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Good morning everyone and thank you for joining us today. Um And it's Mohammed Robby and then the Dukes Club presidente and uh Nicola with me. Um And Nicola will uh finally introduce us to the course today. Good morning everyone. So, welcome to the fundamentals of color proctology course. This is a course that's brought to you by the Association of Color Proctologist of Great Britain and Ireland and the Duke's Club. So as Mohammed said, he's presidente of the Dukes Club, which is the trainee association and I'm chair of the Education and Training committee of the A C P G B I. So, uh we've got a lot packed into the day. We decided to do a one day course rather than two days as we know how hard it is for trainees to get study leave and we've kept the course free of charge. Um uh We've got a great day of talks with some excellent speakers, hopefully giving you everything that you need as a trainee to survive the general surgery and colorectal rotation. Um Apologies if the, if the day and some of the talks are actually, you know, there's a lot covered in each of the sessions. We've tried to keep everything as uh as compact as we can. There will be the opportunity to, to ask questions and joining the chat function. Um And hopefully you'll get a lot out of the day. Thank you to all of our speakers who spent a lot of time creating the talks and have given their time for free to join us. And uh thank you to, to Medal who have offered the platform free of charge to allow the course to go out to as many people as possible. Uh free and open access, you'll be able to watch it live and you'll be able to watch it on demand afterwards as well. So, uh on that note, I will hand over to Mohammed to introduce our first speaker. There's been a slight change in the order of this morning session. Um I'll leave Mohammed to introduce things further. Thanks, Nicola. Um And yeah, thank you everyone for joining and just let you know, we have uh 250 registration from over 30 countries. And it's thanks to middle again to, to allow this to go to uh to surgical trainees from all over the world. Really. Um You will have the recordings available as well after we finish and you got the schedule on your left left hand side. And just to uh if you, if you have any questions, there's a chat function uh on the, on the right hand side, uh the screen, you can ask question there and we will get them to the speaker at the end of the talk. So, our first speaker today is uh and he will talk to us about the principles of uh bowel anastomoses and uh tumor formation. Uh Thanks Chris. All right, Jay Press present, man. Yes, please. All right. So kind of check that people can hear me. Yes, we can, we can see your slides. Great. Right. Well, thank you very much to Miss early and Mr Rabbit, the introduction, if my name's Chris Patties be, I may talk about a consultant in Wrexham. Um and to the point of view, anastomosis, particularly I spent my research years doing that. So I spent a lot of my waking and sleeping. I was thinking about the anastomosis and I can strongly advise you to spend as literally be sleeping hours as possible, thinking about the anastomosis, right? So there's a bit of overlap in terms of the technical perspective from both anastomosis and statements it will come to. But obviously, this is the talk about fundamentals and we're talking about. Yeah, whereas talking about the tech techniques, you will hear the phrase occasionally decisions before incisions. So before we get onto the technical stuff, just to think about addressing your patient's patient's concerns, particularly regarding stones, because a lot of your patient's will come in with the option of either a stoma or anastomosis depending on the disease they may have their diagnosis before they get to the clinic and quite frequent, the patient's be much more apprehensive about the thoughts of the stoma. Um compared to everything else, even the disease that's being treated. But the reality is that a stoma may represent a much better quality of life option for your patient. So it's really important you can address their concerns regarding statements and if it's a likelihood of possibility introduce the concept early, so that they can come to terms of the idea because once they understand it, the patient's often accept it more readily and worked very closely. The ostomy nurse. Is there a fantastic resource? They have seen it all and they've answered every question. So make sure you're familiar with what they do and you'll, you'll learn from the so on to the anastomosis to start with the aims of a gi anastomosis, aiming for a sound anastomosis that doesn't leak and doesn't stricture, think strictures likely to be the other side of the uh schema coin really? So they, so you wanted to, the patient will then have a return to a manageable gi function once everything settled down and they've recovered fully. Now, the longstanding principles of how to uh inform a good anastomosis, you've got to have healthy tissue in a healthy patient. Very important, good blood supply, low tension and needless to say a sound surgical technique. So in terms of patient factors, um if this lady on the on the left of the slide turns up to your clinic expecting a trouble free operation and the sound anastomosis. You may need to have a detailed conversation. We've got a list of them things on the right hand side that I'm not going to go through it all one at a time. But you can see that there are multiple risk factors that can affect and essentially affect tissue healing. Therefore, affect anastomotic healing and increase the risk of anastomotic leak and all of those things, they're cumulative. And you have to be aware of all of the risks and be able to counsel your patient in terms of the risks that may be presented from either their, their disease or their medication or their lifestyle. So make sure you've had a good look at that, that list of things. But if you go through the slides again, because you will get copies of the slides and quite keen to get onto the the technical side of the talk. So in terms of the technical considerations, good blood supply and the low tension are both achieved by mobilizing the colon and it's associated mesentery very well and preserving out of the blood supply. So if we look at these, there is a talk on the anatomy, a prerecorded talk that's coming later. Now, in terms of mobilising, you have to identify and divide the perennial reflections as the vascular white line of Taltz. Um and that's the mobilization And if you think about the blood supply, the little diagram there on the, on the right, it's got all the blood vessels that supply the colon. What you really, really important thing is what you're leaving behind. Because if you take, for example, divide the I M approximately be depending on the marginal artery. So you have to have a really good understanding of the blood supply to the bowel, the variabilities that can occur with that. But it's the mobilization and knowing the blood supply are the key to healthy tissue that can form part of your healthy anastomosis. I think this is the most important thing of all, really the importance of understanding the medicine tree because mobilizing the medicine tree and it's associated colon, that's the key to achieving low tension with a good blood supply. And you got to have a really good understanding of the medicine tree and its relationship with director in Paris. Any um reflecting on my own training and discussing things with colleagues, I think this is nowhere near as well taught as TME, for example, because the legacy of Basingstoke and Bill healed is not only the procedure of TME but training. I think that we're probably not as good at training, mobilizing, amazing training. Think about the bowel as a this bit and then here's the medicine tree and the mesentery takes the blood supply from the middle of the lateralized or to the transverse colon. And you're trying to bring up. You hear people talking about medial collateral, lateral, medial, you're trying to bring all that lot up together back towards the middle. So it's mobile and you preserve the vessels and you really want to have healthy peritoneal tissue on either side from an oncological point of view. So you've got a nicely protected mesenteric package, a lot of variables with the medicine tree, you've got a very thin elderly person with low body protein, low body fat. The mesentery can often be pretty much transparent and the lateral border of the meeting to you. When you're mobilizing, it can be almost indistinct from the retroperitoneum and it can make it very, very challenging. You can easily make holes in the mesentery and someone who's that thin and similar. You got somebody who's very overweight and they've got a poor diet, low fiber diet. You may find that have a very, very thick, short mesentery. It still contains a thin little I am a quite often, but that's a very challenging reason to dissect as well. And it's the sort of fact that can bleed a lot. So it's, it's that's difficult. So just make sure that you're really aware of the variables, even if you're not getting to do the operation yourself. If it's sort of early stage of training, watch what your trainers are doing and watch how they're mobilizing amazing tree and question them and asked to get an understanding because the sooner you understand the me sentry, the more, you know, more quickly you'll learn from your training. Also remember that the colon, the cecum transverse colon and the sigmoid are intraperitoneal, all the other parts of retroperitoneal. And when you're trying to identify the line to start dissecting, sometimes it can be quite confusing, particularly someone with a very long floppy sigmoid, for example, and the sigmoid medicine tree stuck to itself in parts or if there are loads of adhesions under the abdominal wall, make it can be difficult to find you're starting place. The landmarks between the intra and retroperitoneal parts are very reliable. And if you, if you need to find somewhere to start your dissection, that'll take you into the, take you and keep you in the right plane, start with those landmarks. Now, in terms of four million Estima Asus, we've got options including stapled hands own than a combination of the two and the shapes of morphology. They can form the other big side to side, end to end or side to end or enter side. It's important to have a familiarity with all the options. And so I'd certainly recommend getting very familiar with one and having a sort of go to anastomosis, but be familiar with all of the options because really all you're trying to do is to achieve Syria muscular opposition, the deer into the princess, as I mentioned a few minutes ago. And the reason for Sarah muscular position, that's where the strength layers of the bowel are also, you're excluding mucosa from the anastomosis because there's a small chance that increases the risk of other leak or the fistula ation. There's a table here to have a look at. Understand. I'm not going to go through it all in boring detail. It's just something people have a look at later to have a