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Surgery for the for colorectal trainees. So in terms of what I'm hopefully going to be recovering, I'm going to talk about what the job is like as an adult general surgeon who also does a bit of peds. I am not a pediatric surgeon as in a pediatric surgery, C CT, I am a, I am a general surgeon with a pediatric interest. So what's now on the syllabus is general surgery of childhood. I'll talk largely about what my job is um and variations on that according to where you are and so forth. I talk about how I got to where I am um and the training pathway and I appreciate it's going to be a bit of a sales pitch for pediatric, for general surgery of childhood, but I appreciate not everybody will be interested in that and want to go into it in the end. And uh briefly at the, then I will will stop talk through what you will need to know as a day one consultant surgeon and for the exam, which is so why do I just skip two slides of? So the role is a, a general surgeon with a pediatric interest from the outset. This is very, very variable what it involves and it is dictated by a number of factors. Firstly, what you know, and are trained in and are happy to do and are competent to do what the local need is where you are and in particular the availability of services and resources where you are. So for example, whether or not you have pediatric h to whether or not you've actually got urologists who do pediatrics at all, whether you've got um support anesthetic for neonates and things that will have a big influence on what you do. Should you do the job? So a bit of context just to sort of put in perspective, what I'm going to describe about my job. I work Insel Man Hospital, which on the north edge of Birmingham, it is a small to medium size DGH. We I believe still hold the distinction of being the smallest independent trust. Although we are in the process of unofficially merging with Wolverhampton over the road over the other side of the M six. So we will probably lose that particular title. There are smaller DGHS out there, but they're generally part of a bigger trust these days. So, bearing that in mind, what does general surgery of childhood involve? Well, electively, you really are an old style general surgeon. You, it's everything going back to what I was saying before about it. It in part, depend on what you know, and what you're happy to do. You do all sorts. It's very, very varied from a purely administrative point of view, from a job plan point of view. It occupies one pa of my job plan. So I have one pediatric session per week, which translates as two clinics per month and two theater lists on top of which there are other sort of bolt on bits. We have an infant feeding service that provides a tongue tied division. So tongue tied divisions where required and they need clinical oversight for that from a surgeon. So I have whole responsibility for that service and support for it if there are any complications and support for it, if they got cases that they don't think are appropriate for division within the, within that clinical service operating wise. Going back to what I was saying about resources and service availability. So where I work, we don't have pediatric HD, we can set up HD level care in a very, for a short period of time if we absolutely have to for, for a patient that's awaiting transfer. But it's certainly from an elective perspective, we do not have a pediatric HD. We cannot plan around it therefore, and our neonatal service is present, but it is what you would expect for a hospital of our size. The official guidance about from an anesthetic perspective is that we will, we will operate on anything over the age of two. However, we do have two anesthetists who are quite happy to an, a child down to the age of one. And therefore I operate on anything over one. But I have to make sure that the anesthetic department are aware if I'm booking a patient to a list that is between one and two because they then have to ensure that from the pool of pediatric anesthetists, they put, they put one of the two that are actually happy to do that, but it isn't actually a, it doesn't create any problems. It just requires a little bit more planning because of the lack of facilities for support. We only do low to moderate anesthetic risk patients. So anybody, any Children with significant congenital anomalies or anything like that, they will be referred on to the regional pediatric unit at Birmingham Children's Hospital as a consequence of all of that and what tend to be referred third to pediatric surgery. It's almost exclusively day case and it's mainly infants and young kids. Sort of, I don't very often operate on kids above seven or eight really. And the vast majority of them are significantly younger, sort of to be sort of 1 to 5. Yeah. And the from a stress level point of view, I don't do, we don't do any of the complex neonatal surgery. Um, so all the bits sort of Phs gastroschisis, all the sort of dramatic things you read about in the textbooks when you're revising for your exam. That's all done by dedicated pediatric surgeons at tertiary units like Birmingham children's or wherever your regional equivalent will be. So, as if you are doing a job like mine, you, you don't need to do that, you won't be doing that. So, I mean, yeah, a brief sort of guide whistle stop talk to sorts of things I do. Um, that's a start point. That list took me about 60 seconds to put it together. If I kept going on, I probably could have added quite a lot more. Um Some of it is I've put in italics down at the bottom about aces. So Antegrade colonic enemas. So formation of a appendiceal ace or something similar and pyloric stenosis, I don't do that because there isn't from the pediatric side of things and the functional side of things, there isn't required to a requirement to do aces where I am in kids. Although I have trained to do it. Conversely, colleagues in mine around the region do do it in their hospitals because they, I mean, their pediatric gastroenterologists and so forth have an interest in functional work. So they don't refer them out and they do it into internally. And likewise, pyloric stenosis is a very simple, straightforward procedure to do surgically. The complicating fact or the requirement to be able to do it is a neonatal anesthesia. And more importantly, the pre and post operative care, particularly the preoperative care in terms of stabilizing the patient correcting all the electrolytes anomalies for and for that, you need neonatal neonatal HD level care. So there are some units if you sort of trawl around the country where you'll find people who are my equivalent, who do do pylori noses. The one that makes my mind is Coventry it again in the West Midlands. Um But there are others, but that's unusual because it, it's unusual to have th that level of facilities and not be in a by that stage and not to be in a bigger tertiary unit with its own dedicated pediatric surgeons, massage. Haven't seen that long list be on mind on top of that. What get, what actually gets referred to me in a general pediatric surgical clinic in one word. Absolutely everything. I am effectively almost like a second triage service within the last two months. On top of all the usual bits and Bobs that I get. I have been referred syndactyly. So do I want to divide 22 fused fingers together and reconstruct? I've been referred ac cranial osteoma to see if I wanted to do something about the child's skull. Um The list goes on. Um I've been referred stuff that would fall under ophthalmology. I've been referred to various intraoral malformations and anomalies effectively because you are as a general pediatric surgeon. If you're in ad DH, you are usually the only vaguely surgical point of access. So you what you do within what you get referred goes back to what I was saying before is entirely up to you and what you are happy with what you can, you are co feel you are competent to deliver. The key thing is to know what to do with the rest of them and where to send them. So I, I refer on to plastic surgery, pediatric maxillo, facial, pediatric neurosurgery, specialist, pediatric orthopedics for congenital malformations and so forth because these things all come through my clinic, but I'm not going to touch them with a barge bow. But unlike some of the presumably, unlike some of the regional GPS, I at least know the names and the places that each of these should go. So it's, it's effectively a secondary triage service from that point of view. But if you, if you feel you're able to do it, you can crack on and do it right. Emergency wise, mostly what I do, emergency wise is pretty much the same as my non ped trained colleagues. Um, but as as the next line says, there are guidelines in place as to what you would, what any one hospital will do in terms of emergencies because they, it's all set up on regional network basis again from your regional pediatric specialist center and they're fairly blanket rules, sorry, not rules fairly blanket guidelines around the region. So for where we are and where I am in the West Midlands, the guideline is that if you've got a patient under five and you want to send it to the, to the children's hospital, they won't argue, they'll take it. Five is the cut off. We won't, we won't, we don't routinely take under or operate on under fives. However, as I've just said, there guidelines are not rules, these things are flexible, they are negotiable. So, depending on what it is and what it, when it is and how the child is, you can flex around that. So if I'm, if I either if I'm on call or if I'm available and there is a pediatric, trained anesthetist because the cut off of five is based on anesthetics. We, we may well operate on a child that would otherwise be transferred, particularly physical sort, more basic stuff like appendectomy, things like that and kit comes into it. So where, for example, where we are in wars where I am in Warsaw, we're kind of in the process of trying to, or of obtaining three millimeter ports, et cetera so that we can actually laparoscope down to smaller Children with the right with the right people doing it if you see what to me. So there is flex, but again, if they're young that and either haven't got the anesthetic back up available at the time, we just refer out. So it's flexible. A lot of what goes on with emergencies is about the, it does involve the on with the regional unit. BCH. So in particular sort of patients who are either sick and unstable or need more significant surgery because going back to what I said before, we don't have that HD if they need it POSTOP. But actually kids tend to bounce back very, very fast and stabilize very, very quickly. They fall off their perch spectacularly fast, but they also get back on it very, very quickly. So the children's hospital are quite happy to take anything we want to send them that way in terms of anything more major. But they're also quite supportive and very keen in fact, for if you have the skill set and are happy to do it to operate, then transfer. So going back to that saying before we can create HDU level care for a short window of time if we need to whilst awaiting transfer. And there is a regional service which I presume is probably duplicated in most places, which is called the Kids Service in Israel in west mid, which is a pediatric critical care ambulance transfer which comes complete with a pediatric ICU, either senior trainee post C CT fellow or consultant on board, a pediatric ICU nurse, a paramedic who is has additional critical care training. So and they come with the kit in the back that is quite literally an ICU on wheels. It they, when they arrive, they have a, they actually have more kits than we have in the hospital when it comes to pediatric support, critical care support. So if you've got a kid who's sick and considering rapidly be, the pediatric surgeons are very keen if you are happy to do it for you to crack on do the operation and then arrange that critical care transfer immediately afterwards because actually the Children often do better and that, that becomes relevant if you are the one pediatric trained person in the building. Because if you're around you may, you may well get called to either give a hand or come and do it because the chances are on the basis of the training you've had in the past you're probably more comfortable doing the smaller kids than a lot of your