot of obstruction. Um, ok. That's, that's, that's interesting. Fine. But, yeah, it's malignancy for all future reference. Volar is fairly rare. Um, is an emergency but also kind of not an emergency. Um, if that makes sense, it's like it's not something that people would be freaking out about, but it's something you need to do something about very, very quickly. Uh, well, not quickly, but in good time. So bowel obstruction more generally. So your cardinal presentation is vomiting and constipation. So, not having opened your bowels associated with nausea and vomiting. Um, not fecal and vomiting. That's not really a thing that it is a thing, but it rarely ever gets to that point and you'll have abdominal distension as well, usually. So the cause is, again, this is the whole thing of categorizing. So you can think about it in that way. So you have an anatomical obstruction. So this would be your classic sort of colicky pain coming in waves and you might get diarrhea as well, which is overflow from the obstruction. This can be due to things like diverticular disease. It can be due to cancer, any other form of extrinsic mass effect or compression. So that could be literally from an ovarian, a massive ovarian cyst, a fibroid a tumor elsewhere in the abdomen. Um We had someone who had obstruction due to you can have it due to um peritoneal deposits of cancer as well. So, metastases. So not even like one big tumor, like those small ones, which kind of tie up in those different places. Um Hernia and volvulus, which are also anatomical causes. So you can think about them functionally again. So there's no one way to do this. You can, you can do it, however, it sounds reasonable to you. So, paralytic I BS spinal cord injury, um meaning that the bow just can't do peristalsis toxic me colon or POSTOP I BS paralytic Ile is kind of something that happens to old people. Um frailty, long bed bound illnesses or electrolyte deficiency is also another common cause and just congenital, harsh things like that. So again, and this is just more, this is not so much to cover the content, which is a, just to demonstrate that whenever you're talking about this thing in like a pacer station, if someone asked you to talk about bowel obstruction investigations, what would you do? Bedside bloods, imaging back to third year back to basics. So the full abdominal examine history, um your your bread and butter like I know it sounds basic, it doesn't sound smart, but this is really how you do most of medicine. Um You could consider a dre if you want checking for like a stool or an empty rectum bloods, what you want a full blood count using the CRP anything where you think there might be a slight whiff of a surgical intervention, get two group and say s in and a clotting screen because it, again, it's about demonstrating, you've kind of been in real life, you know how things work in a hospital, two group and say half an hour apart alongside a clotting screen. Um Very reasonable thing to say shows a bit of initiatives, shows forward thinking. I think the litmus test for a consultant within paces is they imagine you as the f one. Do I want them or do I not want them cool and imaging consider things. So again, you don't need a, a ere chest x-ray but it allows you to show off your knowledge. I would, I would like a, I would consider an ere chest x-ray looking in particular for pneumoperitoneum, which could indicate a possible perforation. Um, again, you're not committing to it, but it shows that, you know what you're talking about, it shows you're safe, you can rule out emergencies and it shows that, you know, a bit of anatomy as well. Abdominal xrays is a weird finals type thing which does come up, but it is not really ever done in real life. You would just do a CTP because it shows you a transition point. It can show you, it can identify where the bowel is obstructed. Um And it can also show you what it, it gives you a much better picture of if there is obstruction, one nice phrase which like I mentioned transition point, that's the point of obstruction and you sort of get a bit of narrowing with the dilatation or before it. Um And yeah, literally C CTP surgery goes hand in hand, like the abcs of surgeries, airway, breathing and ct abdomen and pelvis. They do it for like everyone and CTS nowadays have actually got fairly low radiation doses because of some new technique. So honestly, I wouldn't even, I'd have quite a low threshold and I think if you can demonstrate that that's quite reasonable as well. Um So distension on abdominal x-ray, there's a 369 rule that I think is worth knowing. So small bowel, three centimeters, dilated, large bowel, six centimeters at the cecum is nine centimeters. Um, well, so another question in this abdominal x-ray, where do you think the obstruction is? And we can talk about how you can try and identify that. Hopefully, it's, it's on the slides and yeah, there's not, not too many options on this one. So I couldn't come on, I couldn't get creative enough. Well, they just wait for a few more. Ok. See where we go. Oh, nice, good. All right. Um, lovely large bowel. Yes. And so given this is a large bowel, um, obstruction. Where is the most likely site of perforation? And this is a nice little fiber question as well, I think, and to be honest, you can work this out using your anatomy knowledge if you have any. If you don't, you can probably still work it out. Um, but again, it's about having that rationale and being able to explain your being able to explain your thinking. It's like, it's like interviews all over again when everyone said, you know, uh, it's not about getting the right answer. It's about, um, showing your school of thought and showing that you can show your way of thinking. Um, that's not really real at med school interviews, but it kind of is real here if you ask me. Oh, so wait for one or two more and then we'll just have a look at what we think I see. Interesting. Ok. So we have a lot, a splenic lecture. Nice. Ok. That's not correct. So, it's the cecum, um, and the reason why, so there's a few reasons why we'll just talk about it. Um, so most of your lower, most of your large bowel perforation is going to occur when you have a clo what's called like a closed loop obstruction. Um That means the ileocecal valve, basically the join from the ileum into the cecum or the transition from the small bowel to the large bowel, um, is patent. So that means it, it, it's shut, it's, it's normally it's closed. Um So if you think about that, that means that sort of again. So this diagram does it quite well. So you can see there's