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dear old Thank you for showing interest in the back to the Future Course, a 12 week program designed by our founder, James More designed for medical students and foundation doctors. Um, my name is Martha Jasmine, one of the organizers of the second edition of Back to the Futures. Together with Marta, Chicana, Garcia and Ashim. We would like to thank our sponsor as it an MD you for helping us in designing discourse. And nonetheless, we would like to thank our speaker of today, Mr Rajiv Lahiri, to give us the opportunity to listen to his lecture. This teaching session will be proceeded by a short video on hand time. After that, Mr Rajib Lahiri will delight Hamza on his lecture on a liver transplant surgery. At the end of the lesson, we will give you the opportunity to ask in the zoom chatter questions who? Our speaker. The cure code for the feedback form will be found at the end of the presentation but will also be sent out by email. And now let's begin within the video. Give me just two seconds, Okay? Yeah. Jesus, it is. Let's see. Thank you. Sorry about that. There is being? Uh, yes, it does sound sorry about that. There has been a technical problem. I will, uh, restart it into second hand size. It is important to be able to perform hand ties as these can give more tactile feedback to the pressure applied for not the most common in general surgery, where achieving the right tension is essential to achieve structural opposition without impeding the blood flow. For example, informing bowel and estima sees starting. Start with a downwards throw. This is with the short end away from you and allow a little more length to give you space to work. Hold the short end of the future between your thumb and the tip of the ring finger of your left hand. Have your index and middle finger under the loop of the short end, with the tip of the thread pointing towards you across the plane of the incision. Now, with the long end, cross over the top of the middle and index finger to the far side of the incision. This will create a loop with a trigger Axion, Bend the middle finger to hook the long end of the suture under the short end, then straighten your finger out again so that it now lies over the short end. Remember, the long end must lie over the index finger. Use your index finger and the back of your middle finger to grab the short end. You must now let go of the short hand held by the thumb and the ring finger of your left hand. Now you can pull the short end held by your index and middle finger through the loop, pulling your left hand or the short end towards you and your right hand. The long end away from you will tie the throw down tightly. After finishing the downwards throat, your left hand should be holding the short end between thumb and index finger. Now we're going to move on to the upwards throat. Hold the tip of the short end, pointing away from you. The rest of the suture should lay across the bottom fingers and wrap around the little finger in your right hand, holding the long end of the future cross over from the middle finger of our left hand coming towards you. You should now have the short tip pointing away from you and the long end pointing towards you again with a trigger Axion. Bend the middle finger to hook the long suture under the short. Then straighten your finger out up over the short end again. Use the back of your middle finger to hold the short end, this time against your ring finger. You must now let go of the short end, held by the thumb and index finger of your left hand. You can pull the short end held by your middle and ring finger through the loop, pulling your left hand or short end towards you and your right hand the long end away from you. You will tie the throw down. You alternate between the downwards and upwards throws in order to tie the knot. Common pitfalls firstly, pay attention that each time you pull the not tight, your hands should finish on the opposite side of the incision to where they started. If you lay the throat but do not cross the incision when tightening, you will not lay the not square. This can result in inadequate slip knots. Secondly, if you're short end of the suture is on the side closest to you, you will need to reverse the order of froze. This means starting on the upwards thrown before performing downwards. If tying over an incision running vertically to you, this can lead to awkward crossing of the hands. In this case, it's easier to rotate your body 90 degrees to avoid this situation. Finally, be careful to avoid any one finger techniques. You might see your general surgical consultants practice. These can be unreliable in the amateur hand and can lead to poor, not tension. Okay, I hope that you all enjoyed the video. Sorry about the sound. At the beginning, there was a bit of a technical issue. So now I would like to give the word to Mr Lahiri on liver transplant surgery. Thank you very much. Thank smarter. Hi, everyone. Uh, my name is Raj. I'm a consultant HPB surgeon and just a disclaimer. I'm not a transplant surgeon, but I did a significant portion of my training in transplant and hence the reason I'm giving this talk. I'm trying to run through a number of topics which will include what is liver transplantation? What does the job involve? How to train in it in the u. K. A couple of interesting cases and how liver transplant is evolving, a description of how we do a liver transplant and why I think it's a great job. So first and foremost, a liver transplant is a complex major operation to replace an irreversibly damaged liver with a healthy liver from another person. We call them an orthotopic allograft, which means grafting of an organ to its natural position from another person. That's obviously different