colleagues will be other things that tend to sort of rock up as an emergency that you might end up doing that. Your colleagues won't torsion and, and undescended testis sounds really awkward but it isn't strangulated hernias in little ones. Um, the issue there is if they're really, really small, even if it's time critical, you still have to transfer them out because we just can't anesthetize them if they're really small. But you do have a window to sort of one around one to sort of four or five where if you, if you're the pizza trained person in the building again, because it's an operation you're familiar with which your colleagues won't be, you'll get a call. So sort of, as you might have gathered from the last bit, you are the, if you are the ped surgeon or you are one of them depending on the size of, of the department you'll often get called for. Well, I say often you can get called for support by your colleagues when you're not on call. And I have an informal agreement with my, with my consultant colleagues that I am quite happy even if it's a weekend or whatever or overnight for somebody's phoned me to see if I am around. Because worst case scenario is I say no, I'm not or I can't come in and that patient would be transferred as if me in the same way as they would have been if they hadn't bothered calling me. But if I am available, I can always come in and give a hand and to be fair, that situation is exceptionally rare. I think I've been called something like three times in the last about four years in terms of out of house. So it's rare to get called, but you are reliant on sensible colleagues if you're going to sort of put that option out there. Other implications of it. Some of this is actually quite positive in terms of implications. It actually has some useful positives for your adult practice, depending if you're into IBD or functional work and things like that, you tend to be the first port to call for transition cases. So those 16, 18 year old adolescents who have been under the pediatric gastro and pediatric surgeons for a number of years as they move into adolescent care. And also, I don't actually, we don't actually have that much of those cases for whatever reason. But during my training, I worked in one of the other hospitals in the region where they've got quite a big pediatric unit, um or pediatric surgical units. The biggest, it's the biggest outside of the children's hospital in the region. And there they actually run a transition clinic. I think it's every other month because of with the team from BC because they actually have that many come through skill and knowledge transfer you through the training, you'll get on that on the pathway. Some of it can move, be useful to be moving into your, your adult patients. Partly it's knowing what they've had and understanding what they've had done in the past. So when somebody comes up and says, oh so and so how did you do? Handle what in the heck is that you actually know and you got the vague concept of what impact it might have implications of it, things like that. But also actually some of the very specific skill sets and knowledge. So mal rotation, which I'll come on to in a bit. I've done a few lads procedures in adults, which is the, which is the operation for m rotation because, and I was able to do it quite comfortably. One of them was done as an emergency purely simply because I've done them as part of the specialist training in, in at the children's hospital that I did. So things like that are quite useful. I'm going back to what I was saying before about aces. So the I've actually I do functional bowel work as part of my adult practice and I have one patient who is currently in the process of awaiting surgery in to form an antegrade conduit, although it is slightly more complicated and his reason because the first time I met him was when I was taking his appendix exam. So I'm going to have to do it slightly more complicated. My but these things contribute and the knowledge, some of it is just a case of drawing parallels, some of it is direct contribution and it, it does help. It's and sometimes some of your adult colleagues will come and ask you about ideas that you might be able to sort of float relating the two. Again, as I say, colleagues come and talk to you, you are the departmental resource for anything vaguely pediatric surgery wise. If, if and to be fair, most of your colleagues will be fairly sensible about it and know that it's fairly general and there's all sorts of things, you know, outside your department, people tend to think of you as a bit of a, as a walking textbook and a bit of a expect you to be some kind of fan of all knowledge, having seen how much stuff gets referred you can imagine you not won't necessarily have all of that at your fingertips, which tends to disappoint a lot of people when they come and ask you. But you do get asked quite a lot, depending on your colleagues, depending on what you put out there. Going back to what I say about emergencies, you can theoretically end up sort of potentially almost always on call. Depends where you draw the boundaries, depends where you put, how, how sensible your colleagues are. I have, I haven't found it a problem, but I have heard people who've put the offices out there and then realized that people didn't really have the right kind of boundaries. And from a job plan point of view, generally something has to give. So unless you're doing just general colorectal plus PS is your sort of extra bit if you then want to do something else extra. So for example, functional work or IBD, because these things all start to add up in terms of clinical commitments whilst you still need to maintain your core activity pas start becoming a bit of an issue. Um So the thing that the main thing that's given in my particular job plan is I don't scope and I'm the only colorectal surgeon in the hospital that doesn't scope, which can lead to some disappointment for people why to do it. But this is the, this is the sales pitch. But firstly, variety you, you saw the list I managed to generate in 60 seconds. You, if you want to, you can do a bit of everything and it really is a list will be all sorts. It's all nice, low complexity stuff. So, which makes it really nice, low stress. Quite good fun. The tissues are beautiful, operating on the tissues of a kid of 12 years old, pristine, beautiful planes. It's not like the classic sort of 60 year old obese smoker who's had a hard paper round. These are really, really nice tissues to operate on which actually makes it really enjoyable. Particularly if you're not stressed about what you're doing. The kids themselves can be quite fun. They generally have one of two approaches to being in your clinic and on your list, they're either a bit scared to be there. They tend to be a bit quiet and maybe a bit difficult, but you can usually win them round or they're really excited about it all. And they're really, really fun when they're really excited about it all. And most of my colleagues experience of pediatric surgical patient parents is they're stress because they're always seeing them in emergency situations. These people are really anxious about their kids. Understandably, I see them when they're completely chilled out about it because they're not there about anything, anything complicated. It's all nice and straightforward, it's all very chilled. They're not stressed, they're really so much easier to deal with. Unlike when you're at someone like the children's and you're doing all the neonatal stuff because understandably those parents are really anxious. So, compared to a pediatric surgeon's job, it's really, really simple being a bit messy about it. Some of you guys are going to be sort of think about where you want to go at the end of your training, where you want to get a job. People, as you get closer, people start to talk to you about added value. At CCT level. Most people have a core a standard offering and people will talk to you about trying to get added value that will give you something extra to stand out, that will be useful. Peds. Training is pretty uncommon and it's really really useful in the hospital. It from a trust point of view earns some loads of money from your colleague's point of view. It's a service that they won't necessarily be able to offer. It's a really good sales pitch. Most places won't advertise for it because it narrows down the pool of candidates so much. So if you can offer it, it really does put you on, on the front foot when you come to apply. Oh, wrong way. Oops, sorry me. But as the various reasons I've touched on already, it's not all silver linings do things do have to give it is an entire extra service in terms of admin and things like that. And as you will discover on to our consultant, admin and management stuff is unfortunately vastly disproportionate to what you think it's going to be even as a senior registrar. So quick sketch out of how I got to where I am. So I did a very old style BS T um And as part of that I did six months in a vascular job where they had a pediatric interest. So I had a regular pediatric list as an sho and because the red wasn't interested in it, I got to play at the end of all my basic social training, I did two years in research. And at that point, I was doing sho tier on course covering both general and pediatric surgery. And because I'd actually gone via a middle grade to year on call, I was quite experienced at that point. So they actually let me do more than was average. So I was doing things like pyloric stenosis and so forth, which was really helpful. Found I quite liked it all but still wasn't really heading towards doing peds. I did a six month then in my second year as a re I did six months in breast surgery again with the boss with a pediatric interest. That's just a once a month list. And whilst I was doing that, the Deanie in their wisdom, decided that my next job was going to be at the BCH doing the pediatric surgical registrar job because no, they hadn't managed to fill it. They didn't, but they just told me, I was going, I have to admit, by the time I finished the breast job, I was actually quite interested in the idea and was quite keen on it. So it, it was a bit of a boon, but I hadn't asked. And then following that, I did, I specifically asked to do 12 months of colorectal in with pe in the unit I was talking about before, which is the biggest one outside BCH. So the requirement at the time I went through was you had to have done at least six months in the pediatric surgical unit. That was, that was the only stipulated requirement plus the usual index, number of volume of index procedures and so forth. But I would say the time at BC is critical to what you need to know in terms of all the complex stuff because you need to know what, what it entails, what, who to send it to and so forth. But you don't get anywhere near your numbers because they don't really do that much of the really basic stuff that's all done out in the reasons by people like me. So you do need those extra jobs with the Peds interest. If you're going to go for it, it's unofficially flexible. They stipulate what you need to do, but trusts will work to work around it if they need to. One of my friends also in the West Midlands was appointed to a colorectal job with the intention of taking up pediatric surgery because they needed the service and they asked them if you do it and he went, oh, ok. If you insist he'd done six months as an sho, at PC H and had no interest in it at the time. So hadn't really paid that much attention. But what the trust set up was a, I think it was an 18 month period where they put an sl a in place and somebody came in and supported the lists for 18 months and trained him up over 18 months so he could provide the evidence that he knew he could do it. He does a much more limited scope than I do. But that, but that is in also, in part because where he is, they have a pediatric urology service where I am, we don't have pediatric urology. It's me, the new curriculum is now officially a, an option in phase three. and despite reading the curriculum three times in the last couple of weeks, try to work it out. I can't work out exactly how that works. Hopefully, Miss Tierney might be able to give you a better idea if anybody's particularly interested, but I haven't managed to work it out and I didn't get a chance to ask the TPD. So if you're not convinced by all of that, what you need