that transition point, there's the actual point of the blockage or the stricture and everything kind of backs up beyond that. Um And then if you think about just where the pressure is, is bigger, so there this law, whatever, if you want to do a fancy French name, but it's quite simple as the pressure rises, essentially the tensions biggest in the point where the diameter is biggest. Um So the secu naturally stretches to the biggest point. And so therefore the most likely site of rupture also, you can think of it in terms of where, um, it's going to sort of all the pressure. If you think about it, it's kind of backed up against that closing point that could relieve the pressure. So that's another way to view it. It's sort of being pushed right at the end of that, that sort of tube if you view the bowel as a tube, um, that's why it's the cecum. So cecum is the most common site of bowel perforation, larger perforation. And it's most commonly in this thing called closed loop obstruction. Uh, we had a guy who had a rectal carcinoma, uh, palliative, which was fully obstructing him. Um, so completely obstructing his large bowel closed loop obstruction. We knew that he was going to perforate, he's probably going to die of it, but again, nothing that we can do. Um So yeah, it's real life as well. Probably why I'm in favor of euthanasia nowadays. Um, ok. So just a little cheat sheet for bowel obstruction, just for you guys to have the slides, something to refer back to you in your own time. A very sort of easy way of sum summarizing basically everything you need to know to differentiate them. The keys to differentiating small bowel and large bowel obstruction on x-ray. You guys seem to know it, but basically, it's about being central or peripheral or sort of circumferential is what they say. Uh, if it's really, really in the center, it's almost certainly small bowel. And if it's anywhere else, it's probably large bowel and then there's the Hatra and the valve, the ventas, those are worth knowing the names of, um, Hatra are the ones which don't go the whole way. And Venz are the ones that kind of look a bit weird and go all the way across the bowel. And that's the other way of telling. And that could come up in, in, I, that could come up in Abdo. So a lot of this stuff has a lot of overlap. Cool management again, categorization, conservative medical surgical, conservative drip and suck. So, uh no by mouth arousal tube. So that's the thicker G tube. You could be asked to explain in your, um what's it called the, the instruments in uh ion um, fluids near by mouth, get out all those gastric contents, comfortable, antiemetic analgesia, those are all conservative measures. You're not really doing anything there and there's not really medical, but you can still consider it and surgically it depends on the cause, which is again, why you do the CTP. And that can lead you into talking about your imaging and the investigations that you would do. Ok. So surgical scars, let's talk through each one of these. These are most of the ones I think you need to know. I don't think you really so many more outside of that. So, a is your laparotomy or midline incision? Um, basically a laparotomy, you can do almost any surgery in a laparotomy. And this guy cardiologist at Brompton Peter Collins, he taught me basically, if you're asked to explain a scar just think about the anatomy, think about what organ is there and think about any operation you could do for it. So you can do almost any operation in a laparotomy. So any hernia repairs, any sort of surgical um hu surgical incisional hernia repairs. Um You can do resections, you can do cholecystectomy is almost anything. And if you're ever stuck for something in surgery, you can always just say removing something that's most of surgery is just removing an organ. So, yeah, uh B para medium, basically the same thing. But alongside it, this is almost never done. But yeah, you can say if you want, this could be things like kidneys or adrenal operations. Maybe another point in laparotomy is I should say that almost always emergencies. You generally do um laparoscopic surgery if it's elected. Nowadays, there's this one c which is the coa coa something like that scar usually on the right hand side of the abdomen because they do it for gallbladder or um sort of biliary operations. Um If it's not laparoscopic and then d is the rooftop or Chevron scar. So that's if you do the whole thing, you can do that for um things like pancreatic surgery, splenic surgery. Um If you have a more un mal patient, um E is the lateral scar, that's more for the kidney. Um, not really common. I think F and G. So F is grid IG is Lanz. Um They're both for appendixes usually ban is the H, um, that's on g basically c-sections or bladder operations. Again, thinking about the anatomy. And then X so, or the belly button is a laparoscopic report. They almost always start at the belly button and you might see them dotted throughout as well, depending on where they were going. And then if you kind of add on like a bit to the, to the, um, grade I and you sort of form a hoggy stick scar or rather rather Morrison scar, they call it um that's often sort of bit further around the abdomen as well. And that's for a kidney transplant and laparoscopic ports can be done for like almost any side if you can resect bowel using that. I had someone who had a total colectomy through a laparoscopic port. Um You could do obviously like cos and stuff like that as well and just give it a good guess. You know, you don't need to learn every, you can't learn every indication because different people do things different way techniques, different surgeons have different sort of preferences with different techniques. So just think anything reasonable, often you can transplant something often you can remove something often you can fix something cool. So let's do another question. So I'll read out this uh little thing. So a 64 year old male who presents Ed complaining of left sided abdo pain associated with constipation, pr bleeding. He's not nauseous on examination. He's diffusely tender in the abdomen, but especially so in the left iliac fossa, what's the most likely di diagnosis? See what you think. And this kind of maybe does that thing that some questions do where there's no wrong answer, but there's a more right answer as well. And finals is like that, especially with this whole UK ML A thing they've done UK M MA questions aren't really designed to test your knowledge, in my opinion, it's designed so you can't get 100 but you can't do really can't. Yeah, basically