Original subtitles

The human body is an extraordinary machine.

Every day, billions of our cells are being replaced with new ones.

But sometimes, things go wrong.

And when they're deemed untreatable, people turn to us.

Because we take on some of the world's most difficult cases.

Patients come from far away

with the most complex medical problems in the world.

And we understand that this is their only hope.

The patients we see will die without our help.

And to save their lives,

we have to push the limits of what is surgically possible.

We get only one chance to get these cuts right.

If it goes wrong, it can do patients terrible harm.

Ooh. Oh. We've got a hole under the vein.

OK, hold it there. Hold it in. Hold it. Quick, please!

In the worst circumstances,

it could even mean not making it off the operating table.

You have to make sure that the risk is justified by

the opportunity to cure them.

It's a lot of pressure on you as a...as a doctor.

I sometimes have sleepless nights.

The stakes are tremendous.

So, you try your utmost to save every life coming your way,

because you realise how fragile life is.

This program me contains discussion of life and death stories

and scenes of surgery that some viewers may find distressing

So, it started two months ago,

when I had an operation to remove a fibroid.

Lots of women get these in the womb. They are quite common.

This is it. That's 20 centimetres in diameter.

And I was like, "Wow, that's huge!"

I think it felt like being pregnant.

Big, all the time. And my clothes obviously wouldn't fit.

You know, my consultant did give me options, as to, er...

"Mel, would you just like to have the fibroid taken out,

"or a total hysterectomy?"

And I thought to myself, I've always wanted more kids,

so let's just have the fibroid taken out and that's it.

That's what I opted for.

My surgeon took it out,

and then, he sent it off to the pathology lab.

Called up, and he says,

unfortunately, they found a few cancer cells in the fibroid,

and they're worried the cancer cells might have spread into my womb.

And I was like, "Oh, my God!"

Lots of people ask me,

"Why do you do these long hours and this stressful job?

It's probably, sort of, the need to be able to help

and make a difference.

And what we are able to do in this hospital

is push the boundaries surgically, which is amazing.

So here we see Mel's CT scan

before her fibroid was removed.

And this round structure is the fibroid.

It was as big as a grapefruit.

When Mel's fibre was removed,

they sent it to the lab, and they found sarcoma cells.

Sarcoma in a fibroid is very rare.

Only five in a million women will have sarcoma.

But the problem is that sarcoma is an aggressive cancer,

and individual cancer cells are too small to see on a scan.

So, we don't know if it has already spread to the womb.

In order to give Mel the best chance of survival,

we need to remove her whole reproductive system.

I feel very responsible for my patients.

When you're diagnosed with cancer, which is a massive event,

and then suddenly, someone says,

"We will need to take your ovaries and uterus,

"and you will not be able to conceive"...

that's...that's a massive news. It's horrible.

And it's...it's really, really difficult

to tell patients this is probably the only way to cure them.

Can I call you Mel or Melissa?

Anything. You can call me Mel, that's fine.

OK. Mel, do you have children? Yes. I have a daughter.

A daughter. How old is she? She's 11. 11.

So I can imagine, this has probably been an enormous shock,

because normally we don't think about cancer cells in fibroids.

Mm-hm. Um...so the fibroid has been peeled out.

Yes. But of course, it was inside the wall of the womb,

so it might be that there's still some cancer cells there. OK.

So, just leaving it like this

and just follow you up with imaging wouldn't be safe.

Mm-hm. Yeah?

And that's why, erm... we have to recommend now

for you to have a hysterectomy.

QUIETLY: OK.

Erm...because of the sarcomatous element of the fibroid,

we would also recommend your ovaries to be removed.

OK. That, of course, has a major impact on, you know,

you will be in the menopause. Mm-hm.

Are you OK to talk about the operation now? Yes.

So what we're going to do is a total hysterectomy,

but we will use a robot to help us to make it easier.

OK. Yeah?

We are able to magnify, we can see everything 3D.

Post-operatively, you will have significantly-less pain. OK.

Your recovery will be quicker. Mm-hm.

So we will blow up the tummy with CO2,

and then we will remove your uterus,

with the ovaries and the tubes, inside your tummy

and take it out through the vagina. OK. Yeah?