to a renal transplant, because in a renal transplant, you graft to a different different position in the body. In terms of history, the father of transplantation is Thomas Starzl, a surgeon from America who initially worked in Denver and then Pittsburgh and first undertook and developed transplant into what it is today. I've noticed first five Patient's, which were a case series, all died. And then Roy Khan, who is a professor of surgery in Cambridge, developed the first immuno suppression drug in Cyclosporin, which revolutionized the post operative care. So what does a job as a liver transplant surgeon involved? Well, it involves these three areas. There's liver implantation HPB re sectional surgery, which will be discussed by my consultant colleague, Mr Frampton, A later date in this course and organ retrieval. So I'll be discussing organ retrieval and liver implantation. Organ retrieval. First of all, this is a bit like the unglamorous but extremely vital part of liver transplantation. So, as I say, it's an integral part. And obviously liver implantation cannot occur without any organs to implant. It aims to tackle an ever increasing waiting list of patient's requiring liver transplantation, especially with some of the newer diseases that are leading to cirrhosis, which will come onto later. It's coordinated by the National Organ Retrieval Service, which is available 24 hours a day, seven days a week and 365 days a year. And there are multiple teams on call for re organ retrieval, which can necessitate traveling long distances to perform retrievals. The longest I traveled was to Plymouth from the Royal Free in north London, which is about five hours in a ambulance. Uh, and so those type of distances with a five hour operation in between can be quite exhausting. Nose performs a national audit every year to ensure standards are being met into from each unit. That, Sir, that's performing retrieval. There are three main types of retrieval and I'll discuss these each of these briefly. In turn, the first is DCD retrieval or donation after cardiac death. And it involves retrieval of organs from patient's whose death, uh, is diagnosed and confirmed using cardio respiratory criteria and is performed in a controlled manner in the UK I know that in some places in Europe, such as Belgium and Spain, there is uncontrolled dcd. But that's not performed in the UK It now provides us with a significant proportion of our organs 40%. But it does lead to a longer warmer ski me a time and a rapid operation. So it's a more risky retrieval and they used to provide us with higher risk allographs, especially kidneys and livers. There is emerging evidence for using DCD hearts, but it is very new and there is no avenue for using DCD Pancreas is, and there is an increased risk of ischemic cholangio pathy and primary non function D B D. Retrieval or donation after brain death is a controlled retrieval performed in patient's who are diagnosed with death on brain stem criteria. This allows the retrieval team to prepare and retrieve the organs whilst the heart is still beating and then finally remove the organs after installation of University of Wisconsin fluid, which is a preservation liquid and gives more guaranteed donors and minimizes warm ischemia time. Therefore, providing better quality graphs and reduced risk of primary non function. The third type of retrieval, which is not very common in the UK in liver surgery but is very, very common in the Far East, is living donor. This forms 3% of our current donut hole here in the UK, and the majority are currently performed in Children used to the size discrepancy. Because obviously most young Children who require liver transplants could not have an adult tracks, planted liver would just simply be too big. So a portion of the left liver, usually the left lateral segments segments two and three are taken from in a donor hepatectomy. The adult patient is left with the majority of their liver in place, and those two segments are transplanted into the child. Most living donor level living donor, liver transplant donors of relatives of the patient's, and it's associated with excellent outcomes in other parts of the world, specifically the Far Eastern career. They do huge numbers of living donor liver transplant due to cultural differences, especially not having an interest or desire to receive a D CD or DVD liver. So what are the indications for liver transplantation? This graph shows it best on the right, but as you can see, there are multiple indications for liver transplantation. But we won't run through all of these. I'll just highlight the most important ones. The most common worldwide is hepatitis virus li related cirrhosis, most commonly through hepatitis C and hepatitis B. The second most common is alcohol related cirrhosis and certainly in other parts of the world, but not so much. The UK hepatocellular carcinoma is one of the more common causes for indications for liver transplantation. The 10% here with cholestatic liver disease is becoming an increasing number in the West Patient's with obesity and developing a disease called non alcoholic fatty liver disease, which can progress to cirrhosis. And this is an increasing burden in the West. Following here, you can see a contra indications for liver transplantation. These include significant cardiopulmonary disease, um, especially end stage heart failure or severe COPD, because the liver transplant is a complex major operation of the threat to life cancer outside the liver is an absolute contra indication, as as is active alcohol use, the presence of active infection is an important Contra indication, and another softer but very important one is the inability to comply with the medical treatment in terms of immuno suppression after