to know, this is what these are the main things you will need to know first. Firstly for your exam. And secondly, as a consultant because you need to know when to go and find someone like me or find BC or whatever. So, in oop, oh hell, that's a funny order. OK. Sorry, that's my fault. Circumcision get referred, I get referred masses of kids for circumcision because they can't pull the foreskin back. There's only actually two indications for a circumcision. One is recurrent balanitis and the other one is a pathological phimosis. And the distinction is what's a pathological phimosis and what's a physiological one. So the physiological one is where everything is actually completely normal. You just can't pull it back, usually due to prep piece of adhesions, not having freed up. And that's the one on the top left. So it all looks pretty normal. There's no scarring in the skin. And the description when you is that when you pull on the foreskin, the, the end of the foreskin will bloom like a flower. It'll open up like I think they say it's like a rose from memory. Uh You don't need to do anything at all with that. A physiological, sorry, a pathological fimosis however, is as the name implies where something is wrong and that's where you've had scar. For example, you've got scarring in the skin, the moment you get any kind of scarring and fibrosis that's not going to stretch that's not going to release. Um There's, these are particularly extreme examples for, for graphics particularly, is it straight after lunch and for everyone, like on a, on a full stomach, those need surgery. So if you've got a physiological phimosis, you can just leave it alone or if it is a bit tight. But it is just logical. Still, you can stretch it with the assistance. A bit of steroid cream. The term that makes my secretary laugh every time is the actual series of exercises with the cream for six weeks and then for six weeks, just for the stretching exercises is officially termed. If you look at up in the literature as for skin gymnastics, prep adhesions, you really don't need to do anything at all with those they will release over time. You used to be a real fashion for doing circumcisions for them or even just doing pre puc releases with a clip with the kid asleep. The evidence is you don't need to if they reach puberty and there's still any adhesions in place, they will release at that point. I guarantee it. So even if their parents are really, really stressed about it or the kids are really stressed about it, you don't need to do anything at all. Cryptorchidism otherwise undescended test is, is. So that's where you have a failure of the migration of the testes from the abdomen down into the scrotum as as you're developing, you can get an ectopic testis. So in an undescended testis, it's somewhere in the, of course, it should have gone down it just hasn't got all, as far as it should be in an ectopic test is, it's gone the wrong way. You can find them in all sorts of places in, inside the thigh is one of the, one of the classics. So it comes down the femoral canal and goes down the leg. Instead I don't do anything with this but crypto so, but undescended testis. Yeah, that, that would be dealt with by somebody like me. Risk factors for it. And these are the ones you need. These are the bits you need for your MC QS. Low birth weight prematurity, family history. It's about a 10% increase, a 10% risk. If someone else is in the parents, if the dad won't be in the mum, will it, if the dad had had it? Mums smoking. Don't I have no idea why? But if your mum, if the mum smokes, it significantly increases the risk in the kid and problems with endocrine sexual development disorders. So it's basically the things that drive the process. 80% of them you'll be able to feel where it is. That number is dropping rapidly because kids are getting unfortunately rapidly faster. Um But officially it's 80%. I say it's I, I would have sketched out of probably 60 to 70 in reality. But if, if you're asked, that's the answer and 30% of it of them will be bilateral. So if you, if you're suspicious about on one side, really make sure you check the other side properly and 4% won't be 4% of patients where it's not in the scrotum won't have a testicle on one side. And the presumption is in most cases, that's because they've had a congenital torsion. So they've actually to it the testis whilst they were still in uteri. So you would turn up with a little blind ending stump of the cord. What you do is you can't feel it. And this is a bit again, what you need to know as, as a consultant, you'll read. Also lots of people send them off for ultrasound. It's absolutely useless. Your specificity and sensitivity is about 60% for both, which basically means you can't rely on what the report tells you. So first step, if you can't feel it, have a look with them asleep because they often wriggle around a bit. You can push in clinic, you can push a lot harder when they're asleep and you can majority of the time we did a sort of quick straw poll and found that eight out of nine, we could feel. So it's worth doing it your way because if you can feel it and it's not coming down, you crack, you under the same anesthetic, you crack on and you fix it. If you can't feel it, even in the U way, they then need a laparoscopy to see if, if they got a cord on the inside and they say where that cord's running to try and follow the cord down to find out where it actually is, whether it's just not got into the canal or whether it's gone the wrong way. Surgery wise. Orchidopexy. Very straight forward. You basically free it up along the cord and stick, stitch it in place. That's if it's in the Inguinal canal, if it's really, if it's low enough, you can actually sort of reach up from the scrotum and just make one incision if it's not in the inguinal canal and you can't get at it. That's when it goes off to somewhere like children's again because they do a two stage one, but they laparoscope them and they divide the blood, they divide the blood supply, relying on the separate supply to the actual vas to, to actually supply the testicle. And if it doesn't, at that point, ne crows, they'll go back in at about, I think it, I forget how many months it is and all that. And at that point, they'll deliver it into the Inguinal canal and then free it up all the way down. So it's not just two steps. There is as you might imagine, there is a risk with that, that when they go back in, it won't be there anymore. When you're doing these, there is a risk of either rev sing it perioperatively. You, you absolutely skeletonize the cord when you do it. And if they're, if when particularly small kids, that's the one bit that can get a bit stressful, particularly in a reading because you're looking at something that's absolutely tiny like this and you, even with your loops, it's pretty small. And I think most people will have heard a story of a named person where they've gone to draw it down and all of a sudden they've got a testicle in their hand and there's a, a bit of cord hanging there, but it, it is actually exceptionally rare. Um But I say most people that work in the field can name somebody that they've heard it happen to, but it is that rare. And as you might imagine, you, you can end up losing a testicle just because you damaged the blood supply to it in the pro again, in the process of sin it. So those are the risks you need to know about for your, for your exams. Again, long term implications of this are you can get reduced, potentially reduced fertility and the testicular cancer risk in that testicle due to again goes up and the longer it is untreated, the higher that those risks get. And it's due to the fact that the canal is several degrees warmer than the scrotum. So you get a failure of maturation of the various cell types. So you end up with a can end up with a highly abnormal test is if you bring it down at the appropriate time, still so fairly early. Both of those are pretty minimal, but you do just need to give parents a heads up to tell the kid as he gets older to keep an eye on things and keep examining himself more than average inguinal hernias. You may well see all the get called about these on call. I might even have been called her as a red. So in little kids, they're, it's a different pathology from adults. It's basically because the PV. So you have a patent PV process of vaginalis where the, where the testis comes down in boys. Round ligament in girls doesn't close. 10% of them will be bilateral common in boys because the testicle means that the PV is bigger to start with family history jumps your risk up, prematurity multiplies it by 10 times it goes from about 3% to 30% risk. There is a high risk of strangulation with these. So these do need treating. If you see, if you get, if you see one or get hear about one, they need to be seen in the clinic. And if they present as an emergency, if you can get it in, if you can sort of massage it back in, they will scream just to warn you, they will scream a lot. If you can massage it back in, they need surgery before they go home. If you can't get it back in, they need surgery ASAP that because these are often kids of under one and certainly under two who they need to go to a pediatric surgical unit for that umbilical hernias. These don't strangulate as a general rule and you can ignore these, 95% of them will close by the age of four. Probably 10% of my clinic appointments are taken up by one and two year olds with umbilical hernias where I spend, spend an awful long time telling parents they really don't need to worry about it. Um, we'd only bother following them up because so many of them will close if they still got persistent hernia at four. Yes, they need an operation at that point because at that point it isn't going to close. So generally devices, if it's, we'll see them again at about 3.5 or anything at 3.5. So if you, if you see one and they're over 3.5, get them back to the pediatric clinic. Otherwise, if they're younger, just reassure them, they really don't need to worry. And don't, if you ever come to do any of these, don't stick a mesh in because the mesh, the kid grows and the mesh doesn't. This is the big scary one. Well, this is mid gut mild rotation. So think about your embryology. If you managed to stay awake in embryology lectures, I didn't. So around about week 10, the bowel moves out it. Well, in uter, the bowel wall moves out goes through two rotations and then back in, it's a failure of those rotations and reinsertion. So what for the, the classic full failure of rotation? You end up with all the small bowel on the right hand side and all the colon on the right, you get varying degrees but, but the characteristics of it are and that you end up with a narrow mesenteric base due to lads bands on it and that has a high risk of vus bear with me a second going to demonstrate this was explained to me by a pediatric surgery. It's a lovely demonstration how I can send to all his patient. You should think about it narrow base. If you twist your like this bit of paper, if you twist that, that's really easy. I can twist that right round. If you widen the base like that, you now can't twist it. So that is the problem. It's that narrow Mesenteric base where things are fat isn't the problem. It's about the mesenteric base. They're just as common in boys as girls. What you're looking for and what you see radiologically is the DJ flexure either at the midline or to the right of the midline. That is diagnostic. If they've got that, they've got some degree of malrotation, irrespective of what you can see in terms of the small bowel and so forth. They, in terms of presentation, they usually present very early, um less, less than or equal to one year old. And the classic is bile state vomiting because what happens is they actually rotate the whole of the mid gut. So if you don't get them treated in time that they pretty much entire small bowel dies, it really, really stresses out the pediatric surgeons. And if you mention bars stay and vomit to a pediatric surgeon, a true as in a full pediatric surgeon, not somebody like me, this was the first thing that crosses their mind. What we're finding these days is actually we're getting increasing numbers presenting as adults as either as an incidental finding on CTS and things like that on. So cross section imaging or patients that keep presenting with recurrent omissions of abdominal pain, particularly severe