you can't get full marks. Um They'll put multiple answers that could easily be correct and not give you enough information um to figure things out. Um So a lot of things like this. So you just kind of need to come up with your own justification that you can, you can live with and explain to yourself often and I'll try and explain the thought process that I took with this one to get to the answer and justify it. So let's wait for a few more answers. Cool. So I see what you think. Good. Yes, diverticulum. Um Yes. So diverticular disease is very, very common in old men and old people in general, especially Caucasian people because of their diet and that's a med school thing. That's a classic or question thing. Um Also to be fair, probably a real life thing. Yeah. Um So why is it this one? So let's have a look. Um could it be a cancer? Yes, it could be a cancer. Is it most likely be a cancer? Most likely not. Um, because he's not nauseous. So we don't think he's necessarily obstructed. Um, it's possible but again, the signs and symptoms more point towards a diverticular disease, um, because of the constipation and p which is quite typical, um, and the localization of the tenderness. So, with, with like a bowel, um, obstruction, you don't really, or like a, a cancer, you don't really necessarily get tender in a local area. It's much more um common for a perforation or something like that. Um strength to hernia, reasonable. Uh Would that present with pi bleeding less reasonable constipation? Yes, he's not nauseous, pointing less towards an obstructive cause. So again, it could be a hernia less likely though. And sigmoid volvulus could be, but it's just honestly not as common as per diverticulum. So there's a few ways of justifying it which they use in different questions. One based on the symptoms, one based on just how common things are. Um But you need to kind of put all that together and see what you can see what you come to terms with. Fine and which operation is he likely to have to resect this. Um I did not know what a lot of these were until final year. So don't worry if you don't, you can kind of figure out for some of them. Let's see what you think. Ok, let wait for a few more. So not a left hammy. Ok. Um Kind of not really. Um, so a heart that the answer is a Hartman's and I kind of wasn't really, I, I never really knew what Hartman's was until a final year. Um, I, I don't know if it's named after the same bloke as the fluid is. Yeah, but I will talk you through all the different types of operation, why you do them. So a left hemi, I'll just say quickly. Generally, hemi hemicolectomies are for cancer resection most often, but let's talk through it. So, a right hemicolectomy, this is what you make up, you remove the right ascending colon. So you do this for tumors. So it's actually quite straightforward um in real life. Um I don't know why it doesn't seem that way in med school, but it actually is. So you literally just take out the right colon if you have a tumor in the right ascending colon, um any scal tumors, any ascending colon tumors. And if you have something on the transverse colon, which I'll get on to in a second, you do what's known as extended, right hemi. Um but I'll talk about in a second. So during these procedures, any, anywhere you're resecting cancer, usually you'll resect other things as well. You'll take out some of the nodes, you'll take out some of the sort of mes and some of the blood vessels. I don't think you need to learn the anatomy of like the superior mesenteric whatever and the inferior, I think just have an idea of what they are. Um And just be able to sort of talk about them in some context. It's not that hard, like ascending colon, superior mesenteric artery, descending colon, inferior mesenteric artery. Um Hopefully, that's right. But you see what I mean, something very basic like that. Um And so you want to, whenever you are removing bowel for a tumor, you want to remove the primary tumor. Um with margins, they say around 10 centimeter margins, which is again, why you remove most of the colon and like, look, I'm not, I should be very clear. This is like a general thing. You remove the colon and you cut at the point where you sort of have the margin, they don't sort of cut in the same place every time. It depends on where the tumor is. But as a principle, this is where they would make a cut to remove this bit of bowel usually. Um And you want around 10 centimeter margins is what they say. And afterwards, after you remove the bowel, you either form a stoma or a primary anastomosis to join the bowel together again. Um Nice. So for an extended right hemi, so any transverse colon tumor, you'll do an extended right hemi to take out a bit more. Um and you remove the transverse colon as well, there's no I don't think there's such thing as a transverse colectomy. It's just an extended right hemicolectomy. Uh The left hemi is for descending colon tumors. So you remove the descending colon um and you remove the mes trees, you remove the inferior mesenteric um vasculature. You can have a sigmoid colectomy. So you can see how it's named off just different bits depending on where you find the tumor. So this is again for sigmoid colonic tumors. Then there's this, there's this distinction of the abdominoperineal and the anterior resection. Uh this confuse me a lot because it's not a straightforward naming an anterior resection. The key difference is an anterior resection preserves the anus and an abdominal peroneal resection removes everything. So this is the approach for high rectal tumors or low sigmoid tumors. That's literally tumors which are high in the rectum or low in the sigmoid. So they typically say around five centimeters from the anus. There's other sort of ways of saying it, but that's a number which I think is reasonable to say. Uh This approach is obviously better because I think it's less painful for the patient. You get to preserve your anus and still be able to have a poo um and not have a stoma. Um and often with a joint so often with joints around the sigmoid, I don't know why, but they often sort of defunction that. So what they mean by de function is they'll make an ileostomy and that kind of diverts all the bowel contents away. So it gives this anastomosis time to rest, um, and reduces the event of a leak. I don't know why it's more common here. Maybe it's something to do with like the poo being more fully formed or something like that. But that's quite common to do with this sort of thing. Much more common with these resections that are done much lower down in the bowel. And