the operation. And this is something that we discuss at length in our multidisciplinary Team meeting, which is attended by transplant hepatologists liver transplant surgeons, HPB, or liver transplant radiologists specialist Andy Statist So clinical Nurse Specialist, Alcohol Liaison Service and our I. T U colleagues. So there's a huge team involved in planning these patient's for surgery. So in terms of training as a liver transplant surgeon, it's extremely hard work, and it's a long road. Generally pay people are required to complete their foundation training and would need to do a general surgery themed course surgical training program. After award of this, they would need to get on the registrar program or higher surgical training again, general surgery themes with a sub specialty interest in either HPB or transplantation. Now, currently, there's no formal training pathway in liver transplantation, which is amazing, really, as it's one of the most technically demanding jobs in surgery. But many people either train in HPV surgery because of its crossover or have an interest in renal or pancreas transplantation and cross over that way as things stand and are either a liver transplant or HPB cancer related higher degree in the form of a PhD is essential for being competitive for a consultant post and generally, as most competencies in liver transplantation, have not been acquired by S T eight. Multiple fellowships are required on top of this. Generally, surgeons have to be willing to move nationwide for a consultant posters. There's only seven liver transplant centers in the country, and there is no way of guaranteeing a spot anywhere. So what's the clinical life like for a liver transplant surgeon? Once again, it's extremely hard and very busy. The impatient workload usually works in a surgeon of the week manner with that consultant who is on call performing daily ward rounds of the transplant and perhaps also the HPB patient's, As he's a complex, sick patients' and the patient's are often seen in conjunction with the transplant hepatologists and the intensive care doctors, the the HPV and liver transplant surgeons have elective surgery lists most commonly HPB cancer resections, which in their own right a complex tech technically demanding operations, which can carry a significant number of complications. There's a busy outpatient practice with both transplant and HPB clinics and the multidisciplinary team team meeting and listing meeting to discuss which new patient should be listed for liver transplants and to plan both cancer resections and upcoming patient's for transplantation. The emergency workloads can include organ retrieval, which can be led by senior registrars or fellows or separate consultants. But in some centers, that is the implant surgeon as well as on that rotor. There's a liver implantation rotor of consultants because it's obviously a consultant delivered service and a separate tertiary HPB on call for referring hospitals for complex liver, pancreas and bile duct problems. It goes without saying this is a very heavy on called commitment and Liver Transplant is one of the few specialties that does complex, major high risk surgery with threat to life regularly overnight with, I would say, at least half of liver transplants currently being performed overnight. So here's our first case to discuss which I've named Transplant after a stay at the Liver Hotel, and I hope it will become clear why I've called it that. So our patient is a 48 year old gentleman with cirrhosis secondary to alcohol use. He has been abstinent for over three years, and as a UK l'd or end liver score a 55 placing him in transplant criteria. He was assessed at the liver transplant MDT, where the team felt he was suitable for either a DCD or a DVD graft. As he was a relatively low risk candidate. He had conventional hepatic artery anatomy, which is important because, um, hypothetic artery anatomy varies in 30 to 40% of people and requires different planning for the patient to undergo transplantation. And he'd been on the transplant list for nine months when his number was called, the transplant coordinator and the implant surgeon were alerted to a suitable D. C D allograft being retrieved. At 11 PM, the retrieval surgeon performed the DCD retrieval and called the implant surgeon with worries that this was a marginal liver. He wasn't sure, in other words, about it, how good a candidate it would be for implantation. So there was a discussion between the retrieval surgeon and the implant surgeon and the implant surgeon was sent photos of this liver, uh, to assess it visually. Himself and the liver was accepted for assessment by the implant center and arrived 90 minutes later. At 1 45 in the morning, the liver was assessed, and it was deemed that it should be placed on the organ oximetric Norma thermic machine perfusion, uh, system to assess its function. And we'll discuss what that is shortly. So the organ knocks machine for shorts was developed in Oxford and has revolutionized liver transplantation. And it allows the liver, especially D C, delivers to be continuously perfused with oxygenated blood, which is cross matched and nutrients at a normal body temperature. You can see two of my old colleagues benching the liver, putting it on the machine with blood running through it here, and it undergoes continuous physiological assessment. It's possible to withdraw blood from the circuit and assess for liver enzymes, including a L T lactate for performance and also to assess bile production and the acidity of bile. And about four hours later, it was felt that the liver was functioning well and could be used for implantation, so the recipient was anesthetized at eight o'clock in the morning, underwent a six tower piggyback orthotopic