abdominal pain that then settles after a while and that sort of a pattern and you sort of ask back and you'll find this has been going on through childhood. There's lots and lots of discussion about at what point you do need to bother doing a large procedure in an adult or not. But basically, the longer they've managed to get by without a problem, the less likely you are, the less the pressure is to do it. But if somebody's sort of twenties thirties, they've got 30 40 years ahead of them, there's a good chance they might still twist it. They do need it doing. Even if they're relatively asymptomatic and purely incidental, the older they get, the less you need less likely the gray area is people around 50 60. But that, that does cause debate. But going back to what I was saying before, a that procedure is really straightforward operation to do. As long as, you know, as long as you understand the principle of it, it's all about dividing the bands. You're not trying to correct the anatomy, you're just dividing those bands and narrowing the base and the one thing you need to remember to do if you do ever do it in, in anger, take appendix now because the appendix won't be in the right place. If ever they get appendicitis, it's, they're not going to get the right symptoms and it usually gets missed. So, what the peed surgeons do is they do a um inversion, appendicectomy is what they call it. They divide all the meso appendix along the line of the, along the border of the appendix. Invert it into the. So you can put a stitch across it to keep it closed and it just necrosis and passes out with the rest of the pig. So you're not actually opening the lumen, so you're not contaminating anything at all. You're not turning it a clean operation into a dirty operation in any shape or form. But it does, that appendix does need to be dealt with and things to remember if you do see 1 70% will have an associated anomaly of some congenital anomaly, whether it's minor cardiac respiratory there will, there is some, often something else going on. The other biggie that again you may well get cool to see just in a general take is interception. So, as know where one bit of the bowel goes inside the next bit, it's a bit like rolling up a pair of socks and the longer you leave it, the further it goes, boys, no idea why usually presents less than three years of age. So the older they get, the less likely it is to be in interception. And classically, uh it's sort of about one year old or just under 90% in little kids are due to pairs patches. So just lymphoid tissue, that's so it often follows upper respiratory tract infections or something a bit, something a bit viral, some shape or form. What sort of flags to think about other pathologies are if it's recurrent, if it's happened more than once have they got a lead point, cystic fibrosis patients get it because they get obstructing mucus plugs older kids. Once you get past four, the risk of there being a le point goes up dramatically and by the time they hit their teens, they almost adult risk of there being a something pathological. And if there's any preceding history of symptoms, then that's pretty soft to be fair. As you might imagine, there's a risk of ischemia inception shouldn't give you a temperature. So if the kid's got a temperature, they probably perforated it the classic is red current jelly. So, but one of the big things is kids, little babies that are inconsolable and drawing their knees up. If you can feel a mass, you've got your answer. If they're parasitic, they're perforated, whatever you can get. Ideally is an ultrasound in the hands of a pediatric radiologist that is the best test. But in end day, whatever you can get your hands on as long as it's quick, even if it's a CT and the treatment is either a pneumatic care enema. If you've got that facility or can transfer to somewhere where they can failing that operate, it is better to reduce it than have to wait a long time. So, any questions, what's a sub for a pediatric visit? Thank you very much Alistair. Um Unfortunately, because of time constraints, we don't have much time for questions if anyone does have questions, I'm sure you won't mind answering them during a coffee break. So, it's my pleasure to introduce our next speaker, Mister Duncan Scrum. He's a consultant, colorectal surgeon from NHS Grampian up in Aberdeen Scotland and he's also an abdominal wall expert. Ok. So he's here today to give us some pearls of wisdom in a very much fast growing field of abdominal wall reconstruction. Mhm. Need to go back to this side. Go back now, go back aside. Sorry. Can Yeah, hard to get so. Ok. Thank you very much. It's an honor to be invited here. To speak at Duke's Club again. Thank you for having me. Thanks for the patient. My name is Lin Crue. I I just mentioned a colorectal and general surgeon. I have the Ro infirmary in the northeast of Scotland. Like most general surgeons. I spend the vast majority of my, my time um dealing with emergency general surgical patients. But my elective duties are met are um divided equally between colorectal cancer resections and abdominal wall reconstruction. So I'm hoping to split this presentation to a one somewhere. That's it. Ok, perfect. So I'm going to split this presentation into three. I'm going to start with elective abdominal wall reconstruction, followed by a video on arrange stopper repair, uh transversus, abdominus muscle release and an anterior co separation and then a little bit by emergency incisional hernia repair and management, which I hope will help for the exam followed by an algorithm on the open abdomen. So a third of the Western world will undergo emergent are, will undergo abdominal surgery at some point in their life and up to 30% if more will develop an incisional hernia at some point. It's the most common long term general surgical complication. Yet, until fairly recently, it has been the most neglected area of um general surgery research. Now there's been an increase, the number of millimeters if procedures being performed robotics, laparoscopic over the last 10 years or so. Yet, the rate of incision of the hernia is not decreasing. And the rate of abdominal reconstruction is increasing. But what defines um abdominal reconstruction? Well, when we talk about abdominal reconstruction, what we're actually talking about a complex hernia. But what defines complexity? Well, there's currently a, a healthy process ongoing just now and we should be ready to these results and within the next year or so. But what, what I use and what I think others use as well is the definition which is based on the algorithm by the, by our colleagues in Denmark, the Venus Hernia Database. And what we define it as is a defect greater than 10 centimeters, a recurrent hernia where there will be mesh present a lateral hernia, a hernia when the patient also has a stoma or a fistula and loss of the me. Now, the term loss of the vein is often freely written in the literature. But what is loss of the vein? Well, I find this usually find this quite difficult to, to understand there are a few complicated volumetric measurements out there. But thank the, there's a definition again through a DELFI process um by an international DFI um consensus expert group. And this is even apologize for reading from my slides. But it's where the simple reduction and primary fascial closure either cannot be achieved without component separation techniques or there's a significant risk of abdominal compartment syndrome. Mhm But it's not just hernia morphology that makes a hernia complex, it's comorbidities. A lot of these patients also have multiple comorbidities. The decision making process is particularly challenging to perform a concurrent gastrointestinal ation versus doing a two stage procedure. And there are a vast array of surgical techniques and options available. The cumulative risk of developing a of strangulating strangulation in an incision, hernia is probably about 4 to 5% over five years. So it's very low. Abdominal reconstruction is not a life saving operation for most patients. It's a quality of life operation. And I have to say over the last two years, if you compare the number of thank you letters I've received in cards of abdominal wall, reconstructed patients compared to cancers, then the abdominal wall certainly certainly will. It's a quality of life operation but does it really improve quality of life? Do we know that? Are there any long term results? Well, thankfully, there's a paper published in 2021 in a hernia. This is, this is very good. It's been incredibly insightful to me. This study looked at patient reported outcome measures in 210 patients with a medium follow of just over three years, 63% had improved symptoms. 20% the same 17% were were worse. But over two thirds of patients actually reported new symptoms, discomfort, pain bulge and one in 10 patients, would they they never had the surgery at all? So what this emphasized to me and I hope to you as well is that this type of surgery quality of life, you have to meet patient expectations. And a lot of this is done in the preoperative and the counseling period. Often when I see patients, their expectations I can't meet. And if that's the case, then we shouldn't be operating on these patients. In order to meet the patient expectations, we have to have an abdominal wall of service and I'll just run through what we do in, in Aberdeen. And we were fortunate to have a service here which we've developed over the last few years. And it consists of an N DT which you've heard a lot about today. A monthly complex clinic, a Botox service which is Nisone and we roughly perform 2 to 3 complex three session, um um lists something in the NDT. It's important to have a G I surgeon present, of course. But in our institution, we have two, we also work closely with a plastic surgeon. Again, an invaluable member of the team for soft tissue decisions, a radiologist. And we, we do this every, every two months, discussing 12 to 15 and sometimes linked in regionally with some of the other centers during the clinic. We're fortunate to have a, a nurse as well who's present, see three return patients who have been operated on the three months prior to that and then every year thereafter, get a CT scan and do that up to three years and then discharge. We allocate 30 minute appointments. For all patients that require lot of preoperative counseling as I've just discussed. And plastic surgeon is absolutely key. Now, you may be familiar with this gentleman to Hend, he's the godfather of abdominal wall reconstructive surgery works at Carolinas Institution. And during the clinic, it's a perfect opportunity to discuss modifiable risk factors. The see up here for your examination. If you mention this, it's a way of being able to show patients the importance and give them some power to, to, to, to, to stop smoking, to lose weight, diabetes, great incentive. But these are the three main risk factors that you must control before you embark upon an abdominal reconstructive surgery. Now, Botox has been a game changer. There's multiple studies out there. This is a very good systematic review meta analysis. Best evidence you've got, you can clearly see here that, that you can increase elongation of lateral muscles by 3.2 centimeters. On either side, what we use is is almost identical to do what Scots paper described in 2011, 300 international units of Botox, 50 units injected into each of the lateral muscles and it's 3 to 6 weeks prior to surgery. In order for all your patients to receive Botox, and we do Botox in every single patient for obvious reasons, you have to have a foolproof service. In order to achieve that we have two nurses, two consultants and ethos so that there's no delays, I'm just going to run through three scenarios. These are are cases of lesions that we we see fairly frequently just to give you a taste of what can be achieved. So this is a gentleman had a perforated tubule ulcer back in 2017. And the team involved saved his life. And unfortunately, he, he developed a hernia and was in and out of hospital with obstructive symptoms. Um and you can see his, his skin is very, very thin there at risk of fisting, which would be a disaster. Now he was, he was, he was a smoker at the time, he was also diabetic. We controlled this and the defect size was only about 10 centimeters. So it's actually quite easy to repair. So really, for me, it was, it was incredibly