thought just to have, have some thoughts about the different anastomosis. Um For idea Pollock, there's there in terms of the time and it's trying to keep it to fundamentals. I'm going to talk about ileocolonic, an estimate osi's and left sided anastomosis because they're the commonest colorectal ones. You'll see that there wasn't really time to cover small bowel anastomosis and it's slightly more of a general, although it's good, good training, good technique. It's a little bit more general surgical. So the 33 likeliest earlier Kalanick and estimates is that IDSA Colectomy, right? Hemicolectomy extended, right? Hemi. And you can have a quick look at the table at some point, just just have some thoughts about where the anastomosis is going to lie when you finish the operation. And in terms of mobilisation and tension free, try to achieve an anastomosis, that's its own separate entity. So the anastomosis can sort of move around separately because one of the enemies of anastomotic healing is tension from one or other limb of your anastomosis. So if the small bowel, for example, trying to pull itself away from the colon, you're an estimated two or if the colon isn't mobilized enough, there's a risk of leaking. That's a particularly pertinent thing for the extended right hemicolectomy as the terminal ileum has been swung all the way up to the, the descending colon. So just think about where your anastomosis is going to lie at the end of the operation and how to make sure that is tension free and a list of the different diseases you might be treating with those different, different receptions. So a standard sort of ileocolonic anastomosis. I think the majority of people staple the anastomosis now. And typically you'll be a 9 to 75 mil stapler to the, to the limbs and then a 19 millimeter right angle staples the enterotomy, although it's reasonably common to hand. So the enterotomy, there's also the Barcelona technique which again, the restriction of time I haven't done a compare and contrast, but I certainly recommend having a look at that, making sure for many of how it works. Because, you know, once you've mastered that technique, it's a very reliable and reproducible technique, hand sewn anastomosis. Typically an isoperistaltic anastomosis. Again, something that people don't do that frequently. I think it's on the the in person part of this course, when you get to do that, it's a really nice technique to be familiar with and you don't want to have to do it the first time ever when you haven't done it for a few years. So do you have a familiarity with it? Essentially you? So the back wall of the to bow, the two limbs, a bow close together before you make an enterotomy and stay close to your knees and tree. So you don't run out bow, make the enterotomy. And then the thing to mastered here is the Lembert suture to be able to do the inside layer and to go around the corners. And so have a, there are youtube videos that is far better to watch it, then have someone like me to just try and describe it to you but try and try and have a look at videos of the Lambert suture. So you, you have an awareness of that technique. So let's the pictures. Now, I apologize that it looks a bit like a child scrapbook. I had a lot of trouble with the photos because of the size of the files. So had to find a way of getting them all in here. Now, the top top left hand photo with the instrument lie against the bowel. This is really, really important. You need to have a slightly longer mesentery than about if you think that the medicine tree is the food, the bowel is the mouths to feed. So you don't want to have more bowel than mesentery. Because if you look at that picture, you can see to the left of the instrument, there's a little bit of bowel that could potentially be a scheme ick. And if you've introduced that into your anastomosis, there's a risk of that corner becoming a scheme it and then the anastomosis leaking. So the middle picture, you've got the, the staple has been angled slightly to have the bowel. So the bowel is shorter than the mesentery. And you can see the staple line that you're left with their before you come to the anastomosis and then I'm just going to go back to that so you can have a look and make sure you're really many of that concept of making sure there's more recently than that. And then top left hand again, taking a very small full thickness corner off the anti mesenteric parts of the staple line, do the same thing for the colon and put the stapler down each limb, keeping the lengths the same and keeping the tension low and making sure the tips of the stapler don't go through the bowel wall. This is pig, by the way, it's very thin. Bowels is just wondering why it looks a little bit unfamiliar. The third picture is a, the stitch, the anchoring stitch. Some people call the crunch stitch. You need to leave the stapler closed through between 15 and 30 seconds to let all the edema and squeeze out the staples are deployed as you in the shape that they need to work. So the time it takes to put a little stitch in buys you that time and then check the anastomosis. So top left again, have a look down the joint. You can see the patent anastomosis, make sure there isn't any bleeding from the staple lines. You can address that at the time if there's any bleeding and then you have to decide how you're going to close the enterotomy. Um So one option is to, this is what I tend to do most of the time. Now, I put Syria muscular stitches in both corner's just to the edge of just, uh to the end of the staple lines and then one in the middle and lift up. And that way, I know that I've got the full thickness layer and it's not going to have a little bit of bowel that's dropped down. You're not going to have a whole, you can put those serum muscular sutures all the way across the closes and that works just as nicely. This is a little bit quicker. And then, so you lift up on the three stay sutures and then use a right angle stapler to do the top. Then we can see the staple line. Generally, the manufacturers' recommend not using the linear cutting stapler for that top bit because as the, as the blade goes across the top, you can cut through your pre existing staple line, which isn't something that happens with the T A because that doesn't have a blade, you have to cut the bowel yourself and then bury the junction, try to offset the staple lines in the middle, the front and at the front and back. And then if you do a square stitch to bury the staple line and have somebody tuck the tuck the thing in for you as you tie it right. So onto colorectal anastomosis, which is the other one that you'll see very commonly um for left sided colonic or rectal pathology, almost, almost the cancer. But obviously, we do left sided operations for diverticula sometimes. And also for recurrence signal involve Youlus um segmental receptions much less commonly for IBD. Again, divide the adequately mobilized bowel, the linear cutting stapler and adhering to the principal's I'm saying previously about making sure there's more meeting through than power, then divide the rectum with the right angle stapler or a contour contour is nice to have got the blade in this as well. So you don't need to be messing about down in the pelvis of the great big long knife. And then the estimate is almost always fashion with a circular stapler, hand stones an option. But it's something of a legacy procedure now. So you secure the anvil either through the end of the side, um really important to put the sizes into the rectal stump. So if you're the person at the bottom end, get the sizes, make sure you understand the shape of the rectum and also understand the instructions of the person at the top end and don't be offended. If the instructions do sound a little bit sort of military and style, you've got to be absolutely sure that both people know what you're saying. So sometimes is stick to really clear instructions, like hands down towards the floor, hands up towards the ceiling, hands away from me, hands towards me and the person at the top end is in charge and is very important that that's sort of recognized. Then once you've got the shape of the rectum with the and you know, the length of the rectum with the sizes and you lubricate the stapler absolutely loads and gently advance it into the staple line. And the other major pitfall here that must be avoided is if you're operating on a female patient, be absolutely sure it's in the rectum to through the anus into the rectum. And that's not a joke. That's something that can happen and particularly the drapes are on and the patient's in a funny position. So if you put your finger on the toxics and slide forward gently, then you know that the first defect you get to is the anus. And then once you get your staples, the top spike comes fully out and you must not let the spike drop back into the rectum cause it can be very difficult to find that whole and uh fix it again. So you keep the tension at just the right level. The ambulance spike click together, ordered li and it's that's why it's important to make sure that you've not got the music on and for this bit, then you slowly compress the tissue to the market on the stapler. Make sure nothing else is incorporated. And things that can be incorporated at this point would include the bladder or the vagina or small bowel, probably other things as well, but make sure that there's absolutely nothing else except two ends of bowel in that line. Once you compressed it and you check again, ensure the tensions low, make sure that there's no small bowel that's slipped underneath your conduit as it comes down on the left side. Um So yeah, fire, fire the stapler and take it out and then that's, that's the time when you check that the tension is low, the small bowels in the right place, then you test it, do a hydro pneumatic leak test. So include the bowel fill the pearls of water, blow air in and make sure you haven't got a stream of bubbles. If it's just a stream of bubbles, usually one stitch or two stitches would address that. And then you can test again, then make sure you check your donuts and then you can do a flexi sig to test the estimate to have a look at the estimations where you can see that the mucosa looks nice and pink. So that's using the contour to divide the rectum below the tumor. Just a few more. Another sort of scrapbook series here too, just to demonstrate what I was talking about. So, Anvil, that's the stitch that I like. I favor to put, that's in the far end of that is the Conduit. You can see if you look at the pictures, you can see the stitch goes I/O rather than over and over and over it. Purse strings, which more effectively I find if it's gone I/O rather than over the top. So, and you can see on the right there, the amble is secured, there's a stapler and you bring it through the rectum, you can see it just starting to peek out. It's below the staple line, just try to get away from the staple. And it doesn't matter if it's above or below is if you try to get the stapler to come out away from the staple line and then on the right, it's all the way out and you can see the little colored mark to