liver transplants and had a 48 hour I t. You stay Multiple abdominal drains were placed, which showed no bile, and the liver kicked in and was working nicely. And on Day eight, the patient had stable liver function. A well healed wound was eating and drinking stable tacrolimus levels and was ready for discharge. So a normal thermic machine perfusion, or M p M or organ ox machine, is revolutionizing DCD graft use. It has led to a 50% reduction in discarded livers that had previously failed the will it work? Won't it work? I test there's been a 50% reduction in allograft injury and a reduction in primary non function after these organs have been placed or tested at the liver hotel or the organ ox. And by putting the machine putting the liver on the organ ox machine at one o'clock in the morning, it increased. It has increased the number of transplants that are performed in daylight hours, and as you will all know from any task you perform after a good night's sleep, performance is improved, and this machine and brother and sister machines developed by other companies are changing practice internationally. The second case, I've termed a rapid look into the future of liver transplant, and I've included a flag of Norway, which is where the procedure was. This procedure is originated and a picture of Blade Runner 2049 which might be about the right time that it reaches the UK. So there's an emerging evidence base that in young, well selected patient's who have unresectable by lobar colorectal liver metastases but no other mets anywhere else in the body. That these patient's if they're stable on chemotherapy, can be considered for liver transplantation. And this really originated. And certainly this procedure did that I'm going to speak about in Norway. The procedure aims to address the worldwide shortage of donor livers by splitting livers and currently remains experimental, with no high quality evidence to support it. So to work you through this diagram picture A is a liver with multiple metastases throughout all segments with unresectable disease segment, be picture be. What the surgeons have done is remove segments two and three, the shaded area here of the liver and tied off the portal vein to the remaining liver, so it only has an arterial supply. They have taken then segments two and three from the donor liver, thereby sparing the rest of the right liver from the donor and implanted this into the recipient, anastomosed it to the left portal vein and the left hepatic artery and would have attached the bile duct to a root, a loop of jejunum, which is called a roux en y pataca jejunostomy A number of days later. About 10 days later, this what transplanted portion of liver will have hypertrophied to a big enough size to provide the patient with enough liver function and the remaining disease liver would be removed. This was first introduced in 2015 and having narrowed their selection criteria to be much, much stricter, the Norwegian surgeons who pioneered this technique have shown some pretty promising with results, with two patient surviving over five years following the procedure, which would have not been the case with chemotherapy and no reception, all surgery being available. They've also evolved the procedure to include the living donor rapid procedure and the preliminary data from this looks promising. So finally I'm going to talk you through a liver transplant and split it into three phases. The first thing to know about a liver transplant is that it is a technically very demanding procedure. It carries a risk of about 5% to the patient's life, with a risk in order of about 30% of major complications. It can be split into three portions. The recipient hepatectomy the removal of the liver, the back benching of the donor liver and the vascular billary reconstruction to plumb the donor liver in. So by far the most difficult portion of the operation is the recipient, Hepatectomy. That's because the majority of patient's have liver transplants for chronic disease and generally have a shrunken, scerotic liver that is very stuck to diaphragmatic attachments and the caver itself. Their usual multiple Barris is around the liver, thereby significantly increasing the risk of major blood loss. And the Cord eight lobe, which is part of the liver that sits on top of the vena cava, hypertrophy significantly in cirrhosis, thereby complicating the inferior vena cava dissection. This is big surgery and requires a senior team with a consultant, senior registrar and corps trainee or junior registrar present, often to anesthetic consultants for an anesthetic consultant and a senior registrar and senior scrub nurses. The liver is mobilised from its peritoneal and diaphragmatic attachments and the hepatic inflow, as in the common hepatic duct. The right and left common hepatic arteries and the portal vein are skeletonized and prepared for explantation, so a cuff is left on each of them for anastomosis. During the implantation, the liver is dissected off the retro hepatic caver, which is often the bloodiest part of the operation, and the hepatic veins of the last structures divided. In very difficult cases, you can experience massive blood loss in these operations. 