you can reverse that 4 to 6 months later, you can do it sooner if you need to. And a way you can test the strength of the joint is with uh contrast enema. Uh We've done that for someone in our department and then from the abdominoperineal resection, you do it for little rectal tumors around less than five centimeters. Um and there you remove everything. So you have no anus left, you have a colostomy and a colostomy, not preferable if you can avoid it, but sometimes needs happen in a total procto colectomy. You take every of the whole thing, not many indications, usually genetic things like ulcerative colitis. If they are not being optimized on medical management, this is the ultimate end goal and it is therapeutic because if you remove the colon, your colon can't get inflamed. And if you remember osteoc cars only in, affects the colon, um whereas Crohn's affects everything, mouth to anus and you can also do it for things like fap uh if you have loads of polyps, it needs to come out as well. So, Hartman's, what is Hartman's? It's, it, it's an eponymous name for a procedure. Essentially, it's an anterior resection with an end colostomy and a rectal stump left behind with a de functioning I ostomy. Uh You do this when you can't make a primary anastomosis. So generally for emergency procedures, um you don't do a Hartman's, for example, for an elective resection of a sigmoid tumor, you do a sigmoid colectomy. Hartmans is done when you don't have time to make, it's impossible to make an anastomosis. So if the sigmoid colon perforates, it needs to come out if it's necrotic, if there's ischemia, if there's a really, really bad obstruction, um you move it and you defunction because it's impossible. Anastomosis could not, could not survive basically. Um And then once the initial pathology settles you can reverse it. So again, it's, it's kind of anterior resection, but it just has a name and a specific indication, common indications most often perforated diverticular disease. Also, volvulus, any big trauma to that area, any ischemia within that bit of colon or previous anastomotic failure. Ok. So a bit about how different colon cancers present. So, right sided colon cancers are more sort of occult. So iron deficiency anemia, um often presenting later abdominal pain. Whereas left-sided colon cancers, you have actual pr bleeding sort of change in bowel habit, the tenesmus that feeling of not having emptied your rectum because there may be a tumor in it. Um, and a palpable mass or like apr exam sometimes as well. Um, large bowel tumors are much more common than small bowel with small bowel tumors. You're more likely to even, you're less likely to have those adenocarcinomas more likely to have sort of, um, what we call like nets or neuroendocrine tumors. Um, that's sort of a path thing that, that can transfers on to final. Yeah. So after surgery for bowel cancer, the two options with anything is chemotherapy, radiotherapy. Much less likely to do radiotherapy only really rectal cancer because if you think about it, you can't really target the large bowel without hitting the small bowel and the small bowel is very, very sensitive to radiotherapy because obviously it's very metabolically active and it's just sort of in the same area. Um And yes, chemotherapy, much more common. You basically do that if there's any sign of local spread. So nodes, any nodes, any metastases, they're on chemo straight after um, a note on screening. So you kind of do need to know this is one of those things like breast screening. Um, this screening and the abnormal aorta screenings like that ultrasound when you're above 60 a bloke, I think it is or maybe 65. Um So screening is offered every two years to men and women age 60 75 and that's done with the Poo test, the fit test ce A is not used as a diagnostic test. It's a very common viva question or very good viva question. Um But it's used to monitor disease progression. So once you've identified the fact there is a tumor, you can check for remission, you can check for disease recurrence. You can test for how, how well your, your therapy is working with your ce a level and do not miss bowel cancer due to sort of your pre your preconceptions of who gets it. Sure in your exams, whatever, fine, go by that. But in real life, young people can get bowel cancer. And I think apparently it's more common nowadays, we have a guy who got metastatic bowel cancer when he was 26. So literally like one or two years older than me. Um, so it can happen and shouldn't be missed because of it. If you have someone who has the symptoms of bowel cancer, get them a colonoscopy, um, you'll never, you'll never be, unless the person doing it is a massive c you'll never be, um, chastised for being safe and for being clinically appropriate, even if you get it wrong. It's the same thing for a cardiac arrest call. If you're thinking me, if you're querying, putting out a cardiac arrest call, you should probably put out a cardiac arrest call because no one shows up if you show up to a cardiac arrest and it's not an arrest. You, your first thought is never like, oh who put out that call? One idiot? Your call is your first thought is like, oh, thankfully no one's unwell. We can go and get back on with my day often. You never even find out who put the call out. So don't miss things due to some perceive like shame of potentially making a mistake, like better to be safe in every scenario and trust your gut. Um OK, so what type of stoma is this? After chatting about stoma and stoma formation, any resection, you can get a stoma basically afterwards. And stoma are very common. My ABPA station was someone with a stoma and a bunch of surgical scars which I I'm not sure I was actually able to identify. But yeah, what do you reckon about this ST and let's see if this is a teachable moment or not? OK. So it is. So yeah, I the ostomy. Yeah, sure. Likely to be an ileostomy, but you can't make assumptions. So you can't actually tell from this alone why? Because they have the type of bag that's not transparent, you can't see through it. So there are some bags which are transparent, you can kind of get a window to see it and they should give you that in your pas in mind. They didn't, they had a bag which was not transparent. I had never seen a stoma before. I never touched a stoma before. I had no idea what I was doing. So I can't just fiddle with it so you can't see it. So you can't identify it based off the looks, you can identify a, you can look the, the being on the right side is like real. That is most common, but you can have colostomies on the right