share the staples all the way out. Click them together. Former anastomosis. Now, this slide is really just to say to make sure that you're absolutely familiar with the kit you're going to be using because if you, it's quite likely you'll get different kit, you'll move jobs as trainee, the procurement people will make decisions that you're not always aware of. And uh you know, the supply chain issues the manufacturers are having etcetera. So you don't want to be familiarizing yourself with the stapler when it's inside the patient. Because I think that's probably negligent. Really. You've got to be absolutely sure. You know what you're using. There's plenty of time while the patient's in the anesthetic room to just going to have a look at which guns you're going to be using for the case and to make sure, you know exactly how to use them and then you can test your on, on the right or you can't tell my fingers do that anastomosis to make sure it's patent, um, on the right. We've got the donuts so we can move onto statements. Now, um, then we like to classify things particularly for exams. Um, so you can classify according to what the bowel, which bowel you've used and you can make statement out of all sorts. But in terms of emergency or colorectal surgery we're going to be doing either Gen Gen Ostomies, Ileostomies or Colostomies, somebody gently normally, um, colon, then the structural nature to loop stoma, the bowel is in continuity and the mesentery hasn't been disturbed as a loop stoma that you bring up the picture in a second and an end when we've transected the bowel and the double barrel stoma, if you bring up, if you divided it to remove the section of bowel, but it's not safe to put or practical to put the two ends back together. But you can bring both ends up the double barrel stoma, we should avert the small bowel stoners, um, and colostomies can be flushed to the skin and there's, the small bowel content is very irritating to the skin as Colostomy output is just normal plain old stool that we're used to. And that's far less irritant skin. Now, again, it's really important to the age of the ostomy nurses as soon as possible to understand what they do. Stoma citing is important and the elective patient's would have been seen by the Stoma nurses, but the stoma nurses aren't there in the nighttime out of hours on the weekends when you're doing an emergency operation. So try to apply the same principles. Keep the stoma away from the bony prominences away from the belt and waistline, the variety of other important things like the patient in a sitting position, a standing position, etcetera. If they turn greasy obstructed, it's very difficult to see what they would look like normally. But there's the sort of principles to a deer to and again, it's very important to have adequately mobilize the bowel and the meeting tree just take a circle of skin. Um, I like to just make a little cross shape and then join the dots around the edge and you get your circular a different way to making the circle, then dissect down to the fashion. You don't need to dissect out this great big alongs of lip you cutaneous call, it looks like a donut kebab. Remember people that was sort of a fashionable thing years ago and I started my training, but just keep all the fat in place and split it and get down to the fascia, make sure you stay perpendicular to the traffic. And again, it's really easy to go wandering, particularly a very adipose abdomen to make sure you stay perpendicular. Open the fascia, split the muscle and just be very mindful of the blood vessels that run through the muscle, then open the posterior sheath and ensure the adequate size to get this, the bowel through. People say two fingers. But that's again, I don't think it's really a very uh politically correct description cause two of my fingers are very different from to sort of small female fingers. So really make sure that about the, the, the national defect is the right size to bring the bowel through. Um your delivery using Babcock's Forceps. Um uh electric, I was thought a few years ago, um use a smaller Alexis wound protect. That's a particularly difficult to deliver the bowel through the stoma defect. That's brilliant, but it takes all the tension, all the friction away. You don't traumatize the tissue, you don't end up with bleeding. Um It works really well. If it's a difficult one to deliver, then we have to avert the small bowel. There's a description there you can read, but I've got a couple of pictures in a second which tell the story far more effectively. So here you go. So you're looking to have, there are three sutures. I prefer to go through the skin first and then you take a little cereal muscular bite your in three places. If you imagine the points on like the points on the Mercedes sign, that's, that's the sort of distance you want them to be away from each other, avoiding the medicine tree. So go through the skin super, particularly the skin, then through the, through the bowel quite low down and then all the way up to the top, you can see the third stitch of the transected edge, put three stitches in place. It's more difficult if the bowels been inflamed. So the patient had a leak or the patient's been obstructed and that can be difficult and making a decent distance. We know stitches is effective. I find it's really helpful to get your assistant to put the blunt end of some forceps into that little gap as you're flipping it as you're flipping the bow just to push it up from underneath rather than people putting Babcock's inside the bow. If you took some, uh, took some forceps underneath the help, flip it up the blunt end that works very nicely. This is a loop ileostomy. You can see that's a little bit like those fancy convertible card where you can press a button and the roof comes fold back over. Imagine that's the sort of the thing you're trying to achieve. So you make your incision away from the apex of the loop and making sure that you've averted the end where all the affluence going to be coming out of. It's actually fine to avert both ends. And it probably slightly reduces the risk of the bowel content trickling over into the defunction end. Colostomy. Generally much more straightforward. Again, ensure that you've got low tension, it's well worth reducing the belt by taking the epiploic a away, then deliver the bowel to the tree. Feen, preserving the mesentery. Again, using the Alexis wound protector can help with preserving the medicine because the last thing you want to do is to pull up the bow and strip the mesentery off because then you're going to end up with a scheme extima and that's a disaster because you really don't want to be having to take these patient's back to theater to refashion the stoma in the first few days. Um It's fine if there's loads of mobile power, it all comes up just divided to keep it flushed. Don't start trying to tuck it back in because then you have a big redundant leap of bowel sitting somewhere, sub particular sutures and serum muscular sutures to fix it in place and then check that its patent by putting your finger on it. The situations that you might find difficult simple mation high B M my patient with a thick abdominal wall. Um If the mesentery is very, very short and thick, it can be difficult if you're doing re operative surgery, either an emergency. If patients have a leak or patient had loads of previous surgery, you have to work out. Sometimes it can be difficult what to do with the other end of the bow generally. And you can bring it up under the abdominal wall, particularly, you can bring it through the same trophy that is preferable rather than leaving closed off about, except, of course, in the situation of a heart mints, you do tend to leave the closed up parental step inside, but don't be afraid at this point to us for help. Don't think I've done, I've done a hold of this, Hartman's on my own and it's really good and now it's the home straight and it's just the stomach, the thought if it's difficult to get the stomach up, ask for help, particularly you're doing the operation with just one assistant because that's quite a common situation these days because you don't want to be in a situation of the patient having a really suboptimal or ischemic statement. Yeah. So the key points of the talk from this from steamer and Estima cyst formation, the thing that will make the biggest difference, understand the medicine tree, understand what makes it with the variables of the medicine tree and it's retroperitoneal relationships and those junctions of the bowel of the intraperitoneal and retroperitoneal colon. You've got to make sure it's low tension and well perfused, predict and manage the challenging situations and manage the patient expectations. So, thank you very much for listening. I'm very grateful to Ethicon for providing me with the bowel ease the photos and for one of the foundation doctors, Joanna Cameron, who helped me last week when we were making the photos. Thank you very much. Thank you Chris. That's an excellent overview of anastomosis and stoma formation. Um I think it's important for everyone to remember that each of your consultants or attendings will have a slightly different way of creating the anastomosis. So uh pay attention, listen to how your attendings and, and consultants do it. But those are really important principles. Thank you very much, Chris. Thank you Chris. And as Chris has risen in his talk, we will be doing face to face courses at regional levels and we're starting the first one in Sheffield tomorrow. So um just keep an eye on when we advertise for the course in your region if you're in the UK. Um So thank you again, Chris and we're going to move to our next speaker and uh it's a pleasure to introduce uh MS usually who will be talking to us today about the theaters and patient. Uh Thanks. Uh Thank you very much more. Can I just check it in here and see the slides? Okay, great. Um So, yeah, thank you. My name is Rosalie. I'm a colorectal surgeon in the said hospitals in the north east of England. I'd like to Thank Dukes Club in A C P G B I for asking me to present today on a fantastic program. I've been asked to speak about theaters and patient setup and this is quite a broad topic and involves a lot of non technical skills. So over the next few slides, I'm hoping to share some basic knowledge and key steps for a colorectal trainee insurgent relevant to our practice, the standardized patient pathway for undergoing an operation is now recommended by the who guidelines to be as follows. So the patient presents for a preoperative check. A team brief occurs with all of the members of the operating staff. A sign in begins before the start of the anesthesia. During which time the patient and operating theaters are set up prior to being the surgery, there's a time out that should be performed. The surgery is complete after which there's a sign up for that procedure. And at the end of the day, when all the operations are complete, there's a team debrief. In my personal opinion, I think the team brief is the most pivotal part of the procedure. It sets the tone of the day. It's an opportunity for