5, 10, 15, 20 leaders of blood. So you need extremely good and specialist anesthetist to help you in terms of the donor liver back benching. This is to provide the minimum time for the liver to be implanted, so a smooth, efficient transfer from the liver being removed to another one being put in for the donor liver being put in there by often a second team are usually available for the donor back Benching. The donor backbench in essentially revolves around assessment of the donor liver arterial anatomy, which will tell you what the arterial reconstruction will be like an impatience with unusual arterial anatomy, such as a replaced right hepatic artery of the SM A or other anatomical variance. Back benched. Arterial reconstruction may be required. The donor cord eight veins, which drain directly into the vena cava, all need to be assessed and sone off. Otherwise, there'd be profuse bleeding from these Once the liver is revascularized and the common hepatic duct needs to be prepared for anastomosis. The donor liver is flushed with University of Wisconsin Solution, which was one of the key tenants in allowing liver transplantation to go ahead by allowing longer preservation of the organ. Finally, the patient undergoes the vascular Billary reconstruction. The first, uh, structure reconstructed is the inferior vena cava, usually with a side to side cable anastomosis, although there are multiple techniques where they can be a cable replacement with two cable anastomosis, and no method has been shown to be superior. At this stage, there's an end to end portal vein anastomosis and then usually the arterial anastomosis, which is the recipient proper hepatic artery gastroduodenal artery patch. So a widened patch to the donor celiac axis patch. So you're widening the base of the arterial anastomosis to try and reduce complications such as bambos ISS. Finally, there's a Billary reconstruction, which can be an end to end common hepatic duct reconstruction. Or the jejunum can be used for a roux en y hepatic a jejunostomy in terms of complications, just like you did at medical school. And for any of your exams, you can split them into early and late or other classifications the most. The key early complications. A primary non function, which is a disaster. It doesn't happen very often, but it means that the transplanted liver does not work, and the patient has to be placed straight on the transplant list in a super urgent category for an immediate another transplant. Otherwise, in all likelihood, they won't survive. Other major complications include bleeding and hepatic, a tree or portal vein thrombosis, which can necessitate necessitate redo, liver transplant and stricturing of the bile duct. It can also be medical complications such as rejection, which is usually managed by our hepatology colleagues. So, in conclusion, what's liver transplant to me? Well, it was exciting. It was competitive. It was scary. It was interesting. It was difficult, was technically demanding. It was life changing. I worked every other weekend for for over a year doing this. But more than anything, I think the thing that reminded me most of or that I remember most of liver transplant life was the camaraderie. I made fantastic colleagues. I they're probably the best team I ever worked with. We enjoy each other's company. We went out, we looked after each other when we covered each other, and it made it all worthwhile. So whilst it's a difficult hard life, it's incredibly sociable. It's very fun. And don't let some of the scary stories about it put you off. Thank you very much. Thank you very much, Raja, for your presentation, it has been amazing. And, uh, now I think that the participants can ask some questions if they want. Uh, there was already one in the chat. Uh, so what is the difference between controlled and uncontrolled this city? So that's a good question. So a controlled D. C. D is a patient who is on the ICU who is felt that if supportive treatment for their cardio respiratory system is withdrawn, the patient will arrest and pass away. In which case the patient is this process. The withdrawal of care happens in the anesthetic room, and the patient is then rushed into theater and the organs retrieved as soon as possible as soon as cold preservation is introduced to stop the warmer ischemia time. I've never personally seen an uncontrolled DCD because they're not in the UK, but I believe that is when patient's have out of hospital arrest or even an arrest in the E. D. And it does it deemed irretrievable and quickly assessed for their ability to be organ donors and, uh, then proceed to retrieval from there in terms of the second question, which I can see on the um on the on the thread about living donor transplantation and excellent outcomes. Really good question. I don't know why it's not so popular in the UK There are many potentially controversial discussion points about this, about the value of family in the UK compared to the Far East and the structure of family. We know that looking at data from Japan and Korea, where elders often live with their family and their value in the family structure is very different to it is in the UK that their grandkids and kids will do anything for their for their elders, and I would quite happily donate a a portion of their liver, whereas that's not done so much here. The other thing is, whilst our waiting list for transplant is quite long, our results with D, C, D and D B D organs and the acceptability of these two people means that people are happy to to have these organs and and go ahead with that. And with the change in law, from opt in donation to a change or an evolving change to opt out, there will be more D, c D and D B D organs in the future. Thank you very much. And then we have the third question with regards to case to What is the risk of metastasis is a spread into the new liver section before the old the liver is removed. So the risk of we're only talking about 7 to 10 days between the the donor portion of the liver going in and the other portion going out. So because the patient has had stable disease, so part of the criteria for these patient's is that they have had chemotherapy and had stable liver metastases for 6 to 12 months. I believe so. There's very is infanticide really small risk in terms of the question above, which is a very useful one from Zoey H