Last Chance Saloon Surgeons: At the Edge of Life

This programme contains some strong language.

Every year, some three million major operations

are carried out in the UK.

Theatre doors are just here.

But few of us will know what really happens once we're put to sleep.

All right, all you've got to do now is think beautiful thoughts.

I don't think a patient can even comprehend what you're doing

in theatre to them. And that's what the plan is,

that they don't know what they've been through.

This series goes behind the theatre doors

of the Queen Elizabeth Hospital in Birmingham...

Let's get cracking, then.

Right, okey-dokes.

..where, for the first time,

cameras have been allowed to join

some of Britain's top surgeons

during their most high-stakes operations.

-Shall we go for it?

-We'll go for it.

Using new technology and pioneering skills,

they're treating conditions that used to kill.

We continue to push the boundaries,

continue to take the inoperable and make it operable.

This is surgery at its most experimental.

This is where I've got to get it right.

People didn't attempt this surgery a few years ago cos it was just

perceived as being too big, too difficult and too scary.

But pushing the human body to its limits comes with great risk...

Keep it together, keep it together, keep it together.

..for the patients AND the surgeons.

An operation will go wrong for a 30-second lapse of concentration.

Please work, because if it doesn't, I'm going to cry.

Things worry you. You get very worried.

This is going in completely the wrong direction.

The trick is to not appear to be worried.

They need to be top of their game every time.

People often characterise surgeons as bombastic and arrogant.

Babcock, please, long one, to me.

Slap it in, sweetheart.

You got to be dedicated to it. You've got to love it.

-Oh, my God!

-Jesus Christ.

You're only as good as your last result.

-BLEEP

-hell!

This is what it takes to operate at the cutting edge of medicine.

You have to be jolly careful that you don't bugger it up.

It's do or die, really.

6am on Thursday. In Birmingham's Queen Elizabeth Hospital,

the surgical department is preparing for 108 patients.

Most operations will be straightforward, textbook cases.

But sometimes, surgeons take on

procedures so complex and unpredictable,

they'll only know the extent of the challenge they face

once they begin operating.

Planning for the unexpected can be difficult,

although it do spend a lot of time beforehand

running through the CT scans again and again.

However, the CT will only give us so much information and sometimes,

we do have to think on our feet.

Surgeons Professor David Gourevitch and consultant Sam Ford

head up one of the only units in the country

specialising in treating sarcomas -

rare, cancerous tumours that can grow to huge sizes.

Sarcomas can be very difficult to remove.

They tend to grow behind all the major structures

in the abdomen and pelvis.

-There it is.

-There it is, going across there.

Yeah. So, it comes right around here?

Yes. This is already something more aggressive.

-It's quite a business.

-It's going to be really treacherous.

It's the sort of last bastion of big surgery.

I think what makes it interesting

is the fact that the unexpected is more common.

That's what keeps us on our toes.

Today's patient will be one of their most challenging surgeries to date.

Five months ago, 71-year-old Jasmine Harkness

noticed a swelling in her stomach.

I'd been to my sister's and I felt sort of bloated.

And I noticed I was getting thinner,

as well, in the face.

And I thought, there's something not quite right.

Within just a few months, the growth has filled her entire abdomen,

from her ribs down to her pelvis.

I've had three scans

and they showed a picture of it on the screen.

I thought, how could one person have something like that?

You know...

You've seen the Alien films, have you?!

The sarcoma is now so large,

it's crushing her liver, kidneys and stomach,

making even eating difficult.

Left untreated, Jasmine will die within four weeks.

You look at yourself in the mirror and you could see, you know,

sort of your cheekbones and things like that.

You wouldn't think over just a few months

you'd lose such a lot of weight.

The surgeons won't know if it's even possible to remove

until they're in theatre.

What do you think? Do you think it's a...a goer?

There's not enough about it to...

..to stop an operation.

I think we're going to have to see how it goes.

I think this is going to be very difficult.

Jasmine appears extremely frail.