everybody to introduce themselves and each of the rules. This is also useful if you have a variety of training operations and you can divide up the operation and kind of explain which part the training will be performing, which part will consultant, be performing the steps of the operation are also highlighted, particularly the use of antibiotics. What patient position that we will be using any extra lines that will be placed into the patient required equipment if it's present or does it need to be brought in from another theater? Any allergies, particularly latex allergies, the estimated time that the whole procedure would take need for vte prophylaxis and the overall room layout. It's also an opportunity to highlight any critical issues or factors. For instance, if the patient's a Jehovah's witness or expecting anything unusual, um it's also important to look at the room layout during this time, whether you're performing robotic laparoscopic or open procedures where across the room with the various equipment be present. If laparoscopic or robotic procedures are being performed, there usually are auxiliary screens and it's important to look at where around the patient, we want these screens, be it the left or the other patient or between the legs. It's also important to understand where the assistant, the Scribners, the surgeon will be positioned around the room. Uh It's particularly important to look at wires and where the wires be laid out across the operating table. Um And it's important to try and not to trip over them and trip stop is quite a useful little plastic tool that could be uh stuck onto the floor to prevent any undue hazards, whether you're performing of right of procedures, whether it's robotic and laproscopic, I think as a trainee, it's very important to step back and understand the layout of the room and where you as operating surgeon would like your equipment to be. For instance, if you're doing an appendicectomy or right hemicolectomy or performing a right sided abdominal procedure, you're probably looking at standing on the left side of the patient and your assistant as well. You'd want the monitor to be aimed towards the right hip and maybe another slave monitor axilla to monitor aimed towards the right shoulder. This allows you to operate in line with the anatomy and you're not sort of unduly, turning your neck or your body in an awkward position. Similarly, if you're performing a left sided laparoscopic procedure, like an anterior section or Sigma colectomy, you're looking at standing on the right side of the patient with the monitor aimed towards the left hip and maybe an auxiliary monitor towards the left shoulder. These monitors are obviously mobile and can be moved around as you need them. So if your anatomy changes and your position, changes of your patient, you can move these monitors to make it in the most ergonomic position as possible. Now, let's move on to the patient position, the various factors that should be taken into consideration such as the type of operation, the length of the operation, the need for an aesthetic access to lines, the patient factors themselves, the surrounding equipment and ensuring the standard guidelines of the ventilation requirements, the presence of wires and ensuring adequate infection control standards are maintained. Particular patient factors that would be of importance would be the B M I either high or low. So if a patient has a high B M I, you may perhaps will need more, more number of staffed position, the patient or you may need special equipment for it or you would maybe look at the length of the procedure being a long procedure would be detrimental for a patient with Hae PMI. Similarly, if a low being my patient, they may be more pro to any pressure damage, age is also taken into consideration in any co morbidities and any pre existing your muscular skin or bone conditions that could be negatively impact with a long procedure in an awkward position. And ultimately, the goals of placing the patient in a safe position is so that you can maintain the airway and circulation throughout. You have adequate access to the surgical field and you maintain a neutral patient position whilst preventing any nerve bone, soft tissue injury. And ultimately, you want to complete the procedure safely and securely. And if you ask me who is, who is responsible for ensuring a safe and secure patient position. And I think it's everyone's responsibility, not just a surgeon, not Denise, that's not describe staff. It's everybody in that room should be empowered to contribute to ensuring the patient is positioned and looked after safely. The consequences of incorrect patient positioning are varied. It could result injury to the patient, which could impact them on a clinical basis, injury to staff by incorrect moving and handling of patient's damage to equipment and ultimately litigation as well. Luckily, there aren't many reported claims are litigations following incorrect patient positioning. However, this is not uncommon, particularly with the patient in uh you know, having a G A or a spinal anesthesia, they lack the appropriate, you know, the appropriate perception and the protective reflexes that they would normally feel if they were awake. So it's up to us and it's our responsibility to ensure that there are patient, the patient is positioned safely one sufficient to sleep the transfer, the patient is the next important stage. Um Ensure the operating tables are always switched on, always be present when the patient is being transferred. Uh A minimum of 40 R staff is required to ensure safe transfer and this is uh an aesthetic leg. Um They are the transfer leave so they can take control of the airway and provide support to the neck with a pillow and the various adjuncts that we have just allow us to transfer the patient safety such as a pap slide slide sheet or for those who have high VMI hover Mattis use, which, which has air that allows us to hover the patient from one bit to the other. Once the patient's transfer is important to secure the patient properly. And this is to ensure that the patient doesn't slide off the table or have any injuries in an awkward position. The most common uh mechanism by which they get uh patient gets position injuries by pressure. So direct pressure on uh lying on the operating table, uh folding of the tissues through sharing mechanisms or frictions of rubbing two surfaces against each other. Here, you can see a picture is a few adjuncts that we've, we have to help secure the patient on the top left is the beanbag. This is a large um plastic material that has beens. It's, it's pretty much similar to a beanbag that you have, you know, a whole while you're sitting outside. It basically has vacuum assisted beans that provide a cushion around the patient prevents them from sliding off the operating table on the right. You can see something called a pink pad. This is patented form technology that the patient lies directly on the pink foam and also prevents any slippage on the bottom. You'll see some gel pads. These should be used to protect all the bony provinces such as the elbows, shoulders, hips, the heels and any cannulas wires that are, you should be also well padded and not in direct contact with the patient's body. We can also secure the patient with different mechanisms. So if their legs are up at syrups, they can be, their legs can be secured secured. That way we can use chest straps across their body and arms and traditionally shoulder stops have been used. However, this has gone out of favor because of their boarded injuries to the shoulder and the presence of better equipment that we have. Now, I think it's worthwhile being familiar with the operating table as a trainee, particularly there are different types of operating table that have different attachments and may influence the position that you use for certain patient's. Uh if you're familiar or you work in a robotic unit, you may be aware that the robot table is different, a standard operating table and it's worthwhile spending some time learning and looking and actually actually what the operating table can do. Now, if you move on to positions, there are a variety of positions, there are several positions that you could put the patient in for different types of operation. And I'll just focus on the three main positions that as a court record training, you'll be familiar with. The most common position that we would put a patient in is supine. This is for a variety of procedures, hernia operations, laparoscopies, laparotomy, small by procedures, right? Hemicolectomies and so forth here. The patient lies flat on the table with all of the bony provinces on the back, directly in contact with the table. The arms should be in a neutral position, palms facing towards the body and thumbs up. It's important to ensure that's not, there's not excessive hyper extension of the elbow and any cannulas and wires should be wrapped and secured well with any padding such as gelfoam or even a bed sheet as well would do. Sometimes the nieces requires an arm access, particularly emergency scenario. In which case, the one arm can be abducted out. Um In this case, the arms should be uh supinated with the palms facing up. And it's important to ensure that the arms not abducted to more than 90 degrees that this can increase the risk of breaking praxis injury. The elbows are slightly flexed and a gel pad should be, should be placed underneath the elbow to avoid all inner damage and eggs or a nerve damage. The legs are strapped either uh individually or separately around the on the bottom of the table and heels are protected with gel pads as well. A modified version of the supine position is that Trendelenburg or reverse Trendelenburg. Trendelenburg is basically supine with head down and this can go to a variety of degrees and traditionally steep head down or steep. Trendelenburg is when the angles go further beyond 30 degrees reversed in delivered is super on with head up. This is commonly used for college vasectomies or bariatric procedures. Now, when we have the patient's in these positions, Supine or Trendelenburg with significant hand down, there are some physiological changes and issues that we should be mindful of while we're doing this procedure. Firstly, the patient will be, their bones will be in contact for a long period of time, potentially. So there could be some damage to the bony provinces. The brachial plexus could be at risk if the arms and shoulders are not placed or packed correctly because of the prolonged head down time, all of the venous return is towards the heart. So you can get ocular injury following venous stasis around the optic nerve or transit ischemia. There's increased interpreted pressure. This leads to global edema. There's lola reduced lower limb profusion and overall difficult ventilation. So, if you're in East, this is struggling to mentally the patient because of prolonged head down time, it's probably worthwhile resetting and taking a break at this time. The second most common position is a lithotomy position. Most colorectal procedures are performed in this position is essentially supine