satisfactory for the patient. Um He had a, he had a great outcome. You can see here, this is 14 months later. So he performed just a unilateral transversus of doin muscle release. The other scenario is when you have a patient that has a stoma, he can't, it can't be reversed. So once you, I hate these operations, stoma parasal hernia appears are an absolutely night. But that's not the reason why we did this. He did have a para colostomy hernia, but he also, as you can see in his midline there, he was a risk of file in and out of obstruction. This poor chap had a low, you know, low anterior resection he wanted the ne protectin I theos he leaked, they then tried to salvage it by doing a Protectin Lo I that didn't work, went back to that anastomosis brought in and then Colostomy and then subsequently reversed his lup I I ostomy. And again, he was in and out of hospital for obstructive symptoms. This is probably one of the most challenging cases that, that I've done over the last um been involved over over the last three years because the abdomen is so rigid, incredibly challenging. So bilateral transversus abdominous muscle releases here, I'm using a biosynthetic mesh for obvious reasons and this is in two months later and I have seen him more recently, several months after he's done very well. He did develop a little wound infection postoperatively, but otherwise he did exceptionally well and still did well. The final scenario, if that's if you, this, this is what I see more frequently. And this is why I operate on patients like this more frequently. This is whereby you have a, a stoma, but you have an option to restore G I continuity and it can be challenging, but you have to get an absolutely right reach for the patient completely optimized. This chap had a perforated diverticular disease. He was young, he was only in his, in his forties. He then um after that, I had a, I had a, he was, he was joint and he had a colorectal anastomosis where I protected with I the ostomy, then COVID struck, he developed a stromal site, incisional hernia, a para I ostomy hernia and also a midline hernia. And you can see the problem you have with the soft tissue. So we managed to do again, bilateral transverse abdominus muscle releases after we reversed his loop iost at the same stage. This is how seven months later this guy's life has been completely changed. He was living in as his recuse. He didn't do any work. He wouldn't go out to work. He's now back working and he's in a relationship. So they're incredibly important. So now I'm just going to run through a, a video, just sort of break this up a bit and you'll just hear me um talking through my slides. Um So three techniques, the first thing we're going to discuss is a read stopper. And this is the most common technique. If I ask anyone in the audience here, they'll probably say they can do it, but very few of you are probably actually done it properly. Um So you can use this for most defects that are less than eight centimeters or 10 linear alper is elevated as you see here after to perform the laparotomy and adhesiolysis appropriately, posterior rectus sheath is incised to expose the rectus Abdominus muscle. Once this has been exposed, you can then just quite rapidly develop and open up the retro rectus space and then develop it medial to lateral until you encounter the neurovascular bundle at the linear Celina. At that point, that's where you stop. As we remove the cordial, our dissection continues, you'll encounter the fat pads surrounding the inferior epigastric vessels. This must be dissected and elevated behind the in the rectus muscle to ensure they're not damaged. 80% of the blood supply to the abdominal wall is from the inferior epigastric vessels. So as an abdominal wall surgeon, I'm quite protective of this. We do the same on the opposite side before we move down towards the retropubic dissection, so called red sea space, which I'm sure many of you are familiar with if you do any laparoscopic inguinal surgery, and this could be very easily developed just with B dissection. You have to be careful, there's a lot of bleeding. So try and control the bleeding and don't go too deep because you'll encounter the doo venous complex in a male or a. And all the reason we're creating this space, yes, it might be to cover a hernia from a fine and steel, but it's, it sort of mesh is anchored. We allow the mesh to a few centimeters below the pubis, there's an anchor point in it and then just by putting a two or pvs preop your ligament, you can secure it on each side and the mesh won't move. So the next part I think is the hardest and that's the sub I point dissection. So to do a full reef stopper to cover a whole midline. That's what you would do. You'd have to go behind the sternum. So we just like to go into that just now. Now, I would avoid doing this unless you've, you've got someone who has, has done this before and can take it through, particularly if it's a hernia there. So we're looking, we're looking at the top part now with the abdomen, we the la the, the posterior rectus sheath which is left in to the linear. Then dissection takes place underneath the XIV sternum and then division of the posterior rectus sheath to, to complete and to allow the joining together of the left and right and retro rectal space. The posterior rectus sheath can then be closed and a mesh can be placed in the retro rectus place. Can we just pause that there for just a second if you can good back here was slightly in May. OK, just sliding back. So we'll get to the transverse of those just want to get that slide up. If you can, you just have to go back for me that's going forward and just where it stops at the CT scan, go a little bit forward, a little bit forward just after this. Just perfect. So OK. Well, what I was trying to show if you could go back to it, positive is text book are nothing wrong. They depict the transverse is a domino muscle there as you see in the top picture as in, in the linear se in a it doesn't do that. If you look at the axial imaging, you can see the belly of the transversus abdominus actually inserts immediately into the posterior rec sheet. Now U Avis in 2012 said I di notice this and I believe you have dissected cadavers and a transversus of dos muscle release report. Please press. Yeah. Thank you very much that, that great. So a retro rectus, a brief stopper is performed on the patient's right hand side. Here, there's a Postiga rectal sheet and beneath that, you will see the transversus abdominous muscle fibers, an incision is then made into the posterior right tissue. Be careful not to damage the lateral neurovascular bundle. Transversus abdominus is then elevated and divided beneath the transversus abdominus will be the transverse this fascia. You can clearly see this, it's strong but very, very thin. So time just has you just have to take your time when you develop this plate. The transversus abdominus is then elevated it and the transversalis fascia is pushed down and that plane is developed carefully at the start, but then you can quite rapidly progress towards the thoracic lumbar fascia, which is where the transversus abdominis originates from as we go more caudal, the transverse abdominus becomes more thin. And at this point, you have to be very careful. You don't damage underlying peritoneum to find that there and then the plane could be continued again, a similar manner that's happened in the top part all the way around towards the th I go the th lobar fascia, the final structure that needs to be divided to join the infra Guin region. Bry space. Theus space is the division of heel back ligaments connecting the transverse fascia to the inguinal ligament. And once this is divided, you will then clearly see the psoas muscle perfect for any lateral hernias. You also see other structures such as the external IAC vessels. So you have to be careful with that, the spermatic cord in a male going into the deep inguinal ring or the round ligament in the femur, which of course can be divided. Now in the final clip of the transversus abdominus, what I want to highlight is how dangerous point where you can damage the diaphragm. So you'll see the big two muscles we've got the diaphragm there and then you have the transversus abdominal. So when you're, when you're dissecting that direction, look out for the water shed fat area at that point, you know, you're about to encounter the diaphragm, be very, very careful and tea component separation. The final component don't do this too often. Now, this was developed by Ramirez in 19 nineties. A lipo cutaneous flap is elevated after performing a retro rectus dissection to expose the anterior rectus sheath and then just beyond where the linear semilunaris is for the ninth costal cartilage to the pubic tubercle. So what you don't want to do is go through the line assembly Aris. If you do that, you'll completely detach all the lateral muscles disaster. So to identify that, place your finger into the retroactive space, you can identify the linear assembly Aris and then just lateral to that make an incision into the external oblique, a neurosis underneath that will be the external bleeding muscle. And this can then be divided. You know, if you're in the right plane, when you see the internal lead muscle fibers, which will of course be um perpendicular to the external bleeding muscles, which we'll see just shortly. So then you want to divide the external, the fully all the way up to the costal cartilage where the external oblique arises, the only muscle that covers the, the the the rib cage and divide the externally all the way down towards the inal. And then the component separation tape can, can take place and that's where you lift the external muscle off the internal obe, develop the plane all the way around again to where it originates from towards the thoracic lumbar fascia. And then a retrorectus, the posterior layer can be closed, a retroactive me to be placed and then the la your elbow can be approximated. So the final two parts of this presentation will be on an emergency, hernia repair and a bit about open happen as well. I hope this is helpful for your examination. Much of what I see here is based on the European Hernia Society and the American Hernia Society guidelines, but also the World General of Emergency Surgery guidelines in 2017, I'm so many. These are a bit small. I thought we to be slightly bigger, but I will, I will tell you, hopefully you can see over there actually. So a patient presents, they have a hernia, two scenarios, they're stable or they're, or they're, or they're stable or they're unstable, unstable patient. Well, you just have to sort out the problem and manage the patient in an open abdomen algorithm. And I'll come to that side of one most of the time we're dealing with a, a stable patient. So a stable patient with a hernia, if they also have loss of domain and a complication such as a, a perforated bowel, a small bowel which is necrose, then you just deal with the complication, forget about the hernia. Of course, just deal with the complication, but you're probably going to have to go down the open abdomen algorithm. A stable patient with without contamination and with contamination. Well, if there's no contamination at all, then just man constipation as you would do the elective set. But if there is contamination, what do you do? Do you use a mesh? Do you just do primary closure? Well, mesh in the contaminated feels been a contentious issue for a, for a number of years. And thankfully there been quite a few reasonable studies out there to support the use of synthetic mesh. This is one paper in particular, a comparative analysis of biologic versus synthetic mesh. And what this tells me is actually synthetic mesh is relatively safe to use a contaminated fiel with acceptable low infection and recurrence rates. Based on this paper and others. The guidelines from the world general of emergency surgery in 2017 have said the if a hernia is present, you've sorted out, you reduced the hernia, you've dealt with it. It's a CDC wound class two, then consider using synthetic mesh. However, if there's, it's grossly contaminated, it's a 34 class, then this is what I'm not too sure. They tell you that you can use a, a biologic or a biosynthetic. If the mesh is, if the defect is greater than three centimeters, I'm not sure about that. I'd be reluctant to do it. I have to say be more inclined to do your primary closure. I