You know, you're losing your womb, your ovaries.

It's not easy for women, especially in your age.

So, we completely understand that now. Yeah?

Are you all right? I'm sorry.

The concept of, like, not, sort of, ever having another kid...

I just feel, like, not so great about it. Erm...

I don't know, it's just...

BIRDSONG

How would you have reacted if you were put in that situation?

Oh, awful! I-I...

You know, my life was destined to have children.

That's what I always wanted to be. You know, a mother.

|—| don't know. I would be dev...

I would've been devastated. Yeah.

But Melissa is an unusual case

with a very aggressive type of cancer.

So, we need to do the operation without spreading any cancer cells,

which is difficult.

PLAYFUL CHATTER

Erm...shall I get a vase, and then, do the flowers?

Yeah, yeah... I'll go and get a vase.

So, when did you first notice something was a bit awry?

I suppose it must have been

I had a croaky voice one morning when I woke up.

The GP was very good and referred me straight to the hospital.

At the beginning, you think, it's only a sore throat,

it's only laryngitis.

And then, it goes a bit further, and you think,

"Oh, it's not quite what we were thinking."

And then he says,

"It's definitely cancer."

How many times has your cancer reoccurred?

Three times.

William and I have been together for 25 years.

And when you're faced with the possibility

that you might actually

not go into the next 10, 20, 25 years,

it completely changes your future.

It's such a small part of him, this is the thing.

|t's...it's that size.

You know, it's the size of my thumbnail, if that —

and yet, it's...

It might as well be everything.

Your local hospital, what were they offering you?

Complete removal of the voice box.

A full laryngectomy.

We obviously asked for a second opinion.

So he arranged, very kindly arranged

to see the professor down at the Marsden.

The voice box is integral to us as humans.

It expresses our personality.

So, taking that away is almost like removing part of a person's being.

And some patients will seek any mode of cure

to avoid having their voice box out.

But with recurrent cancer, there's less chance of cure,

more chance of complications,

and more chance of impact on the patient's quality of life.

So, the stakes are tremendous.

Will's been very unlucky, because these are rapidly-growing tumours.

On the scan here, we can see that Will's cancer involves

the entire length of the vocal cord on the right-hand side.

And if left long enough, it will grow sufficiently

to obstruct Will's breathing passage,

and it will threaten Will's life.

For cancer of the voice box,

a conventional operation is to do a total laryngectomy,

where the entire voice box is removed.

But there is something I hope I can do for Will, which is rarely done.

Which side are you...? This side.

That's the one we've had the luck on, anyway.

And if we can do that successfully, we can save his voice and his life.

WILL COUGHS

just breathe naturally.

There's the tumour there.

You can see both sides are mobile.

OK, I'm happy. Yeah, he can come out.

Well done.

Thank you. You did very well.

So, that was really useful.

Your cancer is about there.

When we do a laryngectomy in the conventional way,

we take the entire voice box out.

And that means people can't speak.

Yes. OK?

But in your case, what we think we can do

is to remove just part of the voice box.

So, that's...? A partial laryngectomy?

Yes, correct.

,So we'll take away the cancer,

take away some elements of the voice box,

but leave behind two key cartilages.

We can use those cartilages and use the nerve supply

and the muscle to make sound.

So, does that mean my voice will be my own voice? Yes.

Your voice won't be as good as it is now, but you'll have

a pretty reasonable voice.

But there's no way of sugar-coating this.

Your swallow will take a pretty long time to recover.

We're talking six months before you get to a stage

where you can manage your food on your own.

A partial laryngectomy sounds like a lesser operation,

but ironically, it's a much more complex operation.

As a surgeon, it's a massive challenge.

And I'm invested heavily in getting this right for Will.

It's got to work for me, and the family.

INCOMING CALL

Good morning, you're through to Macmillan Cancer Support.

When was it you were diagnosed?

Uh-huh. I'm sure it is. I'm sure it is.

We can have a chat through your situation with you.

Cancer can arrive without any warning.

But how it affects each patient can be very different.

INCOMING CALL

The operation is very real and very looming.

And, yeah, that's quite frightening.