with the legs up in stirrups. The patient is slid further down the table at the lower edge of the back plate are supported, make sure they're not hanging off. Um And their sacrum is protected. Sometimes the gel pad could be placed for those who are very low. Be a mine. The legs are put in syrups and the hips and knees are flexed that are around 80 degrees and they should be in line with the opposite shoulder. It's important to ensure that patient's not over hyperflex of the hip and not too far abducted. Uh excessive hip and knee rotation should be avoided. Similarly to the supine position, the arms should be wrapped and rolled and it's important to make sure the fingers and hands are well away from the equipment. Around the bottom end of the table are not caught in any wires. We often create a surgical glove with just some gel and sheet that we can wrap around the fingers and hands to ensure that they're protected. You may have heard of different terminologies, modify Lithotomy, Lloyd Davies. These are all extensions and variations of the lithotomy position and are essentially uh determined by the degree of hip flexion similar to head down time in Supine position or or Trendelenburg position. Lithotomy had down time can also cause significant impact on the cardiovascular system. There's increased venous return, increased cardiac output, increased diaphragmatic pressure and overall lower limb profusion. There have been several reported cases of compartment syndrome in this position for a prolonged period of time. So it's important to be mindful of this when you have the patient's position. The most commonly injured nerve in this position is the common perennial nerve and handed figures can also go numb. My personal opinion and my personal practice in these cases where particularly I'm expecting the procedure to go on for longer is to have a 3 to 4 hour checkpoint would empower my team at three hours to give us a heads up that we are three hours and the patient's doing okay, carry on and at four hours, I would usually level and give uh you know, take a short break to ensure that we can return hemodynamics as normal. I would also ensure that there's adequate padding just over the fibula head because this is probably one of the most common reasons for the common perennial nerve to be injured. Uh In this position at the end of the procedure, always examine the coughs and make sure that there's no undue swelling or abnormalities there. The third position that's very common really used is the prone position. This gives us access to the perianal region. The natal cleft in the lower back, the patient is anesthetized and made ready in a supine position and then moved over to prone. A minimum of 40 R staff are needed if not more in my opinion, to, to get this position adequate. Um The niece is usually has a form rest so that they can secure and maintain the airway and there's not unduly excess pressure on the eyes, no use the hips, shoulders and knees and at all times, airway should be in control. One patient informed position is important to check the genitals and the breasts are in the correct position and any wires are laid out correctly and not wrapping around or the patient's not lying on any of the wires. A modified version of prone is a jackknife position. This is essentially prone position, but there is a, a further break in the middle of the table and has to have a more of an acute angle at the hip. This is good for a pilonidal disease surgery or any anal surgery as well. There are again, significant physiological impacts for having the patient in prone position, direct pressure on the abdomen, increases the abdominal pressure. There is associated inferior vena cava compression which decreases the venous return and increases cardiac output. This reduces thoracic appliance and and sometimes it's helpful and it does sometimes improve V Q mismatch. However, the long period of time it is a detrimental. They're certainly reported evidence, reported cases of ocular injuries by incorrect patient positioning of the face. And pretty much all the nerves from the top to the bottom can be injured in this position. The cervical nerve, the a learner of radial nerve actually nerve the entire brachial plexus and the sciatic nerve. Um on the left of the screen, you can see uh these form headdress. These are I think much better. They're much softer uh compared to the traditional gel uh rings that the patient's head were in and they come in different sizes. And I've seen most of the time in the States are quite comfortable and happy. Using these form head rests. The picture on the right shows you the ideal prone position with minimal neck, neck flexion, the elbows are padded nicely. There's no pressure on the axilla. The shoulders are slightly anterior reflexed, abducted but not in the excess of 90 degrees. There should be no direct pressure on the abdomen to help reduce the pressure. On that aspect. And it's important to check this before you start the procedure. So my, my practice now is every time I get the patient into appropriate position, I do a check and this is for the entire team. Um And we all get involved and make sure that the patient is secure. So check that the, you know, they wrapped accordingly and the position safely, all the pressure points are covered nicely. And before I actually start prepping and draping, I do a tilt test. So if I'm doing a Trendelenburg position or a low lithotomy position, I would get the patient, I'll get the nieces to turn the table to the position I'd like and make sure that there's no slippage or uh do problems at this point. Following all of this, the patient should be safely transferred off the operating table. Um And this is an opportunity to check any skin or injuries or any undue problems here. I always in present for, you know, transfer the patient and I always make sure that this is a point where, you know, you want to make sure that there's no problems with the patient in his, his or her position. We obviously check the swabs instruments and any ads that it concerns can raise here. And most of the reductions can be complete as part of the sign out and the book and the whole day, I think a team brief is essential. So this is an opportunity for the whole team to discuss, you know, positives what could be improved and overall any, any highlighting any concerns as well. So that was, you know, a fairly whistlestop tour of a lot of the non technical skills around the data set up and patient positioning. There is, there is a lot of communication and a lot of responsibility shared across the team. And it's important to get these practices inculcated in us quite early. So that over time, we appreciate the need for ensuring that the patient is correct position. And then we follow um processes to ensure that the patient undergoes operation safely. And that was just like three take home messages would be that it's a shared responsibility to ensure that patient's position is in, you know, an adequate way. Every member of the team should be contributing to this. And we want to make sure that the procedure is carried out safely. So obviously, we usually focus on a lot of the technical aspects of ensuring that we can perform the procedure safely. But a lot of the before and after is also equally important. And checklists are quite helpful just to standardize the procedure, standardize uh position. And that way every time you do a procedure you're not worried about other nerve injuries or bone injuries or prolonged head down time because you standardize it very well in the practice. Um And that's it. Thank you. I'd like to thank again, Dukes and a CBD that for asking me to present. Thank you, Ruth. That's an excellent talk. Um I think the set up in the operating theater is often forgotten about perhaps by trainees as you, you want to go in and just get involved in the surgery part of it. But it's so important and, and now is the time during your training to take particular notice of what's happening in the operating theater and all of the sort of complex thoughts behind uh patient's set up. So, thank you for that. Thanks coach. And if if any questions coming through, uh we will answer them on the chat. Uh So please bring your questions on the chat. Um Our next speaker unfortunately couldn't join us uh live today, but we got a recording and um we will bring it in now. So if we share this screen, uh I'm just, I'm kind of this from my okay with this from my laptop. Uh There with us, the medal platform is a new platform for us. It is excellent in that it allows free open access medical education. Um But if you can just uh with uh so we uh we have a talk from uh Mr Bingo. It is about the applied anatomy of the bowel in general, including small bowel, the cord uh victim, and the anus and the pelvic floor. And I'm just gonna share this from here. Hello, everybody. Sorry, I I can't be there in person, but thanks for the invitation to speak to you today about the applied anatomy of uh small bowel colon rectum anus and pelvic floor. I'm going to keep this uh at aimed at your level of training and try and make it as relevant to your huge in putting in it. So, uh I'll pick some highlights anatomically, try and focus in on those. So I'm a colorectal surgeon from, from Manchester. First of all, a bit of context that the main functions of the small bowel are those of uh digestion and absorption, focusing on nutrition. Uh The small intestine consists of duodenum, jejunum A liam with it's terminating at the loc co junction, the small bowel transport, what we eat and drink and also the internally released fluids from the stomach right through to the colon. Uh The length of the small bowel is largely variable um even before surgical interruption, but typically lies somewhere between 3 to 7 m. Although small intestine lengths have been measured and documented in more than 10 m. Individuals who are very tall, an important clinical point. Uh So you've got all the physiology there and what's absorbed at each stage of the small intestine. And that's clearly important for nutrition. But a clinically an important point for you as a surgeon is, it's crucial that you record the length of the intestine remaining after a small bowel resection, which would happen typically after crone's disease, ischemia or a strangulated hernia or an internal hernia or adhesions, for example, by measuring the remaining small intestinal length with a tie of known length, for example, or a flexible tape measure. Um also record the the configuration of the anastomosis and the length of any gut that currently is out of circulation, but maybe brought into circulation in the future. Residue guts functioning gut is much more important than the length that's been removed at surgery. So it's pretty useless to record that the pathologist will do that for you. Uh And it's what remains as important implications from the patient from that point on. And surgeons were typically measured from the D J Fletcher right through to the ileocecal junction to describe what's happened with the small intestine at those sites at the operative sites. So if we take you on to the next slide, this