side as well. So you can't make assumptions. You can say it's likely to be an ileostomy, but I cannot say this until I've actually examined the stoma myself or know a bit more about the past medical history because sometimes they do bring out colostomies on the, on the right and sometimes ileostomies can be on the left if you remove all of the bowel sometime. Yeah, there's, there's, there's instances and I have seen it in real life as well. Um Fine. So Stoma if you want definition, yeah, artificial between conduits or a conduit on the outside, fine how to examine it. Um, have a look on Kke Medics. Um, there is kind of a protocol but I don't think you necessarily need to follow it. Uh, you can look at it while they're standing up to see if there's a parasternal hernia. These are fairly common. Um, but you can also also just do it lying down, but just get them to stand up if you can, you really kind of need the bag bag off. Um, they will not get you to take the bag off in an exam because it's completely impractical. It takes about a minute to get it off and you need this kind of like special heating thing to sort of get the glue off. Um, but you can say I would ideally want to examine this with the bag off. Um, failing that you have a look through the window, but you just show them that you would because you really kind of need to, um, you want to look around the sites in particular, looking for any dermatitis, any hernia. Um See if the skin looks healthy or if it's broken down slough, what's the appearance of the stoma itself? Is it pink and healthy? Is it slough? Is there any sort of discoloration? Any signs of ischemia or inflammation and look at the content of the bag? Describe them? What color are they? What texture are they? Is it appropriate for what you think the stoma is? How much is there in there? Um stuff like that and palpate around it. So it's kind of fairly basic things. It's sort of look listen and feel except don't listen to it, but like look at it, think about how you could look at it. What you might expect to see, have a feel. So, first principles from the basics. Um and yeah, so when you have a palpate, is it tender, other signs of infection? So it's the classic sort of signs of infection, tenderness, redness, swelling, pain, um all these basic things and that's really what you're looking for with a stoma. When you look at a stoma, the cardinal questions are, is it healthy? Is it output? Are there any complications associated with it? What type of stoma is it? Those are the main things you need to answer within your ABDO exam because a stoma exam is not really its own examination. It's part of an ABDO exam. So you shouldn't sweat about doing, spending 10 minutes doing this. It should only take about a minute, 30 seconds. Fine. Ileostomy, Colostomy. Ileostomy often on the right colostomy, often on the left for intuitive reasons, but not always. What's the difference? That's how I talk. Oh, and I'll actually just talk about different types because the question I got asked in my station was name me every type of stoma that, you know. So Ileostomy, Colostomy loop, Ileostomy, the difference between end and a loop one hole or two holes. Loop ileostomies do not look like this in real life. They look really, really weird and sometimes it's really difficult to find the second hole. Um Often there's like one big hole and one tiny, one sort of hidden the way and a loop ileostomy. I always found quite difficult to actually understand when you look at it like this. So it's, it's kind of like this, but kind of not that sort of inside edge of bow would be joined, but essentially you kind of just have the loop kind of goes above the skin and then goes back down and you have your two holes sticking out there. So it's one loop that kind of just goes around like an ox lake in geography or something like that. Um And so that's what a loop. Ileostomy is a loop. Ileostomy def functions an end ileostomy cannot defunction because what it does. But like there's nothing at the, nothing past it. Um So a loop ileostomy is a de functioning ileostomy, a urostomy or they call an ideal conduit. That's basically when you remove the bladder and you make a bit of bowel into like a, a bit that urine can pass through very, very weird. But it is something that you should know about and a mucous fistula is for people with IBD, lots of mucus production to allow someone to get out and sort of discharge. Um So how can you tell? Um Well, basically a urostomy very, very difficult to actually imagine. This is kind of how it works. It makes a lot more sense for me to do it this way. And a mucus fistula, I think the key with that is a mucus fistula is almost never uh by itself. I don't think you can have just one by itself, there will always be with the presence of another stoma if that makes sense. Um And then in terms of how to differentiate a colostomy and ileostomy. So the geography is one thing is it spouted, what does it mean if it is spouted. This is what it means if it is spouted. So, spout, I think just means it being raised up away and not flush with the skin. So colostomies are flush with the skin because they just output poo and poo doesn't really, it's not nice, but it doesn't really damage the skin. Whereas the, the ileostomy obviously has much more bib content because it's so much closer to the bile duct and the the small intestine, the digestive enzymes. Um so it can damage the skin and cause dermatitis. So you kind of raise it up above the skin in that sort of spouted thing, which basically just means like it's like a cone. That's the way I think about it might be wrong, might be right. That's how you can tell. So basically, if it's raised up, it's probably an ileostomy. Ileostomy is watery contents. Colostomy should be output fully formed feces. Um They have different sort of indications in terms of operations as well and they're just sort of listed there. But those top three are the main ways you can tell there aren't really many other ways to tell if you ask me fine. And then what can the complications be again categorized? Early, middle, late time is a very easy way to categorize a lot of things. So early, any operation, any complications for any procedure, you always have a few things, hemorrhage, bleeding, um always, always, always bleeding, infection, um do almost applicable to anything. So you can have hemorrhage, you can have ischemia if it's, for example, too tight at the joint. Um You can have high output. So that only really happens with a freshly formed stoma. Very serious. You can die of it because you lose