You can pretend that this isn't really happening,

and then, suddenly, it slam—dunks you.

It's like the conveyor belt, isn't it, going towards the...the big...

...teeth, really.

There's an inevitability to it.

We're going to do something about it. Yeah.

Doing nothing isn't an option.

SHE CHUCKLES

Yes, very.

So, what we're going to offer Will is a partial laryngectomy,

as opposed to a total laryngectomy.

But a partial laryngectomy is a more difficult procedure to perform,

and precision is key.

When you're doing something that is not your day-to-day procedure,

you have that rush of adrenaline.

I probably have the maximum experience in the country for this,

but I'm anxious that I give Will

the best outcome we can possibly give him.

So, he's got two young children, and I'm thinking

what I do will ensure how well he communicates

with this family for the rest of his life.

But that's what drives us.

MACHINES BEEP STEADILY

So, we're making the skin incision now.

So my first job is to open the throat and expose the voice box.

So that's the voice box.

This is the Adam's apple.

And the vocal cords are underneath that,

which is where the cancer's growing.

I now need to cut around the voice box,

so that I can remove the vocal cords,

but without damaging any of the nerves or muscles

that are used for swallowing.

Because if these nerves are damaged,

Will will never be able to speak and swallow,

and he may drown in his own secretions.

I have to systematically find the nerves and preserve them.

And these are very small nerves.

DeBakey to me, thanks.

We're going to enter it here.

So, this is an important nerve here.

This nerve goes in to supply sensation to the voice box.

So, don't cause any bleeding underneath it.

That's it. Excellent, excellent.

Excellent. Beautifully done.

We've now cut around the voice box and mobilised it on both sides,

so we can now lift it up

to see the vocal cords underneath.

So, there's my vocal cord.

I'm going to cut through that.

The cartilage behind it is needed to help to speak

and breathe and swallow.

And that's why we fight to save that cartilage.

So, we done it all on one side,

so now I'm going to fracture the voice box.

I need to see more clearly where to cut around the tumour,

and to get better access to it.

The crack along the Adam's apple

is more precise when done with the fingers.

You'll hear a crack.

OK.

So sorry about this, voice box.

CRACK!

GROANING

OK, that's cracked wide open now,

and I can see the cancer ever so well now.

Now I can cut out the cancerous section

with just the right margin of healthy tissue.

So, let's cut here, then.

SUCTION

That's lovely. Look at it! It's beautiful.

This is the voice box. This is the Adam's apple we see from the front.

And if we turn this around...

...that is the cancer,

and the tumour extends all the way across.

So, the lining is healthy, it's nice and smooth.

But when it's cancer, it's irregular and it's bumpy.

And that's all the cancer tissue.

So that's a nice, clean, happy resection.

For the last stage of the operation,

to reconstruct the section we've removed,

we're going to pull up the windpipe to close the gap

and reconnect his throat.

I'm going to put three sutures,

and that's all that holds the entire voice box together.

If it's a complex case, things can go wrong easily.

And, er...| doubt what I do all the time.

BELLS PEAL

Come on, William! Come on, William!

Ladies, gentlemen, on behalf of my wife and I...

CHEERING

APPLAUSE AND WHISTLING

When I first met him, he just had a nice,

very masculine, deep voice.

For a big man, he's very gentle.

He's always made me laugh.

Those little throwaway comments,

and it would have me crying with laughter.

That's it...

I don't know, it's been so long since I've heard it.

MACHINES BEEP STEADILY

Pass me that, er...big suture.

We're sewing these two fragile sections of windpipe together

and hoping it will hold.

If the join fails, we'll have to resort to a full laryngectomy.

There are no second chances, no other options.

OK, we're going to tighten them.

It's really important to get this right.

Let's tie the side ones first.

Yeah. So, we pull this up.

OK, please hand-tie it.

Wait, wait, wait, wait, wait, wait!

Right, are we...are we good? Are we good?

Did it definitely knot? Lift a bit.

Yeah, I think it did.

You want to start again? You want to tighten that again?

Come together.

Careful. Yeah.

OK...releasing gently. Coming away.

Good. OK.

Yeah. That's excellent.