don't think you can keep it simple. Is the key here. Just keep it simple. Now, the final part is that about over abdomen, I heard it mentioned briefly earlier on, but hopefully this will just help to reinforce this. We, we don't see it happening that often. Um I think in the past it was, it was used by everyone because it came from the military and it became quite a, a sort of in thing to do. But what I'm going to show you just now is an algorithm we use in Aberdeen. And it's, it's an amalgamation of Dominic Slade and Jeff Gardner's chapter in this fantastic book, which I would recommend to anyone who's interested in abdominal wall surgery, but also from the European, the Hernia Society Guidelines and the World Society of Emergency Surgery. So, a patient presents unwell index laparotomy. There are three scenarios where you may consider an open abdomen, a logistical, an anatomical and a physiological logistical reason. Well, this would be a patient who's perhaps got fecal peritonitis from complicated diverticulitis. You deal with the situation and then you're concerned there may be some residual sepsis and you think, oh, I should, I should do an open abdomen here. I'm going to have to go back in, but that's not strictly true. You don't have to do that deal with the problem. If there is residual sepsis, you can always take the sutures out and look again a re laparotomy, laparotomy on demand. And there's evidence to support that randomized control trial 2007. But what we'll often see is an anatomical reason. You just cannot get the fascial s together. You're worried the risk of abdominal compartment syndrome, 50% mortality. And then there's a scenario of physiological where the rare occasion we don't see that often. But you have a, a very unwell patient. You want to deal with the problem quickly, get them back to intensive care where they can be fully resuscitated and it doesn't happen that often. But if you've decided to opt for an open abdomen, then the guidelines on the recommendation is to do negative pressure beam therapy and mesh mediated fascial traction. Now, what is it? You're probably familiar with the ARA I think it's available in most, most hospitals consists of a visceral protective layer. And then you have this the perforated feted foam layer sealed negative pressure up to 100 and 25 millimeters of mercury. So when considering an open abdomen, mis medi fascial traction, what you do is place this visceral protective layer in the abdomen after you've dealt with what needs to be dealt with. Don't worry about cutting it, just tuck it into the site. It doesn't matter if you cut it, it can cause more problems. Just tuck it into the left and right how call and cut it. You do that to avoid adhesions, adhesions form within 12 hours, then suture a polypropylene mesh I know was mentioned earlier on, but the recommendation is is polypropylene and just secure it with two old prune round. This fascial edges on both sides, cut the mesh down the middle and trim the, then trim the mesh and then close it with two probe so that you just get enough, it's tight but not too tight and you can be guided by, you need the anesthetist there. So you don't want to be too, but you want, you don't want the fascial s to retract and they will start to retract again within 12 hours. Then patient gets taken back 24 to 48 hours later. An assessment is made. Do you feel that you can and close, take the mesh out and perform definitive closure? But if you feel that no, we're not able to do this. The risk of abdominal compartment syndrome is too great, then trim either side of the mesh and again approximate the two mesh, the two edges of the mesh together with the dual Prolia and continue the process. It is quite large, it is quite labor intensive. This can save lives if done correctly. But at some point, the decision needs to be made and that's usually an arbitrary but uh value, but it's eight days and eight days, we need to make a decision. If you feel you're gaining fascial closure, then continue to do it. Continue with negative pressure and the best we need in fascia traction. But if not, then a decision needs to be made, you're getting very little ground, you're unlikely to close. What do you do? You need to make sure the skin closes, you don't want the heid. So you plan for an incisional hernia, approximate the fascial edges as best you can and bridge the defect and bridge the defect at this point. Yes. With a micro mesh, the mesh can be you put in the approximate to the to the due to the defect, it will absorb fully within about 90 days, but it will give you 80% strength up to 14 days enough for the skin to heal. And then a 2 to 3 layer skin kosher. The patient can if appropriately be followed up in the abdominal abdominal wall clinic. And the decision can be made whether or not to to proceed with incisional cardia repair. Now, finally, I just want to mention this is Dominic Sle and and and colleagues, National um Open Abdomen Audit. I think registration is still available and highly recommended. We're falling behind our European colleagues and and not managing the open abdomen well at all. So in summary, abdominal wall reconstruction, well, it's a rapidly developing subs specialization. It's something I'm passionate about. We happy to, to have a chat with you at any point and please feel free to contact me if you want to know a bit more about it and how I got interest in it. It's a quality of life operation and surgery. The vast majority of the cases are incredibly rewarding the techniques themselves, macular remove stopper repair before you move on to any component separation techniques. Anatomy is key spend time in the cadaver gland or in courses. There's multiple available that are industry sponsored in the emergency setting. Just keep it simple. You won't go wrong and you keep it simple and please please know how to perform negative pressure, wound therapy and mesh mediated fascial traction. Thank you very much for. Yeah. Ok. That was a brilliant talk. And unfortunately you be an interesting time I have to be on. But are you around sleeping? Well, I unfortunately, yeah, absolutely. Thank you so much. Thank, thank so the next session I'd like to introduce our two coa, so we've got Mr Simon Cha who's uh doctor Simon Cha, sorry, who's a gastroenterologist with an interested in IU from hospital And Mr An who is consult the color surgeon also. Thank you for coming in. Ok. Just the, just to make sure we're still aware. Yes, I can see lots of people moving off coffee. There is coffee and cakes outside, but please do bring them in. Um because I promise you this is gonna be a really exciting session. We're gonna be talking about IBDDD cases and the management of um possible cancer dysplasia in IUD. Ok. So I'll start with the first case. We've got a 25 year old male um diagnosed with UC about five years ago. He's got left side of colic and some bronchitis treated with five A S A. He has stable disease and no other associated features such as PS C. So what blood does he need? Should he have son colonoscopy? So, um thank you for the invitation to come and be here today. Wonderful occasion. Um So I think the first thing to say about the management of IBD cases is that uh it's all done through an MDT where possible. And uh increasingly I find myself becoming more of a technician um and leaving the big decisions to be made by my clever gastroenterology colleagues. Um so over to Simon like sa contain and uh and so as most of you are probably aware um inflammatory bowel disease or chronic uh relapsing, limiting condition, sorry. And so IUD is a chronic relapsing um condition. And so almost all patients are going to be under follow up from a gastroenterologist in one way or another, but that's face to face or virtual for some of the more stable patients. Unfortunately, um those with um chronic involvement of inflammatory bowel disease, either UC or Crohn's are actually at risk of developing uh malignancy and depending on which study you read, uh there's an increased risk of developing colorectal cancer after 10 years, up to 3%. Some more recent studies suggest it should be, it might actually be a little less. Um So really, rather than having a patient who has presented to you with colorectal cancer, uh we would want to try and catch them before they uh progress to this stage. And as most of you are aware, the adenoma cancer pathway, we tend to perform regular surveillance on those patients who have inflammatory bowel disease typically. Um after uh eight years of of BSG guidance. And that is often uh so the frequency after that has been based on the degree of inflammation and the extent of the disease. So for this particular patient at the moment, it doesn't actually require any surveillance colonoscopy if you want to add else. No, I, I have to say that, you know, if you're looking for an O level answer, that's exactly it. Those who have just done a last will agree with me that that was a, that was an excellent answer. Um So going forward, uh so key discussion points here and I'm sure orthopedist will, will um will have already captured some of this. It's widely accepted that IV is a risk factor for colon cancer. And risk of uh uh uh of colon cancer will increase with duration of the disease severity of, of in information. And when you're answering a question about it, it's important to highlight that in the oc that you're aware of what, why we're, we're surveying these uh these patients, newer population studies do suggest that some of the risk of developing colonic cancer may be overestimated as before the age of multiple biologics. So that's something to be aware of that. Things have changed in the age of biologist because some of the um key areas that you can look into um just for your own knowledge. But do you want to go through this one a little bit more? Yeah. So, um as we said, Dino, oh, sorry, he just this one, you can speak into that one. I use that. Oh OK. Give me another one, this one, this one, this one and speaking of both. Ok. Um, so those who've had inflammatory bowel disease for um, eight years should have a surveillance colonoscopy. You don't need to survey those who have isolated proctitis. Ok. So just proctitis alone doesn't require a surveillance colonoscopy and surveillance colonoscopy. I suspect. Um, as colorectal surgeons, you won't, you're unlikely to do this. But, um, what you want to try and do is a colonoscopy where the patients had a fairly good bowel prep. Um What we tend to do if we just move on to the next slide um is we spray a blue dye? It's very low tech. It is literally just a dye which is sprayed under the bowel, but it provides a better level of resolution. So you can try and look for any polyps, uh flat lesions or dysplasia and that's normally seen by uh elongation of the pit pattern. So, um can I ask with these Cron endoscopies? Should we be doing one on every surveillance colonoscopy for someone with colitis or so, um in an ideal world, uh we would be sorry, every patient who get when they have a surveillance colonoscopy, it should be done with chrome endoscopy, gone on the days when we used to just take random biopsies to look for dysplasia. Uh The idea of chrome endoscopy is to look for lesions. And so if there's anything you're uncertain of, you try and biopsy. So the idea is targeted uh lesions. Um Unfortunately, I guess at some places um sometimes colonoscopy will be done on a list where the endoscopist doesn't have the skills to do chrome endoscopy. Um What I'd suggest is done there is yes, you might want to take a couple of biopsies every 10 centimeters, which is the old protocol. But ideally, you probably want to ask this to be repeated on someone who does have the skills to do a chrome endoscopy fast for his diet. Um At the moment, um all the guidance is still for chrome endoscopy virtual. Uh The thing is here, I when you say virtual, you're talking about um CT colonoscopy in um so at the moment again, going head to head MBI has shown no advantage over chrome endoscopy. Um The recommendation from the international um scenic guidance is to try and do high resolution with chrome endoscopy would be the method at the moment. Some of the other data suggest that as technology gets better and better, we might be able to do away with the uh chro endoscopy as resolution improves at the moment. Not quite yet. Can I uh ask a question, show my nurse, how does grand endoscopy work? Uh Excellent question. Um