electrolytes. Um So they say it's an output of around more than 1.5 liters in a day, high output stoma. How would you treat it? How would you treat diarrhea, loperamide? So you just slow down the output of the stoma with loperamide. Um So it kind of makes sense, you know, all kind of makes sense. Parasternal infection or abscess, you can get as well and retraction of it. Kind of just tucks back in late, those more classic things that you're not so worried about, but kind of too something about as well. Hernia dermatitis. So, in inflammation around skin prolapse stenosis or stricture and you get fistulae as well. Um But one or two from each one is fine. This is not sort of something that's going to be exhaustive in A MC Q. It'll be something you talk about in terms of Aviva. OK. So next question, a 30 five year old woman presents ce D complaining of sudden on 10 out of 10 right sided abdominal pain, she was intermittent in nature but is now constant. She has no past surgical history. What is the next investigation? You should order? What do you think? Oh, wait No. What is the most likely? Ok. I've got my questions mixed up. Never mind. Basically the whole point of this one. Do not forget a pregnancy test. It's really, really important in, in real life. Um Never forget a pregnancy test is someone who it is possible could be pregnant. You can't really trust what people say. You always need to be objective about it. Um And most people are reasonable and if you explain what you're doing and why you're doing it, they will understand. So always rule out pregnancy wherever it's reasonable as a differential because it will help you out later down the line. And it's a very, very easy test to do and it rules out a lot of things and people always want you to do it fine. So let's do this one because this is the actual question. Um, a 65 year old male on your ward is complaining of right in I fossa discomfort. You examine him with a chaperone, a two centimeter in diameter lump in his groin does not pop back out when you push it in, cover it and ask him to cough. What is the most likely cause? What do you think again? Uh Extremely, I think they examine this every single year and it's one of those things, I think you tend to kind of vaguely run from the third year and then forget by final year. But that's really a lot of what final year year is just reminding yourself of these things because they're med school bread and butters for, for a reason. And honestly, like finals is, is pretty similar to third year exams. Uh, I think I got similar results in both of them and they test similar content in a similar way, maybe a bit of a step up. But, yeah, finals written finals I should say is not that different to third year if you ask me. Cool. Let's see what we think. Yeah. So basically, yeah, one of the inguinal. Yeah. So this isn't indirect and I'll talk about why and hopefully we can just cement the distinction within your head. Um So types of hernia should know most important inguinal from oral. Most of what you'll get asked. But no, have an idea of what parasternal umbilical incision or spigelia are because they do happen spon rare. But for some reason is asked about, um, it's the one where you kind of have it at the rectus muscle, very, very high chance of strangulating compared to others. So that's one of the ones you want to repair. Um So you can learn about the borders of the different canals of the femoral canal triangle, anatomical stuff. I would not bother. I think it's a poor use of your time. Extremely low, your knowledge unless you want to be a bowel surgeon in which case good for you. But all of this stuff, this is the stuff that I don't think you need to be learning. I think the stuff you need to be learning is how to speak to someone, how to rule out important negatives, how to take history, how to think in an appropriate way. Fine. So, Inguinal and femoral, what's the difference in? It's all about the pubic cubicle, um which is sort of near the symphysis. Um Inguinal is above and medial, femoral is below and lateral. That's it. That's as simple as it gets. That's basically how you're gonna tell every single time. What's the important thing? Inguinal has a lower risk of strangulation. Femoral has a higher risk and is more common in females. So the most likely to strangulate are spaghetti and, and femoral. And so they really need to be repaired. Inguinal can be a routine sort of we'll sort it out in like a year or something. I we'll put you on a routine list whereas femoral, you kind of want to be a bit more, bit more. Um trying to do it a bit more inguinal. If it's, if they're really old, if it's not causing any problems, you can just leave it. But the others you need to repair how to tell direct, indirect. So I always had a bit of weird stuff about this. The easiest way to think about it is think about direct, direct pushes directly through a weakness in the abdominal wall. It's a traditional hernia. Ok. So think about it as the direct and then work it out by exclusion. Whereas indirect doesn't go directly through the abdominal wall, it goes through the inguinal canal. So therefore you to check if it is indirect, you obstruct the canal by putting by pressing down at the deep ring, which is you can say at the midpoint of the inguinal ligament. But what that means is the midpoint, the ais and the pubic tubercle. So everything relates to the pubic tubercle, you basically press down there. So you can say many different anatomical markers, whatever some say, like just above the femoral pulse, whatever you want, you press, ask him to cough. If it doesn't pop out, it's indirect. If it still pops out, it's direct. Simple as that because what you're doing is you're pressing down on the bit where it would pop out on the canal. And therefore, if it doesn't, it's indirect. If it does, it's direct, it's circumventing that. Incarceration versus strangulation is something that I didn't really understand either. Incarcerated means it's irreducible when you try to. So it's obstructed, strangulated is much worse. It means the blood is so tight, the blood supply is cut off and the bowel is dying. That's they're both emergencies. But strangulation is very, very bad, may require resection. Incarceration just requires repair. So that's the difference. So you're much more worried about a strangulation than an incarceration. I think this is we're getting towards the end. This is the last question I'll skip this one. Yes. So, while you're on board cover 26 year old male post-op complains of new-onset chest pain. What is the next thing you would