Perfect. That looks good.

So, the voice box has been put back together.

From now on, his voice is going to be quite harsh and breathy.

What voice he gets six weeks, 12 weeks down the line

will be what he will have for life.

Hello, Bebe. Hello, gorgeous.

It's much easier to burn £10 notes than to keep horses,

but horses are much more satisfying emotionally.

Come on. Come on, Bebe.

There you go. They are lovely things.

My first encounter with cancer was actually way back when I was 23,

and I was diagnosed with a testicular tumour.

That didn't stop me being a man.

Er...it didn't stop me doing things I wanted to do.

It stopped me having children, which is a great loss.

But who I am grew out of all that experience.

I've had 45 years, and I'm very grateful.

But if there's a chance to grab some more of it, I will.

So, erm...|'m not going to give up yet.

This thing is called a retroperitoneal liposarcoma.

A fatty soft tissue tumour.

When I first started noticing it, it was kind of about

the size of a book here, sitting on...

And it's gradually spread.

So, it now stretches from here.

It's basically...basically the size of a rugby ball.

They did a biopsy and decided it is

this particular sort of cancer.

Erm...the team said, basically, we can't do anything,

and concluded that it was untreatable.

And so, we were basically into palliative care. Erm...

The Macmillan nurse was very quick to say,

you must talk to Marsden, cos they have some expertise in this area.

As a surgeon, sarcomas are a really fascinating job.

It's very much an umbrella term

for lots of different types of cancers.

It can affect either the bone or the soft tissue,

and is very, very rare.

If you look at the UK, in a whole year,

there will only be 3,500 cases.

So it's a very privileged position to be in,

to be able to help a patient with a rare, complex problem.

Ian's cancer is a very large tumour

in the back of his tummy.

It involves several organs.

So, below the under surface of the liver, and the right kidney

is completely encased by the tumour.

It has only one curative treatment, and that is surgery,

where you have to remove the whole of the tumour,

as well as the organs involved.

That is quite an undertaking.

So, we need to be very careful,

so that we don't risk the patient's life.

Morning. Good morning, sir. How are you? I'm well. Good.

As well as can be expected.

So, Ian, I think we can help you with this.

But it is a complex and very major surgery. Right.

The aim is to remove the whole of the tumour and the organs

that is adherent to this tumour.

And that will most certainly be the kidney and probably the bowel

on the right—hand side.

I think we're doing the right thing.

But all this is based on the judgment of the scans,

which are very, very helpful and accurate. Yes, yes.

But we are sometimes surprised at the surgery. Yes.

And we find that it is not possible

to remove the whole of the tumour

because of important things it's grown into.

And then, we have to make a very difficult decision at the surgery,

whether we proceed or not.

OK. You're giving me a potential future.

I'm quite happy with that.

We're going to try our best.

That's all I can ask. you do your best job, and I'll be happy.

If we do not do anything about it, it'll get bigger,

and patients will usually die of organ failure.

You have to make sure that when you put someone

through a major operation, where we're going to remove organs

and expose them to significant risk,

that the risk is justified

by the opportunity to cure them from the cancer.

It's quite risky, but I would think

he has a chance to be cured from this disease.

So, I think that's... it's the right decision.

My daughter, she said a little prayer for me,

and she asked, "God, please, Mummy should have safe surgery,

"and that she comes back home to us."

Bye, mummy-

I trust in God.

But sometimes things don't go the way you plan it to.

When we see these patients...

...we completely understand that they're frightened.

We understand that this is maybe their only hope.

OK, do you want to come in?

Hello, are you ready? Hello, hello, welcome, welcome, welcome. Hi.

They're coming to us because they...

...they hope that we can solve it.

And for us, it's daunting.

It's difficult.

Melissa is an unusual case

because her fibroid has sarcoma cancer cells,

which is a very rare and a very aggressive type of cancer.

So, I now need to remove all her reproductive organs

to save her life.

Because she's had a previous operation,

we know that scar tissue can develop, which makes it difficult

to remove these reproductive organs without spreading cancer cells.

And this is what we want to avoid.

So we've got a five-millimetre scope, laparoscope?