However, she's frail because she's carrying around a very large tumour

that's slowly consuming her.

It represents a third of her body weight.

Five years ago, we probably wouldn't have taken her case on.

Lovely to see you again.

-Good to see you.

-How are you?

-Not too bad.

Have you got any questions about the operation?

Well...

-How long will it last?

-It's difficult to say at the moment.

Do you remember we were talking about this being

quite a big operation?

And it might just take a little bit of time

for us to get the tumour out...

-Yes.

-..in entirety.

The decision to go ahead with the operation is not straightforward.

At all.

Jasmine understands that without surgery,

she will certainly die.

But there is a possibility that once the abdomen is open,

we can't remove the tumour.

We'll only know if it's actually possible once we're operating.

It's a significant responsibility.

Come on in, everybody.

I'm obviously a bit apprehensive,

cos it's a big operation.

I've never had a big operation before.

But it's either have it done,

or that's it.

-Right, let's go.

-Righto.

Because it's an operation with so many unknowns,

Sam has called upon David to support him during this complicated surgery.

I'm just the old man of the department, really.

And as such, when there are difficult patients

or cases to be done,

I'm often asked to come and give a hand.

There has to be a captain. He's the captain,

and I will be his number two, his wingman.

This is obviously an operation at one extreme

because of the size of the tumour.

So we are aware of the possibility of the unexpected.

Guys, just until she's asleep, just keep the noise down.

OK? Thanks.

No problem.

That's you, you're checked in.

That's your boarding pass.

Sue Sinclair is lead anaesthetist.

You're going to start feeling

-a little bit light-headed, darling, OK?

-Yeah.

All right? All you've got to do now is think beautiful thoughts.

There's a lot of sort of traditional argy-bargy between surgeons

and anaesthetists. Anaesthetists are very...well balanced.

We've got chips on both shoulders

because no-one thinks we're as important as the surgeons.

Sue is the matriarch of the anaesthetic department.

Without her, it'd be very difficult

to undertake an operation of this size.

Go on, you hold my hand. That's lovely.

Can you open your eyes for us, Jasmine?

There's a good girl.

OK, we're in business.

When you're anaesthetised, you're defenceless,

you can't do anything for yourself.

You can't even blink.

You can't breathe.

Our real job is keeping her alive.

Now Jasmine is asleep, it will take another hour

to prep her for surgery -

five times longer than more straightforward procedures.

Now, very, very gently, chaps.

Sue and her team insert a seven-channelled catheter

into Jasmine's jugular vein

to monitor her vital signs.

She's so fragile.

Poor love.

Mrs Harkness is a very frail girl.

There are surgical risks to her and there are anaesthetic risks that she

just, her circulation just will not withstand this scale of surgery.

That's it. Beautiful.

Some people would find that that was maybe a risk too big to take.

But the alternative is that she will die.

OK, guys, I think we're good to go, aren't we?

-You bring her, I'll take the drugs?

-Yeah.

-You've still not seen her, have you?

-Yeah, I've seen her.

-Yeah.

-Gosh, you've made us work for it.

13 experienced clinicians are needed for Jasmine's operation.

Sam and David lead another two surgeons.

Sue leads a team of two anaesthetists and two assistants.

And another five specialist nurses

oversee the surgical equipment.

I think we're ready to start. Are you ready to start?

Is everybody we need in the room?

-Yep.

-Yes.

-OK.

-What are you doing for this lady today?

We are going to excise this massive liposarcoma

from her retro peritoneum on the right.

Fantastic. Expected blood loss?

Difficult to say.

There will be some blood loss.

-OK.

-And she's cross-matched for ten units, I think.

Are there any issues of concern?

Plenty of surgical concerns, mainly due to size and access.

Yeah. Expected duration of surgery?

As long as it takes.

-That's it. Time-out over.

-Great.

-Thanks very much.

-Thank you.

-Can we have the operating lights on?

Light angle, please.

-And we're ready to go?

-Yeah.

-Sue, are you OK to start?

-Yeah.

-Off you go, boys. Have a good one.