mentioning about the involvement we have with the snowbirds and the patient's family. So we meet the snot at the We meet the snot at the hospital when we go on retrieval. But when we walk into the hospital, uh, we immediately escorted to theaters soft in the middle of the night, so you get a cup of coffee with the snowed and the whole history is given to you. But to avoid any conflict of transplant ethics, we never meet the donor's family. We cannot be involved in any of those discussions with their purely as the technical team, because obviously the aim of our job is to retrieve the organs so numerous other patient's can retrieve their heart, lungs, kidneys, liver, whatever. And it would be inappropriate for us to be involved in any counseling or two, color the water, so there's very strict criteria involved, and we cannot be involved in that. There is an A Maria, which is asking there are situations when a family member is not perfectly compatible, but in the same time the best option for the patient. Uh, so So this is a very This is a controversial area and usually for the majority of patient's. If the patient who has passed away or is going to be the donor has agreed to be a donor, and they've often made those wishes clear to their family, they may have a donor card or beyond the donor register. And these are discussions they've had with their family. And while there can be some acute upset, especially if the death or the the or the terminal decline is unexpected, the majority of families don't have a problem with this. If the family also have the ability to change the decision, what like and refuse it so we would never go against the family's wishes. Okay, I, but generally generally they're all on board. Generally, the snobs, the ICU, doctors at the hospital and the nursing staff have done a fantastic job, explained everything, and I've never seen a scenario where that's happened sexually. Thank you very much, Raja, I can't see anymore. Um, any more question at the moment if you guys, uh would like to ask something the Meanwhile, we can give you two more minutes. Uh, yeah, I think one of the things that one of the things just while you guys are thinking of any questions is, um, surgeries changing quite a lot. And the people who do surgery is changing quite a lot. Unfortunately, in many ways, liver transplant is still extremely mail dominates it, and that's something that needs to change. But part of that is designing a working template or a working life that allows both women and men to do the job equally. And and currently, the working patterns for liver transplant surgeons are so demanding and so long it's extremely difficult to have a normal family family life. Um, so the question that's just come in from Erin Kelly is an excellent one. Uh, So why, um, why did I decide not to specialize in transplant liver transplant surgery, where it's kind of what I was saying? So my wife is a pediatric surgeon who works very hard, and HPB is a hard job as well, and we have a six year old daughter, and whilst I love to liver transplant surgery and and and from a career point of view, you found it absolutely fascinating and would have loved to have done it. At the time that I spent doing it, I I really didn't see her and and that wasn't good enough for me. So that's why I chose HPB alone, which is busy enough rather than liver transplants, Uh, in terms of his liver surgery usually open and big, as opposed to keyhole surgery. Um, that's changing over the last 10 or 15 years. Liver, a sectional surgery. There's been more and more uptake of laproscopic surgery, and it's certainly an organ that's well suited to doing robotic surgery. So, uh, I work with martyr at the Royal Surrey in Guilford. We started our, uh, robotic liver resection program two weeks ago, so it certainly helps. It makes life a lot easier, and more and more of these big operations will be done laparoscopically. But the issue with liver transplant is you've got to put something big in as well. So, uh, they're they're always going to have a big incision. There was one case report recently of a black presc OPIC had protected to me to removal, and then a smaller incision used to put the donor liver in, but I think I don't I don't see why anyone would put themselves through that. And then we have got another question asking, Do you have any major advisor to anyone who wants to go into general surgery? Um, nothing in particular, Really. I mean, the one bit of advice I would probably give is try and do your MRCS as early as possible. Um, then that gives you an idea of if you find the pathology interesting. Try and make sure if you're in the UK, you do rotations into general surgery, See if you enjoy it. There's a lot of avenues. So the great thing about it is you can go from wanting to train in liver transplant surgery. Or you can do breast surgery. Do colorectal surgery. There's lots and lots of different avenues with it. So it's very good if you're not entirely sure what you want to do. Okay. I think, uh, I can't see any more question if you guys would like to send us a question. And, uh, we can, uh, Mr LA here will answer. Okay, So I had one question regarding, uh, this is a technical question because the cure could couldn't be accessed Do not worry about it. We will send an email to all our subscriber So we link both for the recorded version and also for the feedback form for Mr Lahiri. So don't worry about it them And obviously you can find if there is an issue you can always drop us a message journey Malanda, we will always be there to answer. Okay, so I think that there is no more question. Okay, great Thanks everyone very much, Mr Lahiri Problem. Martin, Nice to see you. Enjoy the rest of your trip. Thank you. Ok, Bye. Nice evening. Goodbye. Bye Bye bye.