It's very simple in the sense that um a blue dye methylene blue or interco is diluted to around 0.4 to um 0.1%. And once someone's done a colonoscopy and got round to the sequence as you come back, a catheter is inserted um down the um colonoscopy um channel and literally it is just um a syringe with the dye and it just sprayed out onto the bowel. So you just highlights the lying up about. And what you try and do is you try and spray in the superior direction so that all the fluid comes down, pools down at the bottom and then you can just suction out any pools of fluid to just have a look. Um Is there any a change in the pit pattern? Are any lesions highlighted? You do need to have a fairly good bowel prep. And the other thing just to add is in an ideal world, a patient's disease will be um quests or in remission because if it's um actively inflamed, it's quite difficult to work out whether it's dysplasia or inflammation. Is that right? Brilliant? Thank you. So, this is just another slide silent. Yeah. So um if you just look at picture uh a on the, you can probably just now see the uh lesion here. OK. But once you add on um endoscopy, uh big, big is and slightly large, but it just becomes a lot more visible. And certainly once you can start to raise it, you can see the lesion is quite clearly dysplastic. Uh there, this just highlights how it can be helpful, particularly when you're uh maybe not for poro lesion, but certainly for very fat lesions, which is the main problem, what we try to really detect here. So, you know, but you're on the spot here. So we find a lesion like the one picture be that lifts and it looks like seats. So I'm going to give you some different scenarios. The you take some biopsy. Ok. Let's, let's say you can you feel comfortable taking that polyp off and you do. So, but you also take some biopsies from around the area. Let's take the first scenario where the polyp comes back as low grade dysplasia and the biopsies around it don't show any features of dysplasia but show inflammation. What's next. So I think the first thing to say is if you're going to take the polyp off through the patient with I VD, make sure you're happy to do it because what we really want is we want the polyps to be completely excised. And as Amy mentioned, once you've taken a polyp out, ideally, you should biopsy around from the polypectomy site. What you're trying to look for is an invisible dysplasia. So given the scenario, you've just presented, if we've taken the polyp out and then biopsies around the um polypectomy site show the evidence of dysplasia, the false would be this would be a sporadic adenoma and then you could treat it accordingly. You did mention about inflammation which um can sometimes make it a little bit more difficult because ideally you want to be as we said earlier, trying to do dye spray when patient's disease is all uh quiescent. So, if it's inflamed, I guess you might want to push your uh his pathologist. Are they really happy? That was just inflammation or is there an evidence of dysplasia? And often cases like this may sometimes get taken to a histology nd just to get a second opinion with regards to the histology and ensure around the polypectomy site, it is just uh inflammation and not dysplastic. Ok. So same situation and the pathologist is convinced there is evidence of dysplasia in the surrounding tissue which is invisible to us. So, um if you've got biopsies from the polypectomy sites, and as you've said, they're dysplastic if it was performed on the chrome endoscopy, um by an endoscopist who uses this technique regularly. Um Then we do have a problem in the sense that they weren't aware that there was dysplasia in the um sorry when that colonoscopy was done from around the polypectomy site. And therefore, we then we need to discuss how, where do we proceed from here in terms of surveillance or more definitive uh treatment, excising that uh dysplastic area, obviously, if it was um say the scope wasn't done under chromoendoscopy, um The next thing to do would be to get the biopsies reviewed and ensure that those dysplastic changes you saw in the polypectomy site were definitely due to dysplasia. Um And then the question is whether it's low or high grade dysplasia. But I would often suggest that the scope is repeated by someone who does do colonoscopy to see if the biopsies taken around the polypectomy site are actually part of a lesion, which can be, which is actually visible because if so you potentially could remove that by polypectomy and um potentially um not require any further intervention. But otherwise, um if the biopsies that were taken turn out to be a spastic and there's, it's all what we call invisible dysplasia. In other words, there's no lesion that you can see, then it's going to be back to the MDT for a discussion with regards to uh intervals for surveillance or whether they're going to require a colectomy because of potential risks of malignancy. So, this slide is uh just a great um summary of uh surveillance recommendations from the BS G. And I think everyone should just have that with them in their pockets when they're in clinic. Moving on to case two, we've got a 45 year old male who's been diagnosed about 25 years ago with left sided colitis. He's uh had a surveillance colonoscopy which showed one adeno a slight lesion slash mass. The questions we have here uh Here are how are these lesions managed in IVD? What are the considerations for managing a patient with multi or unifocal, flat, low grade dysplasia? And how are patients with flat, high grade dysplasia managed? And you've kind of touched upon some of it already. Yeah. And I guess, I guess where we will goes from here as well. It's, uh, the sort of distinction between talking about surgery, segmental colectomy, subs social colectomies, the impact of the type of IBD that we're dealing with as well. Um, but I'll, I'll hand over time to ask and answer those specific questions. Um, so if we just, let's just take them one by one. So how would you manage Aden an masses or lesions in IBD? Well, you ideally want to manage it like any uh polyp you'd see. So when you see any uh Agnos uh changes obviously have a good view of it. How would you describe it? Is it a polypoid lesion? Is it a flat lesion? What's the size of it? Is this something that you can actually uh take off uh safely assuming you can resect it? Um And as we've said, you ideally want to take biopsies from around the edges to look for invisible dysplasia. But at the same time, if you can't take off the polyp, that's fine document what you've seen. If you think it might be difficult to find the lesion, again, then it may be worth considering placing a tattoo um not too far from the um adenomatous lesion. So that another colonoscopist or someone with um expertise in chrome endoscopy and potentially EMR of these large um lesions can find the lesion a lot easier to assess and then decide where to go from there. Um You've mentioned here one of the considerations for a patient with multi or uni focal flat, low grade dysplasia. Um Again, the problem here or the thing we need to assess is, is this lesion, a discrete lesion as in you can actually see the borders or is it one which is very difficult to define um or sorry, not, not easily visible? Um Assuming it is visible and you can um take it off. Oh, sorry, you've got to consider when you can take it off and then flat lesions are much more difficult to raise. It's more difficult to get a snare around it. And ideally, you'd want to try and take off um polyps um in one piece, accepted large lesions would require EMR or occasionally even ESD most gastroenterologists would feel that the risk of unifocal flat, low grade dysplasia is much lower for developing colorectal cancer compared to multi focal flat, low grade dysplasia. But again, this is the sort of thing that will probably be discussed. NDP. How feasible do we think this is going to be um removed, endoscopically? And certainly if it's not going to be removed, endoscopically, um what are the potential surgical options? I will just um briefly add that. Um As we've mentioned, it's low grade dysplasia. There is the argument that you could survey these patients at regular intervals. Um Sort of at least annually to just see whether there is any progression or not. Whereas if for argument's sake, this was high grade dysplasia, assuming you can't and see a discrete lesion to remove. Then the discussion for the need for colectomy becomes a lot greater. How many uh a grade dysplastic lesions with many choice? Um It depends on the number of um lesions. If there's multiple lesions in a small area, then I think that's something that potentially we could um look at either lots of um polypectomies. Um However, I think if it's much more uh dispersed or throughout the colon, then the ability of a patient to maybe tolerate this. And our um I think, I think the likelihood that we feel we really cleared the lesion becomes a lot less. So I'm afraid I'm going to avoid it by giving you a definitive number, but just say it's, it's a lot and depend on how discrete the lesions are, how easily visible um they are and whether they are scattered throughout the colon or not. So it looks like spor and if they have lots of ointment used to cool down. But if they, yeah. So um if I'm honest with you, it's really difficult to tell whether it's just a sporadic adenoma or in the old sense, what we call um So dysplastic associated lesion mass, which is the idea that an adenoma has arisen in a um lytic segments. Um I think pro provided you can take the polyp off um safely and then you've taken biopsies from around the area to see whether there's any dysplasia in those. If there's none, then most people consider that a sporadic adenoma and then treat that accordingly. If there is inflammation dysplasia, we treat it as we just mentioned, but it wouldn't, it wouldn't worry me. I think the only thing you'd have to think about is if there's dysplasia in the biopsies you've taken is just surveillance at a slightly shorter interval, potentially assuming it's low grade and not high grade. I think we've kind of touched upon all of these points really. Um One of the things that I've always uh wondered is in terms of classifying these polyps. We've been asked to talk about the Paris classification, especially in the FCS. Is it something that you might be able to? So I, I let Simon the Ari but again, I'm going to put, I'm going to put my cervix out and, and say, um when I, when I describe polyps or haven't described to me, I simply describe them. Are they flat? Are they raised? Are they se do they look like cancer? Um And uh I find that terminology, I understand. Yeah, I agree with that. It's very straightforward if we just actually skip forward. Um So yeah, that, that's fine. So this is the Paris classification for trying to describe um um polyps. It's fairly straightforward, you're asking, are polyps, are they polypoid so raised? And if they are, they're either sess or pedunculated. OK. Um So if it's pedunculated, it's one p, if it's ses R it's one s then you have your, what you call um your, your, your pas two pacification parts and these are all flat lesions A B and C um two. It's a flat lesion, minimal elevation. So less than 2.5 millimeters. If it's genuinely um flat, that's a two B um um lesion. And if it's slightly pressed, central depression, it's a two C and then people can sometimes combine these uh classifications because sometimes you might find the point where parts of it are minimally elevated, other bits where it's a bit more ses and that's where people start to combine the classifications uh together. I think as Annie said that I would, if, if you're having difficulty, I'd probably say, yeah, go for whether it's polypoid, non polypoid, whether it's um pedal chelated sessile and whether it's flat or depressed. Thank you. OK. So, moving on a little bit. Um we've talked quite a lot about polyps and what to do with polyps themselves. But what if there is, there, there are uh lots of polyps and a simple polypectomy surveillance is in sufficient. What are the criteria that we need to think about when we uh offer patients either a prophylactic colectomy, IRA A versus panoptic colectomy or just simply surveillance of a rectum. So, so um so mady, let's do, let's go one at a time. So, suppose you have a patient who's had a, a prophylactic subtotal colectomy. Yeah, rectum is still in place. Uh, I suppose