-Geronimo.

Despite weeks of planning,

it's only now the team will see for themselves

exactly what they're up against.

So the tumour is just coming into view now.

This large, white structure that trusty Gourevitch has his hand on.

Can I have the scissors, please?

Oh, my God!

It's a big bastard.

When we opened the abdomen for the first time, and we get first sight

of the enemy and appreciate its sheer size,

we always look at each other in amazement.

Just to say, "What have we got ourselves into here?

"And how are we going to get this out?"

-Wow.

-Shit.

Right, let's open it. Let's open it out.

Keep going, Max. We need all the space we can get here.

Forceps, please.

I tell you what, this tumour is bloody heavy.

-THEY LAUGH

-We've only just started!

Have you not been to the gym recently?

-I don't need to go to the gym!

-Look at him, he's like a honed athlete.

-Look!

-I don't need to go to the bloody gym!

Did you have your Weetabix this morning?

I had three, yes. It doesn't seem to have helped. There we go.

-Let's go wide, darling.

-I know.

Into the chest nicely.

-This bit is going to be...

-It's going to be an absolute pig.

Jasmine's tumour needs to be removed completely intact

if it's not to return.

Difficult access here.

Just a few cells left behind could cause the cancer to regrow.

Bloody hell, it goes on for miles.

Right, careful we don't puncture the tumour here.

You're full of confidence and bravado before you start

and you open the patient and you feel that slight

uncomfortable feeling on the back of your neck.

And your colleague looks at you and you look at him and you think,

"Have we made a terrible mistake?"

Most of the 36,000 operations

performed each year at the Queen Elizabeth Hospital

are straightforward.

Like Sam and David,

consultant urologist Rupesh Bhatt specialises in rare tumours

that most surgeons wouldn't attempt to remove.

I take on the things that other surgeons can't do,

or won't do.

The unpredictability of these big cases

really makes me feel quite excited.

How I'm going to rise to the challenge.

There's also a bit of anxiety, as well,

but you learn to control it.

67-year-old grandfather of four Bob Moran

has been told by his local hospital

that his tumour is so advanced,

there's nothing more they can do for him.

Open the door, please.

What do you say when a doctor just tells you that?

I'd got a tumour. It's a bad one.

And that's when my world sort of fell out, you know.

I just... Bombshell hit me.

You think...is this real?

Am I dreaming this?

Bob has a very rare form of cancer.

His tumour has grown from his left kidney

into the surrounding blood vessels

and is making its way up a major vein

called the inferior vena cava, or IVC.

A piece could break off at any time and travel into Bob's heart,

killing him in minutes.

I'm happy for you to ask any questions as I go along.

-OK.

-So, recapping...

Only a handful of surgeons in the UK are willing,

or skilled enough to carry out this operation.

-I think you know everyone here.

-Yes.

I'm Rupesh Bhatt, the surgeon.

Surgery to remove a kidney cancer is already a challenge,

but, in Bob's case,

that's a whole different ball game.

The tumour is untreatable by chemo or radiotherapy.

Two surgical teams will need to remove Bob's left kidney

and the rest of the tumour that has grown within his IVC.

The only way they can do this is to stop Bob's heart,

then drain his blood,

slice open the vein,

remove the tumour

and restart his heart.

I would do about six of these cases a year.

That's very rare.

By the time the patient is coming to see me,

they really are at the Last Chance Saloon.

OK, let's go.

-Everyone is ready for you downstairs.

-Right, then, OK.

So we'll crack on with things.

-Thank you.

-OK.

-That's all I want.

Good. I'll see you down there.

Urologically, I'm at the edge of what I can do.

The anaesthetists are doing the same.

What makes this procedure unique

is that we are really at the edge of what we can do as surgeons.

There is no alternative.

That's the end of it for me.

The end of everything.

-They can't start without you.

-No.

So this is the only chance that I've got.

You put your hand out, you take it.

One, two, three.

-OK, let's go.

-Thank you.

It's estimated the operation will take seven hours.