is typically with some colors, what, what an operation would look like. So we measured from the D J Fletcher, we've got 65 centimeters to uh end to end hands, anastomosis. And then after that, we've got 100 and 10 centimeters to an island ostomy. So we can work out that we've got some colon that's out of circuit. The colon is not been removed. We've got 175 centimeters of uh to an Islay ostomy that's in circuit. And that's important for nutrition and tell us that the patient will probably be okay without long term parental nutrition, providing that gut that's remaining is healthy. They may need some um anti motility agents in the early stages after after surgery to get the storm a out put down. So the small intestine is intraperitoneal. So the alien and jejunum of all intraperitoneal, here's a sagittal section through the, through the, through the human body. And you see these with the pointer, multiple loops on the medicine tree with the blood supply of Jejunum and ileum. The duodenum. Here you see circled, colored in green is retroperitoneal. Apart from in, it's very first part. So, apart from the first part, the other three sections, the other three limbs of the sea of retroperitoneal, it's important to remember that we typically get intraperitoneal, perforated duodenal ulcers. If you get a retroperitoneal perforation, it's more complex, not always requiring immediate surgery and typically the the domain of the hepatobiliary surgeon. And if you look over here, this is what a retroperitoneal structure looks like the covering of retroperitoneum over the anterior border where as an intraperitoneal has a peritoneum covering the mesentery, the whole uh circumference of the bowel and the mesentery down the other side. So, uh small intestine is intraperitoneal. It's floppy, moves around the peritoneal and, and pelvic cavity uh is easily accessible, uh very commonly operated on in, in emergency surgery. If you look at the blood supply, we here we have, uh in, in green, you have the superior mesenteric artery, which is the key blood supply to the mid gut. So, uh it comes off the abdominal aorta. You have the celiac access below that celiac access. Below that next branch is a superior mesenteric with it's uh Jejunal and I'll a little branches with the multiple arcades. And if you look at the black and white shots on the left from the old anatomical diagram, you can appreciate the rich blood supply to the jejunum and I'll e um which is why small bowel heals very well. It's got a profuse blood supply. So you can take sections away and join it up and it will heal very well with leak rates of 1%. Typically. Um As we move around, we start to get some blood supply from the coming off the Eylea colic to the terminal ileum. Uh And we'll discuss the right colonic blood supply in a little bit more detail when we, when we talk about the colon. So the S M A is a key blood supply here. You see anterior to the duodenum uh gives off the also the middle colleague and the right colic as well. The superior mesenteric vein uh typically lies to rite of the superior mesenteric artery. Although there are some variations here and drains the same tributaries, allele and digital tribute tribute. Uh it passes anterior to the duodenum before joining the splenic vein here to form the portal vein, the main in flow to the liver. Uh this sort of area here is banged it country trying not to get yourself involved down there. Work out where these uh major blood vessels are bleeding down here can be very difficult to control. So now we're gonna move on to the colon. We have the starting with the uh Leo Seiko junction uh and the appendix, the cecum which is intraperitoneal uh and can be found above or just inside the pelvis. Uh The ascending colon, don't forget, is retro personnel. The transverse colon again, intraperitoneal, descending colon, retroperitoneal and the sigmoid or s shaped colon is again intraperitoneal. You've got some unique features of the colonic anatomy highlighted here. So you've got the appendices, EpiPen Eliquis, which are unique to the colon. You have these circulation's or house tre that form as a result of the uh the circulation caused by the innermost circular layers. So, again, for like the small intestine, four layers of the bowel wall mucosa submucosa muscularis appropriate. And the cereal muscular uh serosal layer all important when we're looking at anastomosis and uh and also pathology particularly in cancer. So, and there's one or two key areas I'm going to focus on. The other point to mention is uh the taenia coli, which is a condensation of the longitudinal muscle of the colon. Again, a unique feature of the colonic anatomy. So we start transitioning from the small intestine to the large intestine with the ileocecal junction. You see the ileum highlighted in green with its mesen tree and the bloodless fold above that which is also eponymous lee known as a fold of trees. This is the fall. Typically, you lift up to elevate the Aaliyah colic pedicle when you're performing a medial to lateral dissection, a right hemicolectomy, the starting maneuver of a right hemicolectomy. So your left hand lifts up here, the laproscopic grasper and your right hand incise is the peritoneum under the eyelid colic pedicle to get into talked plane and we'll talk about that a little bit later, which is the key plane when you're mobilizing colon, right side or left, left side. So you need to know about that. The Eylea mentors here with the Ileocecal valve that controls the proportion of G I content from the ileum into the colon and prevents uh flow backwards if it's competent. This is important in large vial, a competent ileocecal valve will allow the cecum to distend until eventually it splits and perforate. If the valve is come incompetent and it's more likely to become incompetent as you get older, then the air will move through the valve into the island and buy you a bit of time. So on your, on your, on your imaging, you'll see some dilatation of the small bowel as well. So that's competent, that will give you a closed loops, mobile obstruction, which gives you makes that a surgical emergency and you have no real room for manoeuvre. You have to get in there quickly. Uh the appendix you see here with its mesentery attached to terminal uh, blood supplies. The appendix is the appendix color artery, which you'll regularly divide when you're doing. Appendicectomy, a branch of the posterior sequel artery which comes off the ileo colic artery. Um, and important to take that medicine tree if there's anything abnormal about the appendix seen on imaging, uh particularly if you think there's a suspicion of the carcinoid mucocele, an appendix tumor. Here we see the intraperitoneal transverse colon with it divided just beyond the hepatic fletcher and just proximal to the splenic flexure to give you the uh anatomical um context. It's intraperitoneal. You see what changes here at the just before the attic fletcher, it's relation to the duodenum. So when you're mobilizing the right colon, uh antibiotics lecture underneath, you need to sweep the duodenum down with top plane, some retroperitoneal structures we've already discussed. You can see the transverse colon mesentery here with its double layer of peritoneal covering and the attachments of the Spanish lecture to the spleen. The pancreas would also see the diaphragm on there and the kidney as well as that turns around to become once again the retroperitoneal descending colon. So, what about the blood supply? So the blood supply to the right colon is the dominant blood vessel is the Eylea colic pedicle patient's variably have a right colic vessel. Um It's reported in the anatomical textbooks, but laparoscopically, we're seeing you see less and less of the right colleague. Uh and then as you. Um Yes. So they supply the terminal ileum and the right colon together. So a leo colic, right colleague colic. If you, if you have one, the middle colleague, then um has a short stump, typically 1, 1.5 centimeters and then gives off branches to supply it the transverse colon. But also the transverse colon gets its blood supply in a marginal vessel which comes around from the polio colic and also back up from the left colic here, which is a branch highlighted in green, which is a branch of the inferior mesenteric artery. And that's why this marginal circulation is key to our understanding of where we're going to put our, our anastomosis. So left side, we have the inferior mesenteric which branches into the sigmoid branches. It continues as a superior rectal artery and it continues up as a left colic. So if we're taking this vessel flush on the aorta, there's a potential to make from here down a ski make because you've got your marginal artery coming up to descending colon here. So there is some variation here about the blood supply and how that runs. And I don't need to go into that in too much detail, but the marginal artery is key and we can use things like I C G to highlight which areas have perfused. This is a key landmark I want you to be aware of which is Taltz Fashir Carl told was uh anatomist born the 19th century described this avascular plane between the retro peritoneum and the back of the clonic meeting tree. And this is a key to laparoscopic and robotic and uh surgery. Whether you approach it me an open surgery, whether you approach it immediately as we tend to do in the minimally invasive techniques or laterally along the white line of Taltz. This is the plane, a vascular plane that gives you the whole medicine tree along with the lymph nodes and the important blood vessels for an oncological reception. So that takes us around to the sigmoid. Uh and the transition to the rectum variably described where the rectum begins. And anatomists s two s three surgeons, we used to say maybe the top of the pelvic brim. But nowadays, we have a uh an MRI guided definition of where the rectum starts at the sigmoid take off, which is is now well described in the literature as you can see there. So next, we'll talk about the rectum and the anal canal moving on to the rectum. Typically 16 to 18 centimeters in length, around four centimeters in diameter has predominantly a storage function but equally as a absorptive function with water, some chloride and some some potassium impasses. Um coordination with the anal sphincters in the anal canal enables the process of defecation which we're not going to go into too much detail. The upper third itty rectum is intraperitoneal covered on peritoneum, anterior and lateral surface is the middle third of the rectum is retroperitoneal covered anteriorly only and the lower third is totally extraperitoneal. You can see on the left the we have here the, the rectal vows of Houston which may delay the fecal bolus as it passes down the rectum. And here the key feature uh the highlight rectum is highlighted in green as you can see the mesorectum. So the fatty envelope behind the rectum, that is a key part of rectal cancer surgery, the key anatomical landmark. And as you progress through your training, this will become more critical at this stage, you probably won't be focusing too much on rectal surgery. There, you