do? Ok. Yeah. Let's see what you think. Good. Yes. Very good. You'll be good at one. yeah, a to e so I think back in my year they did not teach us an A te formally at any point during, um, final year. I own the Atlantic because of the SFP. Um I think they do it for you guys now, which is good because honestly the most, the most important thing and the most important thing you do with anyone who you think might be unwell is to do a full A to e don't fall into that trap of like, oh, I need to get the single best investigation and jump straight to that. Um Do your assessment stabilize them, the rest can come later. Um Great. That's very good. I'm very glad you all picked that. Cool. So I'll just chat briefly about the POSTOP timeline and complications that happen because this is really good to know. So it can be split mainly into days 1 to 3. So immediate complications, medium from day 5 to 7 onwards and then late 10 to 14, I had this, I never really knew. But when you just picture it out in a timeline, it's much, much more straightforward. So day 1 to 3, what you're worried about you worried about atelectasis due to pain, not being able to de breathe due to someone being all in your guts messing around, cutting stuff up. Um, atelectasis, which leads on. Yes, ale is bad, but what it leads on to is pneumonia and people die of pneumonia. You don't like pneumonia. Um, you can also get some urinary retention with certain operations if you're fiddling around near that and you can get reactive hemorrhage. So this is known as bleeding within the 1st 24 hours, is reactive hemorrhage, usually due to a nicked vessel or a slipped stitch. The reason you don't find it intraoperatively is because your BP is dropped by the propofol when you're put to sleep. Um So your BP is dropped, your vessels are dilated and so you get less bleeding. Whereas when you start to reperfus, you get higher BP. Um and cardiac output after you wake up and your anesthesia wears off, you start to bleed, which is again, I think why they call it reactive bleeding days 5 to 7. That's when you get your infections. So you get pneumonia or a wound infection or a urine infection, all your infected processes happen around five days after. So that it's less rare, less common that you have it immediately after. And it kind of makes sense because if you soil the area, like unless you have like zero immune system, the chances of you getting infection like the day after doesn't really fit. So all of your infections associated with the operation tend to happen 5 to 7 days after and you can get secondary bleeding, which is bleeding after a day really. And that's usually due to an infection as well. So it's usually a sign of a wound infection. And then from day 10 onwards is where you get wound dehiscence. So the wound is decided to break apart or DVT or P. So DVT or P fairly common after surgery because often you have many risk factors. So surgery itself is a big risk factor and often the reason for the surgery itself is also a risk factor in and of itself like cancer or something like that. Um And so that happens day 10 onwards, day 12 is I think, sort of classical or two weeks and just towards the end, I thought I'd leave you with this, this sort of thing to refer back to just, just, just before you start. It's nice to have a written down solid A to E and this is the one that I sort of made or had for my SFP prep. And honestly, when it all goes to ship it all leaves your head. So you go down to your sort of basic lizard brain. So sort of mentality and you just, so it's good to have something to fall back on, ok. Just to close off, you will be ok, you will pass your exams, you'll do very well and you'll be good doctors final. That is great. Um And on a, on a, on a so separate note, like I know Imperial has its ups and downs, but it does train you to a decent degree and most people and people are fairly put together. So you will be fine in the broader scheme of things as well. Organize a nice elective. It's not too late. I sorted mine out in November if you want a tip, the best way if you haven't got it sorted yet is just to send out emails to people and just get them to agree to take you and then it all works very easily from there. I got an email response within a day from someone by email, which is how I ended up doing my elective. I had an amazing time, best time in med school once in a lifetime opportunity. Sort it out. Try and try and get some money if you can. It's very good. Um Don't forget to enjoy your life honestly. Like it's up to you, like doing well is nice. Be good at your job is nice. But if you just want to pass, that's fine too. Um Because yeah, this stuff doesn't really count much anymore. It's more of a personal choice. Uh do not be a scab when you graduate it, it ruins the profession for everyone else and it, it just fucking sucks. So please don't do that. Um it's not worth selling your soul for a bit of low income. Pay for, like, what, like 25 lbs an hour. Um, and yeah, be nice to each other. Like, what one thing I've realized is that it's really nice. The medical community is really nice. Um, the only people who really look out for you when you graduate are other doctors. The only people who have your back are other doctors and like, yes, there's drama and stuff now but like it means nothing and you, you realize that so don't, don't be sneaky, don't sort of be, be good to each other. Um And yeah, any questions, any eyes feel free to get in touch, drop a question now or e drop me an email. Um I am in hi done for the whole year, unfortunately. Um So if you want to drop by to do an out of hours shift or something to get some experience of, of that, feel free to let um drop me an email or if you need to sign off also feel free to drop me an email. Um, unofficially, but yeah, great. Any questions at all? Um Let me know otherwise thank you very much for coming. Uh Yeah, thanks to um, that was really, really helpful. I do have one question. I don't quite understand what you mean by the functioning idiot toy. Yeah. Sure. So um essentially let me just get a bit of the bowel up. Oh, sorry. And while you're doing that, uh the feedback is the feedback um form is in the chart. I, I don't know if that's the same one that you got the QR code, whichever one is fine, honestly. Um I, I don't know, feedbacks real like people say you need it. But yeah, I it'd be nice to please do for that. But yeah, not a big deal. Yeah, I mean, yeah, in guys because it's, it's right there and that was actually really, really helpful. Yeah. So um yeah, a lot of things in medicine are actually