Rupesh will work with urologist colleague Richard Viney.

Can you give us a little twirl?

Thank you very much.

Cheers. Right, let the magic begin.

I always enjoy working with Rupesh,

particularly when it comes to the big cases.

Because they're few and far between and because they're complex,

we tend to try and do them together.

I think it gives the best expertise for the patient

and he's also very easy to make fun of, which is great!

Table up a bit, please.

Oh, I love these.

-These are like a treat.

-Thank you.

Oh!

Most surgeons undertaking this kind of surgery

are slight adrenaline junkies.

There is an immense sense of build-up

when you're undertaking this kind of work

and you'll often see a lot of dark humour.

This is like what I have to do to my wife

when she's having her fake tan applied.

See? Look! I mean, that looks like a week in St Tropez, doesn't it?

But inside, everyone's heart's pumping away.

There you go. Done.

And everyone's sort of very much at the edge.

-Thank you very much.

-Cheers. OK.

Let's get cracking, then, yeah?

The challenge for Rupesh

is the sheer unpredictability of the tumour's growth.

OK, knife, then, please.

Until he stops Bob's heart and opens the IVC vein,

he won't know whether the tumour is loose...

Watch your fingers, mate.

..or worst-case scenario,

stuck to its lining and much more complicated to remove.

A surgeon has to have strong self-belief.

Bit of lint on that, please.

You're operating on somebody who's got a beating heart...

..and you're opening up their biggest vein.

It's a very complicated, very stressful operation.

By 11:30am,

28 patients are already out of theatre.

Oh, my God.

Nice cup of tea or coffee.

Oh, please. I need big one!

They've had surgery to repair damaged nerves and stop nosebleeds.

In Theatre 15, surgeons are only beginning

to remove Jasmine's tumour.

What's this down here? Is that peritoneum or tumour?

It's grown so large, it's displaced much of her anatomy.

-There.

-We think the other ureter is going to be in here somewhere.

Sam and David won't be able to remove it

until they establish exactly

which organs and vessels are where.

It's probably there, isn't it?

Let's just work out where we are...

Cos everything is on its side, isn't it?

-Shall we take this gall bladder out of the way?

-Yeah.

-Where's her kidney?

-Kidney is going to be...

..in your hand somewhere.

Oh, fuck. OK.

-Are you serious?

-Well, it's in the tumour, isn't it?

We would have seen it by now.

The tumour has grown so much,

it now extends all the way from Jasmine's diaphragm

to her pelvis.

Her liver, intestines, and stomach

have all been pushed aside,

and the tumour has swallowed up one of her kidneys.

How are you going? How are you getting on, boys?

Just as you said that, we found something.

It's "spot the organ", isn't it?

-Jeez, this thing's heavy.

-I know,

it's just the sheer weight of it is...

As Sam and David navigate through

Jasmine's radically altered anatomy,

Sue is constantly monitoring her vital signs,

from blood pressure and heart rate

to kidney function and oxygen levels.

Sue's imperative.

During the operation, there's potential for massive blood loss.

There's potential for big swings in the blood pressure from us moving

the tumour around, so she knows what

we're going to do so that she can be a step ahead of us.

There's a small vessel coming out.

Can you see that?

Simon, can you come in, please?

Sue, if you want us to back off, just let us know.

Um, I've got no return at the moment, guys.

OK, do what you need to do. We'll just back off.

Just 20 minutes into the operation,

Jasmine's blood pressure suddenly drops.

Her heart rate's the same. 120.

Very little blood is pumping around her body,

restricting oxygen to her organs.

We're not losing any blood. We've got no blood down here.

Are we tensioning the chest, maybe?

Couldn't...just take it this way...?

..OK on the vent...

No problem with the chest.

Sue suspects it's the weight of the tumour that's the problem.

As they roll it around in the abdomen,

it will press on the major blood vessels,

going to and from the heart,

which means that we will have instability with the circulation.

Quite significant instability.

-Have you got it there?

-Got it.