can see the anterior mesorectum. And if you look at this in cross section, you can see here the rectum with, in this case, a rectal tumor and by taking this whole mesorectum package and with these so called buttocks at the back and the anterior mesorectum behind the neurovascular bundles or preserving the nurse structure, nerves and vessels of Walsh just behind the prostate in a man. Then by taking this envelope, I was able to increase the uh improving oncological outcomes of rectal cancer by taking the lymphatic pack and reducing local recurrence. And here you see it in the lateral diagram with a tumor invading through the rectal wall, interim mesorectum, but will be fully respected by the TME total mesorectum exceeding operation. For a final slide. Here we have the anal canal shaded in green, typically 3 to 4 centimeters in length, important for defecation. Here, you can see the anal glands, columnar epithelial lined with reducing, releasing mucus to lubricate the the stools. And at the level below this, you have the transition from school because of the skin and lowering oh canal into columnar epithelium at a line called a dentate or pectinate line, which is a key anatomical landmark above this. And the cancer cancer will be an adenocarcinoma. So, colorectal cancer below this will be a squamous cell cancer. So, anal cancer is a different uh different beast altogether in between this. That there are Columbia sell columnar epithelium within the anal canal. So you can get, you know, I don't know, adenocarcinoma, which is very rare but important to, to define uh surrounding on the diagram. We have the internal sphincter, a smooth muscle keeps the anal canal closed at rest and the external component which is under voluntary control and allows us to squeeze to augment the defecation of postponed defecation. And here we have the pelvic floor, uh the elevator, a nine muscles, puborectalis stretching out to the pelvic. So, sidewalls here we have the obturator uh internist muscle and the vessels which is important for providing support to the organs which which go through the public floor to include the g eye structure's we talked about. But also the Euro genital and structures. So important to understand the the anatomy of the public floor muscles and the sphincter's with regard to fistula surgery, gynaecology, surgery, prolapse, surgery, hemorrhoid surgery. And for the extra levator plane, which features in ap reception, whether cancer is low. So you can't and join restore gi continuity and you have to have an end colostomy. So this plane can be important when the sphincters are involved. I've gone slightly over time. So, apologies for that. But thanks for the invite. It's just a brief guide and some um applied anatomy for you to build on with your reading. Thank you. Thanks Ben. Great overview of uh colorectal anatomy. Really important for our practice. You will be able to watch this video on demand afterwards. So it's something you might want to replay before going to the operating theater um so that you can refresh your anatomy. So we're now going on to our next talk and this is principles of oncological bowel resection and this is by Dina Haji. Um If you just bear with us for a moment, we will load the talk. Hi, good morning everybody. And thank you very much to the Dukes Club for the very kind invitation to come and speak to you or I'm very sorry. I can't be there in person. My name is Dina Haji and I'm going to talk to you today about the principles of oncological bio reception. And I think that the first thing to talk about is when you're considering bowel resection is understanding the stage of the tumor. And we use TMM staging to classify the current stage of the overall cancer. And that's based on three key distinct aspects. The T stage, which is a tumor stage itself, looking at the depth of invasion of the bowel wall, the nodal stage, which looks at the number of nodes invaded and then the metastatic stage or the presence of metastatic disease. And that gives you an overall stage from stage 1 to 4. And how you treat these, treat these different stages and how you implement oncological treatment varies on that TNM stage. And I think if you go back even further than TNN whole study in principles for oncological colorectal reception, really centered on three key aspects, wide margins. So we look for it to store margin of approximately 2 to 5 centimeters with a colon cancer or one centimeter with the rectal cancer, a radical impact next to me and then central vascular allegation. However, 2023 no longer follows the whole steady in principles because the oncological face of managing colorectal cancer has changed significantly. So, although we still follow the principles of um wide margins, radical lymphadenectomy in central vascular ligation, we have to a whole host of other factors when considering bowel resection, including uh the role of new adjuvant chemotherapy and new argument chemo radiotherapy. And now new adjuvant immunotherapy, we have to think about preoperative patient fitness and pre debilitation. We have to use the principles of shared decision making. So the M D T in 2023 looks very different. And I think that talking to you about oncological Barmer section actually is a huge topic. And I'm going to focus on sort of four key aspects of what you may see in your M D T in 2023 to try and guide, guide you in terms of your own decision making. And I'm going to send to that around um polyp cancers, which we're seeing more and more of due to screening locally advanced colon cancers, chemotherapy, radiotherapy and immunotherapy under the realm of new argument, treatments and rectal cancer. So, let's start with polyp cancers. We're seeing more and more polyp cancers due to the National bowel Cancer Screening Program. And as a result, we're seeing the development of dedicated high risk polyp and polyp cancer MG T S across the United Kingdom pathology. And understanding the pathology of a polyp cancer is key to it's further management and it's really important to understand whether there are any high risk features associated with the polyp that are indicative of the presence of nodal metastases, which might require a formal bar reception compared to those that are low risk and can be appropriately surveyed. The key pathological features that you need to understand really relate to the morphology of the, of the polyp. To start with the first words really important that you understand whether the polyp is a productive related or SASS are malignant polyp. And the reason being is that this allows you to identify the appropriate classification system and apply it to understand what the depth of invasion within the sub mucosal layer is. So, for pedunculated polyps, we used the Hagit classification and for CSR polyps, we use the classification. We also need to understand a number of other key pathological risk factors including margin positivity, the presence of um lympho vascular invasion, the presence of tumor budding, the degree of differentiation of the tumor and the depth of invasion within the submucosa. Using these array of pathological risk factors. We can then apply the guidelines from the A C P G B I to identify what the risk of nodal disease is and to guide decision making as to whether the patient requires a bowel reception to remove all the nodal disease potentially associated with the polyp cancer or whether they can be suitably enrolled into a surveillance program. So let's discuss colon cancer. I think the management of colon cancer is really evolving in 2023. And that's partly down to two things. First of all, the application of the argument chemotherapy, particularly the locally advanced chronic cancer setting. And secondly, is a use of new surgical techniques and we'll come to talk about that. So that's just cause the adjuvant chemotherapy. I think if you're a trainee in 2023 interested in colorectal um surgery and interesting colorectal concepts really important that you are aware of the results of the Fox Fox trop trial. So the Foxtrot trial looks out the application of six weeks from your item in chemotherapy in patient's with locally advanced came on cancer and they identified or defined these as patient's with T three or T four disease nodal disease and no evidence of metastatic disease. They had to be mmr proficient and they gave them six weeks of upfront new adjuvant oxaliplatin based chemotherapy. And what they found was that patient's who underwent neoadjuvant chemotherapy controlled, compared to controls, had a higher rate of pathological regression, had a lower rate of two year old, two year local recurrence and had no increase in adverse surgical postoperative outcomes suggesting that now we should be giving patient's with a locally advanced colon cancer upfront new adjuvant chemotherapy prior to oncological reception. How however, alongside the concept of new adjuvant chemotherapy and local advanced colon cancer, there has been the development of uh increasing radical surgical techniques such as complete music olic excision, music olic excision um is a uh ultra radical technique that aims at dissecting the colon within its embry logical plane, preserving its music olic package, including a central vascular ligation and A D three lymphadenectomy allowing greater lymph node yield. And it's felt that this technique um enhances the practicality of surgery and does improve overall survival. Patient's with locally advanced chronic cancer. It's particularly complex technique. Um and it involves a dissection of lymph node stations that are not typically standard in what we would consider a standard, right, hemicolectomy, including the pancreatic lymph node stations. And in some cases up to the nodal stations, up to the level of the greater cabbage of the stomach. The jury is still out there with regards to the evidence based for CME with its proponents and with its opponents, there are multiple systematic reviews arguing both sides of the story. This is one of the most recent ones. And I think what it's safe to say is that CMI is associated with an increased lymph node yield. And in those who um benefit from increasing load yield of those usually with nodal disease. And in that group, CME is associated with improved survival and reduced local recurrence rates. However, the trade off is the increased complexity and surgery and the associated morbidity that that carries. So, CME is associated with longer operative times. It's associated with a higher risk of conversion, particularly from laproscopic to open surgery. It has an increased risk of both inter operative complications, particularly vascular injury and those who are an experience and it has a higher rate of cavi in grade three and grade for postoperative complications. So, in my mind, CME is reserved for those experienced surgeons, but for those patients', you have nodal disease who would benefit from achieving a higher noodle yield and in improving their survival. So let's move on from advanced colon cancer to your rectal cancer. And I think that I could talk to you about rectal cancer all day. It's a huge topic and it's a exciting and evolving topic and