Yes. Yes. Perfect.

Knife to skin. Thank you.

Gas on, please.

The first thing we do is inflate

the abdomen with carbon dioxide.

What we can see is this will blow up as a balloon.

This will let us see the organs more clearly

and gives us more room to work.

Now for the cords that will attach to the robots.

I like to think of them as spider arms.

Each has a different function.

To grasp, to cut, and a 3D camera.

Can I have the camera, please?

OK, can we have head down and the gas on to 12?

Let me have a look here.

So, you can see the uterus is here.

And we see that a fibroid was removed

from this bit of the uterus.

Marie, if you could just move the uterus up and down.

It's a little bit stuck here.

It seems like bowel is actually stuck to her uterus,

and that's not good.

I didn't expect this to happen.

This could just be scar tissue, but the worry is that it's actually

cancer spreading from her uterus to the bowel.

I love you!

I love you! Have a nice day.

I will miss you. I will come soon.

With Zoe, it wasn't planned, let's put it that way.

But she's the best thing in my life.

That feeling of being needed,

I think that's the biggest thing, you know?

And of looking after another human being,

nurturing them, making them better people.

But over the years, I feel I've done pretty well

for her, because she's turned out amazing.

Laparo LIP-

We'll do a Pfannenstiel incision.

We'll just give her lots of local, yeah? Right.

The uterus is stuck to bowel.

This could mean that there is more cancer.

So, we have to abandon the robot and do this by hand.

That was not the plan.

But you can't anticipate everything.

OK, knife to skin again.

We need to make sure we remove it

in a safe way, without spreading it.

Otherwise, you change her prognosis from good to significantly worse.

So, here it is.

This is where the disease is, yeah?

Yeah.

We need to make sure we do this safely.

Let's have a look. This is bowel.

This is all uterus.

I need to run my fingers along the adhesions

between the bowel and the uterus to feel for disease and find areas

I can separate safely.

This is stuck.

So, can I have Mclndoe scissors, please?

Yeah. Just go through here.

It's just very stuck.

There's a loop of bowel, there.

OK, I just need to pick it up, and we just do it gently.

We must avoid cutting into the organ

and risk spreading cancer cells.

So, you know, you can't do this robotically

and you're just tearing it apart.

You don't have a clue what you're doing. Look at this.

Then it will start bleeding, and then... Yeah.

Yeah? OK. Let's do a little bit more.

It's just one final push as we cut

around the last few structures

to get the uterus out.

Join the dots.

This is a really big step.

So we're just going to release it now from the vagina.

The uterus is out now.

This is her cervix.

So this was attached to the vagina.

The vagina is normally here.

And this is one big muscle,

and it can stretch to have a full-term baby in.

It's just amazing.

So, on both sides, you've got tubes and the ovary.

So, what you can see is there is something here.

And this is where she had her fibroid removed.

So, that's in the back of the uterus.

And you can see, there's...

This was attached to it.

This is what we call omentum,

which is a fatty curtain hanging

in everybody's abdomen.

And why we have released this and not just taken it off here

is because we want to know if there is any breakthrough

of cancer cells.

The pathologists will be able to tell us.

PHONE RINGS

Hello. You're speaking with Macmillan. How can I help?

I've always had in the back of my head the feeling that at some point,

cancer is going to come knocking on the door again.

After you, my lovely. OK.

I just want to get on with it and get to the point where somebody

can bring me a cup of tea.

Hello, again. Hello. Can you spin yourself around?

The plan today is to completely remove this vast cancer

from Ian's abdomen.

The tumour is enormous,

and it's already encased some of his organs.

So, we have to remove this with the tumour.

This will be a significant insult to his body,

and there's a high risk of causing catastrophic bleeding

from the major blood vessels behind the tumour.

Enormous tumours are quite a challenge.

There always will be a huge responsibility

on the surgeon's shoulders.

So, the focus in your mind is just,

you've got to make sure you do the best for this patient.

Their life's in your hands.

You happy for us to start? Yes, please.

Here we go.

The first step is to get to the tumour without cutting into it.

We don't want to spill any cancer cells.

Currently, everything is contained within the tumour capsule.