It's coming out now. Hold on.

As they move the tumour again, the blood pressure returns.

-Hm.

-OK.

-Very strange. Don't like that.

I don't think it takes a lot of obstruction.

It must have been compressing a major blood vessel.

The trouble is, those blood vessels aren't where they should be.

Sam and David must now find them.

We're heading up into tiger country here, aren't we?

We sometimes use the phrase "tiger country"

and that really refers to the

frighteningly large and thin-walled blood vessels.

I just want to know where this effing IVC is.

Particular tiger country is around the IVC,

the inferior vena cava,

which is a very large vein

that takes blood back from the legs back up to the heart.

Normally, it looks blue.

We should have seen the bastard by now, shouldn't we?

-You know, I think it's going to be in here.

-I think it's that, is it?

-Is that it?

-I don't know.

-I'm not convinced yet.

-I know. I'm not convinced, either.

There's the cava. Look, there.

There. Got you. Just there.

Yeah, it's blue all right, isn't it?

-I'm happy now we've got a glimpse of big blue, there.

-Yeah.

I'm not so happy that it's going to be...

an absolute devil.

The full length of the IVC vein

is stuck to the tumour.

To save Jasmine,

they'll need to detach it meticulously

without penetrating either the tumour or the vein.

You can actually see the blood flow, streaming through it.

It's transparent. It's so thin.

So it just tears like tissue paper.

That's the perfect thing.

Get on top of the cava, isn't it?

They bleed out very rapidly and much more scarily, probably,

than any other blood vessel in the body.

Can we move the light over here, please? Get the light.

Just wait for it to come in. I can't see shit.

-It needs to come around a bit more.

-Can that come round?

Absolutely dead still now, James. I know you're not moving,

but it's just a couple of millimetres

and the tip of the diatherm is into the cava.

James, keep still, for Christ's sake.

You have to be jolly careful that you don't bugger it up, really,

and that's why you need to operate with a colleague

on the other side of the table.

So when I get a bit nervous and uncertain,

Sam takes over and vice versa.

Yeah, it's not very nice up here.

The diathermy, please.

Professor Gourevitch can be a bit of a handful.

He's very forthright.

Quite noisy and opinionated at times,

but one of the biggest things that he's taught me is that

you just have to get on with it

and believe that things will work out.

This is clearly monumental scale surgery.

She is one of the few patients

that you would counsel may die on the table.

Underneath the operating theatres in the basement

lies the Molecular Pathology Department.

All tumours removed from surgery end up down here for investigation.

The team are expert in analysing cancer cells

in unprecedented detail.

Molecular pathology has really been a game changer in certain cancers.

It means that now, we're able to transform what were otherwise

potentially untreatable cancers

into ones that we can control and essentially treat

like chronic diseases.

One of the latest innovations in molecular pathology

is the use of robots.

So in the past, pathology was very, very labour intensive

and with labour-intensive procedures done by humans,

you're increasingly adding in the risk of say,

for example, contamination,

which can have really severe effects for patient samples.

More accurate diagnosis makes for more effective treatment...

..so the team have also started to use fluorescent dyes

to detect specific genes in the DNA of tumour samples.

Each of these blue dots is a cell

and within those cells,

you've got green dots and you've got red dots.

Now normally, you should expect to have two copies of the green

and two copies of the red, but what you can see here is

that we've got huge numbers

of these red dots and that supports a diagnosis of liposarcoma.

In the past, a lot of these cases

would just have been diagnosed as being undifferentiated sarcomas

and those patients would generally just have received

quite aggressive chemotherapy,

which brings with it lots and lots of side effects.

Now, we can pick and choose which patients

need to have that aggressive chemotherapy

and which patients could potentially have lighter, more tolerable

chemotherapy with the same effect.

Overall, that means that for patients,

they have an expectation of how

likely they are to do well or poorly,

which means that, on a very human level, they can plan their lives.

Clean swabs like that, please.

Are you happy with the place?

-Can it go there?

-Mate, you can go wherever you want.