even more so than colon cancer. And I think whenever I'm considering managing any patient with a rectal cancer in my practice, I think about their oncology, both with regards to their second official reception margin, but also they're distal margin and the presence of metastatic disease. I think about their risk of an anastomotic leak and I use the anastomotic failure, observe risk or to give them a personalized risk or and I think about their postoperative function namely around low anterior resection syndrome and and use the polar score to provide them with a preoperative prediction of what their postoperative function might look like. And I use all of that information and I balance it as to whether I can safely receptor this rectal cancer and whether I can afford this patient primary anastomosis and allow for g eye restoration. And as I said, this is a really complex arena and it's not just about surgical technique. It's understanding what neo adjuvant treatment you have available to ensure that you can provide your patient with the best possible oncological outcome. Now, if you look at the latest nice guidelines and management and rectal cancer, they say that any patient who has either a teeth realty for rectal cancer, a low rectal cancer, a rectal cancer involving the elevator place, any nodal disease are threatened or a positive um circumferential resection margin should have some form of neo adjuvant treatment. However, the array of near uh adamant treatments available are vast and there is a huge amount of evidence behind a lot of the New Agreement treatments available. So I'm just going to give you a real whistlestop tour about the trials that you might need to know and when you might need to apply them. So, first and foremost, there's a Stockholm three trial which was delivered by the group in Stockholm, no doubt. And it looked at short course radiotherapy followed by immediate surgery, short course radiotherapy with delay, usually 4 to 8 weeks. And then compared that to long course chemo radiotherapy and its primary endpoint was time to local recurrence. And it found that actually short course radiotherapy would delay was similar, had similar outcomes too long course chemo radiation without any increased risk of postoperative complications suggesting that short course would delay was a possible appropriate treatment strategy. But then came along with this trial. This is Rapido which is starting to explore the role of total neo adjuvant treatment. So total knee management treatment is when you give radiotherapy and some form of chemotherapy, either before the radiotherapy, which is called induction chemotherapy or after the radiotherapy, which is called consolidation chemotherapy followed by surgery. And what the repeat a trial group did was compare short cause chemoradiotherapy with consolidation chemotherapy followed by surgery. And compared that too long cause chemo radiation followed by surgery. And what they found was that the rates of distant metastatic disease at five years was much lower in those who had the short course rate therapy followed by the consolidation chemotherapy. And that the rates of pathological complete response was high in the short course radiotherapy compared to the traditional group. However, it's long term results suggest that the local recurrence rate is slightly higher in the experimental group compared to the long course chemo radiation group in the control arm. And so I think there is a movement away from repeat. Oh, however, it's still maybe potentially suitable in patient's who may not tolerate long course chemo radiotherapy and alongside Rapido, we had the French developing the procedure 23 trial and the prudish 23 trial looked up the role of um induction chemotherapy with long course chemo radiation compared to long calls chemo radiation alone in locally advanced rectal cancer. And what this trial identified was that induction chemotherapy with long cause chemo radiation was associated with improved pathological um complete response. It was associated with a higher distant disease free survival and with no adverse impact on local recurrence rates. Suggesting that perhaps it's the combination of long course chemoradiotherapy to sterilize the pelvis and improve local recurrence rates. And coupled with induction chemotherapy to reduce the risk of metastatic disease that is associated with the best outcome in rectal cancer. But then to complicate matters further, the Americans developed the opera trial. So the operatory A was looking at whether um T N D or total knee urgent chemotherapy can be used for organ preservation in advance rectal cancer. Because as we've seen from Rippetoe and prestige, both of the experimental arms, irrespective of whether they were induction or consolidation chemotherapy and irrespective whether it's short or longer human radiotherapy were associated with higher pathological and complete responses suggesting that potentially those patients' could have avoided surgery altogether and opted for organ preservation approach. So, opera looked up the uh use of both induction chemotherapy with chemo radiation, long course, chemo radiation and consolidation chemotherapy with long course chemo radiation and looked at the rate of organ preservation. And what it found was that there was no difference between three year disease free survival with induction or consolidation chemo radiotherapy groups. However, what it did find was that three year TME free survival was higher in the patient's who had consolidation chemotherapy. So those who had chemotherapy after their chemo radiation compared to those with induction chemoradiotherapy. So what this group concluded was that um consolidation chemo radiotherapy and T and T in the context of consolidation chemo chemotherapy should be given to patient with advanced rectal cancer to try and achieve an organ preservation approach. So all of that is very confusing, but it's important to understand that there are a whole variety of different treatment options available to patient's who require some form of neo argument treatment prior to rectal cancer perception and some of that will depend on your local oncologists, the availability of their resources and your M D T. But I think it's fair to say that total knee argument chemotherapy will totally ardent has several benefits including improved pathological, complete response, improved treatment and compliance, particularly taking that adjuvant chemotherapy um away from the adjuvant setting and putting it into the knee argument, preoperative phase. And that's needed a lead to systemic control for micro metastatic disease as demonstrated by the improved disease free survival across all of those trials. And it allows you to assess the chemo sensitivity and tumor response of the tumor before you consider surgical resection. However, to confuse matters even more, we've got the new kid on the block and the nuclear on the block is immunotherapy. Now, immunotherapy is being investigated in those patients who are mmr deficient currently that represents between 5 to 8% of all colorectal cancer. But what we're starting to see is the use of PD one blockade monoclonal antibodies in patients' with mmr deficient tumor's. And we're finding that the emerging results from this and this was published in the New England General Medicine are that these patient's are highly sensitive, you know, therapy and that it's associated with a complete clinical response in anything between 75 to 100% of patient's. And so this is where a lot of resource is currently going into, see if we can use immunotherapy in rectal cancer. And I think it's just a key that you are aware of that. And so those of you are a student of have probably worked out that the majority of total new argument treatment or neoadjuvant chemoradiotherapy is really gearing towards this notion of non operative treatment for digital rectal cancer. And that approach was really popularized by the South Polar group and Angelita Habit Garma. And I think it's really important that you understand um some of the work that that group have done. So they looked at total of 265 patient's who they treated with upfront human radiotherapy and they were able to elicit a complete clinical response in just over a quarter of that group of patient's. And what you can see is that those patient's who then had a complete clinical response were observed um in and involved into a strict watching weight program. And they were compared to patient's who then underwent reception of their primary rectal cancer. And you can see that there is no real difference in terms of patient or tumor characteristics between the two groups. However, what they did notice was that there was a significant improvement in overall survival and those that had a complete clinical response, both in terms of overall survival and both in terms of disease free survival. Suggesting that in those who are biologically sensitive to neo adjuvant treatment have much better clinical response. And much better overall survival and can potentially avoid the significant morbidity associated with surgery. And so those of you who are a student, if have probably worked out that the, however, the reality is is that the majority of rectal cancer is managed surgically and we use the principles, talk to us by Professor Bill healed with regards to TME or total muse a rectal excision. And we ensure that we dissect the rectum in its TME plane all the way down there, potentially to the level of the pelvic floor. We do that preserving the muse erectile fascia and ensuring that there is no damage to the autonomic nerves that of the pelvis. And if you follow the principles of TME, you get this beautiful smooth specimen and you can see that the meds, a rectal pressure is completely preserved in the specimen here and you can do TME all the way down to the level of the pelvic floor for very, very low rectal counselors. So I'm going to leave you with this. I think it's clear to say that the management of colorectal cancer is evolving and increasing in its complexity that the court hell stadium principles still apply. Stay in 2023. However, oncological reception of colorectal cancer is not only a surgical treatment and it's important to understand all the oncological treatments and therapies available alongside all the treatment outcomes to ensure that you have an appropriately informed patient and that you embark on shared decision making. I think that is what makes oncological bile reception modern in this era. Thank you so much for the opportunity to speak. Thank you, Dina. Another excellent talk there. And I think what this goes to show is that colorectal cancer management is ever changing. And it's quite important that as trainees, you get to the colorectal MDT meetings or the tumor board meetings to uh really get a feel for the modern management of colorectal cancers. So we're over running slightly. Now, we're going to go into a break and then we're going to come back from the break at 10 50 when we will go into the second session of the day, which is the clinics session. Thank you. Thank you. We'll see you in 10 50. Thank you very much.