you can kind of work out from the name and I think that's kind of yeah, a good way to do it. So de functioning. So the function of the bowel obviously is to make poo and pass poo through it. So this is your large intestine, right? And you would normally pass poo. Let's say you remove like let's say you remove this bit of it. So what you do then is you basically take the bowel here, you join it to the bowel right at the end. So that's your anastomosis. And it's essentially two bits of bowel that are kind of stitched together, that's very fragile. And if you try and like send a big poo through it, it will break, it will leak and you can get complications, you can get collection, you can get abscess infection. Um You can go back to theater. I know a few cases who've gone back to theater. Um, and it just puts, I guess it puts, if you have a piece of bowel that needs to work metabolically, it will put a higher sort of stress on it, it will need more oxygen as a higher chance of going ischemic. Whereas if you, if you kind of just think about if you put it on rest. So, uh, after surgery people aren't up and about running around, they're on bed rest because they need time to recover. Your bowel is exactly the same. It needs time to rest, to rest. You need to take away all the poo away from it. So what you would do is, uh, we can, you do it with the small bowel usually, but we'll say that you can imagine this is a, this is like a bit of the small bowel, the cecum here. So you basically just take a loop and then you kind of where, where is our diagram? You take a loop of the small bowel and you kind of take it out like this. So if I can just draw, yeah, I'll just try and draw. So you take it out like this. So this is all one loop and then this is the skin. So you literally have a little hole and you have one loop of continuous loop of bowel coming out and then you make a hole here and you make a hole hit and that's your loop ileostomy. So anything passing through, essentially, if you think about food, passing through, being tied in the stool, it passes through, this limp goes up and then it would normally continue to pass through. But because it's been taken out, it's more like it's going to instead fall out on into the stoma bag. Um, if it doesn't, it will fall out of this hole instead, but it, what it won't do is pass any further through the, the bowel, the small bowel. Um In which case, basically, you get no downstream flow. So no stool will flow into the large intestine to form stool. So you get nothing flowing through your anastomosis. Therefore, you've def functioned it. So you, it's not functioning as normal bowel and you'll ref function it when you put, when you fix this ileostomy and just connect everything back up together. So this is why it's a loop because you kind of use one loop of bowel to form this loop. And this is, yeah, that's a loop ileostomy. And the end ileostomy is literally just if you take your ileum out like this and then that's your whole and that's your stoma. So end and loop, that's the difference. Um Loop iost is almost always temporary. You would not have a def functioning ileostomy, permanent. Mhm Sure. Well, why does that have to have two holes then in my? Is it just so everything gets out cause I guess if you were to completely cut it, you would kind then have to rean it. So if you just cut it, if you just made end, I, the ostomy just had a free sort of stump, you would then have to join up together again. So you kind of create the same problem if you see what I mean. That's my rationale. It's not based on anything, it's just based in vibes, but I think it makes some sense, but the truth of the matter is you don't need to know and I think that's a reasonable enough explanation. But yeah, that's why I would say thanks if, if anyone else has got questions, if you don't want to, I mean, you can just put it in the chat. I'm happy to read them out. Um I did have another question while people type or whatever. But if you scroll back to the um one where you were going through the different types of uh colectomies. Oh yeah, this one. So for the right hemicolectomy um are you, do you remove the appendix as well or is that just where you put the line? Oh yeah, you remove the appendix as well like, yeah, you people, they remove people's appendix as if they don't like the look of them. But you know, it, it's such a minor thing like honestly sure. Um operations. Yeah, there's different tiers to operations like a la laparoscopic cholecystectomy. It's like an appendicectomy. They're day cases, you know, like you could do it easily on anyone. I could probably do one. if they actually, yeah, sometimes in f, one year to do an appendicectomy just to illustrate how easy they are and how sort of low risk they are. Um, there's no benefit to having an appendix so they'll just remove it if they're in there anyway. Poking about. So, yeah, they would. All right. Thanks. I think there is someone typing a message in the chart. So if you just do, I still, I still don't understand. Sorry. Yeah. Yeah. What was it? I still don't understand why the leep ST there has to have the second hole. Um Basically the same question I just asked the minute. Yeah. So basically they call, they call it the, um, afferent and efferent limb. Um, and I think so. I think the reason is so you don't have to make, um, the end and you don't need to rejoin it. But also because it just reduces the chances, let's say anything gets passed here, it will go out of this hole instead. So I think it works to reduce the chances of anything at all getting through. Um, I think that is why, but it could equally be because you don't want to make another anastomosis because that leaves you the exact same issue and the exact same problem. Um If you are curious, it's something that you could give it a Google as well. But to be honest, this is just one technique that we do in the UK. They have other ones where, for example, they make these pouches where you don't even need to have a stoma. So again, like surgery, I think for, for, for finals level, this is all you need and this is the most common thing. Um But that this stuff is not like, well, it is a science but there's a bit of sort of freedom to it if you see what I mean. But yeah, this just typically how it's done. Um And also happy to answer any questions on anything else you guys are unsure about. If any, if there's any just random things you just never knew the answer to. I'll try and answer it if you want. Cool. Yeah. Thank you. I mean, yeah, go ahead, ask questions. I'm just gonna end the recording now. Cool.