-You're the boss.

-Perfect, thank you.

In Bob's operation, Rupesh has made a start on the tumour.

The only way to remove it from the main vein

will be to stop Bob's heart

but first, they must remove his kidney, where the cancer started.

Cut along the dotted line.

Rupesh and Richard must carefully

disconnect the many veins and arteries supplying the kidney.

Ligaclip, please.

-There you go, my friend.

-Thank you, sir.

This is, so far, quite nice.

-Shh!

-I know, exactly!

You had to jinx it. You HAD to jinx it!

I'm always worried about bleeding.

It's a real threat.

You need to make sure that every single little blood vessel

is completely tied off.

And the liga, please. And the ligaclip.

Because next step is that Bob is going to be given medications

to completely thin his blood...

..so his clotting will not work,

so if there's a little tiny hole,

even if it's a millimetre,

it'll keep bleeding until all the blood is gone.

Hold on, hold on, hold on, hold on.

I think I've just caused some bleeding there.

Sucker, sucker. Where's the sucker?

Can we have a suction on?

There it is.

Naughty little artery.

It takes Rupesh and Richard two and a half hours of painstaking work

to seal the blood vessels before they can free the tumour.

It's coming, it's coming.

It's coming. There we go.

-It's come.

-It's there.

-Done.

-Ta-dah.

-OK? Done.

The only remaining part of the tumour is inside the IVC,

the vein leading straight into Bob's heart.

Good, OK.

To remove the tumour within it,

they need the IVC vein to be completely empty of blood.

This means that all the blood in Bob's body needs to be drained.

So now would be a good time

to get Mr Rooney to start opening the chest.

Consultant cardiothoracic surgeon

Stephen Rooney and his team will join Rupesh and Richard

with this, the riskiest stage of the operation.

So have you got any more dissection to do?

No, no. We're done. The kidney's through the mesenteric window,

ready to lift out, basically.

Sweet. Enjoyed yourself so far?

It's been awesome. It's just a pity you have to put up with Rupesh,

but, you know, what can you do?

-Right, then.

-Starting the chest.

The first step is cutting open Bob's rib cage

to access his heart.

There we go.

SAW BUZZES

Lamps back on.

The saw can go.

When you're looking over their shoulder

when they've got the chest open, you just see the heart sat there...

Quite an extraordinary thing.

It is life right there.

Can I have...

..15 blade,

a pair of forceps

and aortic cannula.

Here we go.

With the chest now open,

Stephen starts by inserting two cannulas directly into the heart.

The process involves making an incision in a beating heart,

which to an onlooker is kind of a very, very weird thing to watch.

See someone actually stabbing someone's heart with a knife,

but it's what the cardiothoracic surgeons do.

OK...

-Yeah?

-Do you want to go on to the pump, please?

Thank you. Going on bypass.

That's on bypass.

And start to cool, please.

-I have started to cool, thanks.

-Excellent.

For Bob to survive having his heart stopped,

and his body entirely drained of blood,

they first need to gradually cool

his temperature from 37 degrees

down to just 18.

Cooling to 18 degrees.

At normal body temperature,

without blood flow,

Bob's organs would fail in minutes.

But the cold will protect him

by putting him into a kind of hibernation,

offering a few precious minutes for Rupesh to open the IVC vein.

It's mainly for his brain.

When it's cooler, the cells aren't requiring as much oxygen.

They go to sleep, essentially.

So we've just got to cool now.

Very cool.

To bring his temperature down,

Bob's blood leaves his heart via the cannula into the bypass machine,

where it's gradually cooled and then returned to his body.

This cooling was discovered accidentally.

There's a famous medic who fell through into a frozen river

and they fished her out a long time afterwards.

Even though she was technically dead as far as the heart was concerned,

they still carried on and on and on and what they found was,

as she re-warmed, she came back to life again.

As the cooled blood returns to Bob's body,

it shuts down his organs

and slowly stops his heart.

To see it stop, it's very odd.

It's an incredible notion.

It's a bit like suspended animation.