they're 30 year old female. They come to you in the clinic and they're wondering what to do. Now, can they have a gastrointestinal continuity or should they remain for the rest of their lives with a stoma? Do they need to have a proctectomy? What do we need to think about when we decide what to offer? So, uh in that situation, you've basically got four options. One is you do nothing and leave the rectum in situ. Um And with that comes the discussions about what do you do? How do you survey the rectum? And we'll ask Simon about that in a moment. Um And the risks associated with doing that. The second is to do a ideal power, ideal Power table or anastomosis. Again, we can talk about that. Uh The third is to do an anorectal anastomosis, which is very popular places like Sweden. And uh we've certainly started doing a few in our unit. Uh And there's certain caveats with that. And the fourth, which I'm not going to talk about because I do have some experience in my training days of doing cock pouches. But uh that, that's always another option. So specifically, um patches versus um either erectile anastomosis. What are the advantages? What are the considerations? Well, in order to do how you have to take the right amount. So there's the associated morbidity and mortality, morbidity, I should say with that. Uh the risks of fecundity and uh and sexual function. So, particularly in no to younger people, uh and various risks of pouch failure. Uh It's usually a staged procedure. Ileal anastomosis. You avoid all those morbidities, but you leave the higher risk of cancer within the rectal stump and it may be a temporizing operation. It may be temporary thing and, and you go on to do a, a proctectomy, a completion proctectomy or, or after a later date, I think there's a few people who do both. But um but uh those are the sort of basic considerations and discussions that you have when patients with the patients in clinic, which we often do. Um But uh Simon, what are your thoughts on seve the rectal stump when you've done a colectomy? I, you were the next. And so um um is a little bit, the, the advice is a little bit vague. Um They suggest that as the risk of developing um lesions and dysplasia in a rectal spine is quite low that you may not necessarily need to do any surveillance. And so if you look at guidance, it says consider so in uh remaining rectum every five years personally. And certainly most of my colleagues I work with uh would aggregate uh s at least every five years. But if patients have uh other risk factors, so if there's been a family history of colorectal cancer under the age of 50. If they've got things like primary s and cholangitis, which increases your risk of colorectal cancer, or is there quite a little atrophy in the um um muco what they call type C changes, then you probably want to consider annual surveillance again, you know, potentially with a chrome endoscopy as well. Yeah. And obviously there are other considerations, uh other considerations when talking about suitability for the pouches. And uh I guess I think that's why it vaguely touches on consideration. If you do an eye rectal, there has to be sort of no ongoing active disease or where I think um differentiating diversion, bronchitis from actual oop proctitis in the stomach can be difficult. Um You'd have to have some evidence that the rectum is compliant. And um I think what we've got on the next slide is uh sort of things to think about as contraindications to doing without. So these are relative contraindications. There are people who will do it in these circumstances. Um obese patients increased risk of complications including uh pouch function, incisional eyes, which we've heard a bit about today and uh probably need to manager, try to get your waiting list down longer o of time. People with obstetric complications, 10 to have um bo power obstruction, elderly patients tend to have sphincter dysfunction of some sort. And although it shouldn't be a contraindication, there's probably a in most people's minds, a mental cut off of about 65 or they probably wait about two PALC radiotherapy. That's an unusual circumstance. That, that's probably a contraindication. And certainly I, I wouldn't put a pau in someone with Crohn's or, uh, indeterminate myself, indeterminate colitis. And certainly, if they've got PSA on me thinking about it just, um, out of just my own interest in a clinic, how do you, I mean, how do you explain to a young lady who is hoping to have Children in the future? But she really wants to wants a pau how do you explain the concept of uh reduce fecundity? How would you, what would you say to her? So, um if it's a real concern, if the, so I I don't go into anatomy or physiology, but I just explain that fertility is an issue after our surgery. And I think that if there's no clinical urgency in proceeding with that, I recommend that young women complete their families before we start talking about ouches and sorry, I think that summarizes sort of indications for an ileal anastomosis. We've kind of touched upon this as well. Um Oh yeah, this is a study that's out um being conducted across Sweden and England, looking at sort of quality of life outcomes after colorectal anastomosis and pouch. I think the original plan was to randomize patients. But actually, there's been some amendment because patients were actually choosing one way or the other. I'm not going to say which. But um, do you know what was more the, what was the popular choice? I think people were on rentals, but that's definitely a change. I think even a few years ago people were really keen to have pouches, but things have changed quite a bit. Ok. Um What about a approach? Poom? Me funny. You should ask that. So, I, um, you know, the question people ask is, should you be doing a proctectomy? Whether it's a completion proctectomy or is it part of a, a power formation? Should you be doing a TME type rectal excision or a close rectal dissection? And each has their advantages and disadvantages. I mean, the main thing is that most of us are used to doing TME surgery. So those are the things we used to, but with that comes the added risk of nerve injury, I think that's probably you're going to find these nerve complications go down more and more sophisticated, uh, sophisticated, uh, operative approach has been found the whole idea of enhanced uh robotic surgery, er, reading things and so forth. So it may be less of an issue. But, um, uh, certainly there is evidence to suggest with the TME approach that you have higher rates of pelvic sepsis and um, and uh how trade it. But um, there is some evidence that actually if you leave the fat behind and leaves the rectal fat behind, then there is a, a higher cancer rate with that. Uh, or cumulative cancer risk through the years. I think I got. Ok. This uh will have to be our last case because we are running out of time slightly. Um So 38 year old lady, 10 years since IPA, she now presents with um a very poor pouch function and posy is in uh in keeping with pouchitis. So I think some of this is for you. What are the risks of developing pouchitis and what's the management for this lady? And is there any surveillance that she needs? And thanks. So, risk of pan titi. Um it varies depending on which study you you read. But then in my personal experience, I've seen actually all patients develop panis of some sort um at one point to another and there are studies that it's up to 40% in the first year. Um Risk factors obviously have been just mentioned there. So effectively, you been on anti sorry antigen alpha agents. Your disease must be more aggressive. Um radiotherapy psa have been touched them as risk factors um previously. So I think the risk, unfortunately, for arthritis is high regards in treatments. Uh if we move to the next slide, the usual convention uh would be um medical therapy in the form of antibiotics, either um Ciprofloxacin or metroNIDAZOLE have all been used successfully. Um co as well. But unfortunately, for the patients who might be developing persistent uh bouts of Poch, so they have pouchitis, you treat for a couple of weeks with antibiotics and it comes back uh very rapidly. Within a few weeks. Occasionally patients are put on uh rotation courses of antibiotics to try and keep the pouch away. One thing to add though, if you do have patients on long term antibiotics, things like metrozole, uh increase your risk of neuropathies and ciprofloxacin increases your risk of spontaneous uh tendon rupture. So something to counsel your patients on with regards to that. Um Beyond that, yes, occasionally we do use topical therapy in the form of steroids and sometimes uh we will consider uh restarting biologics. Um But that's not quite as common. I've had patients in the past with on PSL three probiotics which no longer follow that can comment on that. Yeah. So there are trials shown that they are clinically effective. Um As you say, unfortunately, uh certainly now a lesion. No, but we cannot um access them anymore. Uh So unfortunately, it's just something that patients can't uh get hold of. Although uh the other week, I did have a patient who told me they could buy it on Amazon, but you didn't hear that from me. So you told me. So, so essentially, if all things fail, then we move on to either dysfunctioning or removing the pouch. Um There are uh I'm just going to speed up a little bit. There are because we are, we've run out of time for at, at this stage, but there are obviously there's, there are classification, classification systems for common pouch disorders, which is worth looking at for the FCS. There are investigations that you need to think about when you're um assessing a patient with pouch dysfunction. Obviously, ua posco and ava procto. What's WS CS C? That's contrast, enema, enema. I see. It's also called brought some centers but without the actual evacuator thing, it's like due for a art I see. So OK. All right. I've not seen this abbreviation before. Fine. Uh MRI Pelvis. Yep. And this is actually an excellent um diagram there just to, to give you an idea of uh the algorithm of diagnosing these and there we are and that was it the time. So, yeah, we, it's, I, I just want to say that's a reflection of IBD always on time. OK. So any questions guys, anything that you want to burn your ca we've got a burning question here. But if you have an injury, both me, you haven't mentioned about men's fertility. Uh Yeah, I guess we're talking about, yeah, that's a good question. Uh because we tend to tend to. So that's a good question. Uh uh 10 to this is such as the um what's the word disor we tend to focus on sexual function in men and the baby producing abilities of women. Um I think there is evidence to suggest low lower toes rates in men. Um But you're right. You're absolutely right. That is how I focus the answer to that question. Um What are your thoughts on the matter? Because we don't know the pathology actually for. So it's unclear if I think we need more research studies going by here. Fine. He so just around 5%. So we consent because that was not the case last year. Four lbs. I so good or not pouch. That's why you can go use it. Um So I couldn't be great combination call dysfunction. And what do you do if you have a patient who say I'm a patient at space as well? And then of us, so um one, you've got to balance um repeated surveillance. Are you actually document in a patient's demise? We know that people with psa untreated risk of uh cancer, um 10 years goes all the way up to um 30 sometimes even 40%. And if they've got psa unfortunately, these patients may become cirrhotic. In which case, if you leave things for too long as in um even they don't have problems from dysplasia necessarily immediately progressing to cancer. If they become sclerotic varices, all these problemss, it makes surgery a lot more difficult. Uh The cases we've had like this at the MDT, we try to really push and um suggest patients that, you know, they do need to think about colectomies if they hold off and they have all these other um complications. And then I guess you'll end up referring to a transplant HPV Center if they're gonna be considering surgery at that stage, it's, um, the gray area, which is now rights and wrongs about it. And I think you'll have to take over all your patients issues at the same time. So, thank you very much. It's, uh, uh, very, uh, uh, it's an excellent decision. Um, I thank the speakers and our chairs position and.