Good. So this is the tumour here, under my hand,

this big lump here.

This is the large bowel,

and it's completely stuck onto the tumour.

We won't be able to separate that.

It's going to have to come out with the tumour.

The kidney is somewhere in here, in the middle.

I can maybe just feel it there.

These vessels that feed it just disappear into the cancer.

That will have to go.

But he has a normal kidney on the other side, which is fine.

You can survive with one kidney.

I think we should start with the bowel.

So, we're going to divide the colon now.

We're going to cut through the bowel

where it starts and ends on each side of the tumour.

I think we're going to have quite a bit of trouble,

because this is where it goes in.

But we'll have to see.

We have to be really careful not to damage any healthy bowel

that he needs.

Induja, a stapler.

I think just divide it through here.

OK, thank you.

So, right at the back,

we're starting now to see the big blood vessels.

I think this is the left renal, here.

It's a blood vessel going off towards the kidney,

but it needs to come with the tumour.

As long as we divide the blood vessels, then the whole kidney

will come with the specimen.

Let's cut through them carefully.

The blood pressure is quite high here.

Bleeding here.

Stitch ready?

Erm, give me the smaller needle. OK.

We should be able to see, as long as we keep a view. Yeah.

Surgery always has inherent risk,

and sometimes things do go wrong.

You've got the end. You just take the end.

Just, just the end. Give me...

Let it go. Yeah.

You have decide what is the best way to stop the bleeding.

Erm, get a stitch, please.

Even a small injury can cause catastrophic,

life—threatening bleeding.

It can be very difficult and challenging.

It would be great if everything in surgery always goes well,

but it does sometimes go wrong.

Get a 4-0 prolene suture...

Although inside, you may panic,

you have to be able to control the bleeding.

That's got it, I think. That's good.

Yeah, it's under control. Yeah.

OK. A bit of a breather.

Well done. Good.

We're making progress.

The kidney is divided from the main blood supply it receives,

so the kidney's free.

So, just the last bit of the tumour

right at the top, top, top, top.

We're there, we're done. That's good.

Have we got a table, guys?

The table behind, there.

This is basically the whole of the tumour.

Just for reference, this is a little ruler that's 15 centimetres long.

The one issue is our normal theatre scales

only measures up to 2—3kg.

So we've got to put it on a human weighing scales.

Good. Let's see.

It weighs 7.5 kgs.

It's always a worry, especially when patients get turned down elsewhere

for surgery, whether your judgment is accurate in whether

the tumour's actually resectable.

So, it's a great relief when it is actually possible

to remove it completely.

And it all went well, so I'm very happy.

Our role is to come up with ways of taking cancer out,

while allowing the patient to enjoy near-complete quality of life.

For Will, that has meant a long recovery

and learning to swallow all over again.

HE COUGHS

But I am constantly amazed by the resilience

and the determination of the patients we see.

For Mel, luckily, there was no residual disease,

so her prognosis is extremely good

and we've given her that positive news.

One of the reasons why I keep doing this job is because of patients

like Mel, where you think,

OK, well, hopefully, it was good what we did. Yeah.

It just feels like a weight has been lifted, and I feel,

like, a free spirit, you know,

like I can sort of now go off and do whatever I want to do,

not be afraid about anything.

It's a happy ending, which... I'm thrilled.

It's just amazing.

The scans and the blood tests so far say I'm clear

as far as the cancer is concerned.

I've got my strength back. Most things I can do.

So, if I needed to move a bale or whatever, I could do it.

But I couldn't do half a dozen.

Come on, you, walk up.

We start off as doctors with the goal to help people.

So when things go well for patients, it makes you proud of what

you've been able to do for them.

I want to go back in time and start retraining as a cancer surgeon

today, which would be just amazing because in 20, 30 years' time,

the cancer cells in the future will be completely unrecognisable.

There is so much development happening

about different techniques,

different robotic platforms.

That's one of the amazing things about this hospital.

It's not just the treatment of the patients,

but it's also the support.

How do we make things better for the future,

and how do we learn more about each cancer?

It's a fascinating future we have ahead for cancer surgery

and for cancer treatment in general,

because we're understanding cancer so much better.

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