I'm a scientist and yet there is

something special about this state that patients are in.

With no pulse or blood pressure of his own,

Bob is now, to all intents and purposes, dead.

The surgical team have just 30 minutes

to remove the remaining tumour.

I'm not going to get sort of religious about it.

But it's quite awe-inspiring.

He is literally on the edge of life and death.

In theatres around the unit,

surgeons make progress through their daily lists.

Ligaments are tightened,

heart valves replaced, a pancreas transplanted.

Babcock, please. Long one to me, please.

Slap it in, sweetheart.

In Theatre 15,

the sarcoma team are slowly removing

Jasmine's tumour along with a margin

of healthy tissue around it.

OK, that's it. Good.

Ooh! That's good.

-OK, that's enough.

-Well done.

We're trying to concentrate on the operation,

-you're thinking about alcohol!

-Well, you know,

have to think of the future, haven't you?

LAUGHTER

-Do you think you're nearly there, then?

-No!

James, you OK? Do you want a rest?

OK. James, have a rest.

-Could you make it any more difficult?!

-Exactly!

An operation to remove a sarcoma

can be prolonged and we need points in the operation

where we can release the tension.

We quite often poke fun at each other, have a bit of banter.

Stop slacking. Get on with it!

We're just having a breather!

Sue, can you put the table up a little bit?

Again? What, more?

-In your own time, darling. Don't worry.

-God's sake, man!

We saw you sneaking off.

Well, you're certainly making it LOOK tricky, aren't you?

-Up in the air?

-Thank you, Sue.

Sorry to disturb your chit-chat over there!

All right, we've got to get this bloody kidney, haven't we?

We've had a bit of cowboy action.

The cancer is thought to have originated

in the fat around Jasmine's right kidney,

which is now buried so deep in the tumour, it can't be saved.

-Are you going to take the kidney?

-Yeah, the kidney's definitely out,

-yeah.

-It's got to come out.

-No, that's fine.

In order for Jasmine to survive this disease,

the tumour has to be taken out intact.

The tumour contains a kidney, so that kidney's going.

It's an important consideration, though,

because on a healthy person with two kidneys,

there is still a risk of them going into renal failure.

It is very possible that Jasmine's

remaining kidney can't cope,

so she's between a rock and a hard place.

-Ready?

-Yeah.

-Shall I pull?

-Yeah.

Normally, to remove a kidney,

the surgeons would simply cut the main artery leading directly to it.

I'm just worried the anatomy's so distorted here.

The trouble is, Jasmine's kidney is so deep inside the tumour,

they can't see which artery leads to it.

OK, what have we got here? Behind here?

That's the renal vein, isn't it?

The surgeons have in their mind

a road map of how the anatomy should look

and when anatomy is so distorted

by the sheer size of the tumour,

you have to be very careful not to make assumptions.

-Yeah? Are you happy?

-I don't mind, it's your operation.

You bloody well picked it up,

so shall we think about it a little bit? Cos it is big, isn't it?

We've taken one back already and we are upside down.

Let's have a look, let's have a look.

Stop, stop, stop.

They need to decide between two very similar-looking blood vessels.

One supplies the kidney,

the other is called the superior mesenteric artery,

or SMA,

and supplies blood to the whole of Jasmine's bowel.

James, suck this stuff out here.

And here, and here.

The superior mesenteric artery

comes off the aorta,

almost at the same point as the right renal artery.

They literally come off within a millimetre of each other.

This is a very, very dangerous part of anatomy.

-Is that the vein?

-It must be the vein.

-Shall I just be brave?

No. Don't be. Don't be brave.

If we were to divide the SMA,

mistaking it for the renal artery,

then Mrs Harkness would lose all the blood supply to her small bowel

and that would be a fatal mistake.

-Yeah.

-SMA?

-Yeah.

-SMA is in my hand.

Can we stop here for a moment, please, chaps?

-We've just got to be certain.

-SMA is here.

-Have you got it?

-Put your hand around here.

Yes, SMA is in my hand.

-Sure?

-Yeah. Are you sure?

-Well, I think so, because this is going

in completely the wrong direction

and going into the tumour, but if we do take it, we're up shit creek.

Yeah. Put a bulldog on it.

-OK. Can I have a vascular bulldog, please?

-Yes, OK.

Long one. Thank you.

They clamp one of the arteries.

If the small bowel drains of blood,

they will know they've got the wrong one.

-What's her blood pressure?

-Enough.

Let's just talk our way through this again.

I've got my finger around what I think is the SMA.

-It's pumping.

-It is pumping nicely.

At some points in a sarcoma operation,

we have to be absolutely certain

that we know which artery it is we're about to divide -

a little bit like bomb disposal.

If we were to divide the wrong artery,

then it can have catastrophic consequences for the patient.

We are absolutely and utterly committed, once we divide that.

-There's no going back.

-OK. So, we're happy?

-Yeah.

-You sure?

-Yeah.

-Yeah. OK.

The deed is done.

With the kidney disconnected,

they've cleared a major hurdle.

But unless they can get the tumour out intact,

they won't know if they've done enough to save Jasmine.

The theatre has ten units of blood ready

in case Jasmine has a major bleed.

Surgeons at the QE are reliant on a steady stream of blood arriving from

the NHS Blood and Transplant Centre just half a mile away.

State-of-the-art surgery requires the blood bank to supply

all the components of blood in immaculate condition.

Red cells are used for volume replacement during operations.

They're also used for people whose red cells are not correct,

like leukaemics.

Frozen plasma contains the main proteins.

So they can be used again for volume replacement

or to replace specific proteins, like clotting factors.

These are where we store platelets,

which is a special clotting cell.

They have to be kept again in temperature-controlled conditions.

They're also kept agitated. This is to prevent them settling.

If they settle, they could start to aggregate,

and once they've aggregated, they can't be used for a patient.

The red blood cell units are kept alive in a solution of sugars and

metabolites and have a short shelf life of just over a month.

A highly sophisticated tracking system

follows each unit of blood all the way from the donor

to the patient who receives it.

In Bob's operation, they're five hours into surgery.

-We happy?

-Yes.

-OK.

-Can you turn the pump off and drain the patient, please?

-OK.

Draining the patient.

His heart has been stopped and all the blood drained from his body.

And can someone start the clock, please?

I have got the clock on here.

The team has just 30 minutes

to remove the tumour from the biggest vein in Bob's body

and then bring him back to life.

You are under extreme time pressure.

You've got about half an hour

before you start causing damage to some of the vital organs -

brain, heart, etc.

Then the risk of stroke.

The risk of cognitive damage increases.

So this is very high-risk surgery.

All the banter stops. Everybody focuses.

Everyone is very much aware of how close to the wind we're sailing

in that particular instance.

I try to find out as much as I can

about what I am expecting before I go into the operation.

But there are always going to be some unknowns.

One of the unknowns which really can stress me out

and will certainly keep me awake

is what the tumour within the IVC is like.

OK, I need a blade, as well, please.

Rupesh must now slice into the IVC,

the largest vein in the body.

It's the most critical moment in the operation.

When you make the first cut with the knife, it's pretty scary.

It's absolutely going against your training.

You think you've got it under control, but it's big stuff,

it's frightening stuff

and it takes quite a while to sort of overcome that

and you realise that you need to be the master of that

as opposed to the other way around.

-Sucker up.

-Up on sucker.

Despite all their planning, it's only now with the IVC open,

that they'll discover if they can remove the tumour

before their 30 minutes is up.

You're never quite sure whether the tumour

is going to be stuck to the lining of the cava

and whether you're having to scrape it off,

or whether it's going to lift out, literally, like a long tongue.

The worst-case scenario is where

the tumour is still attached to the vein

and you could leave little elements behind, so you don't want do that.

Think of porridge which is dried out,

stuck to the bowl,

and you're sort of peeling that away.

You are free.

I think I will get my finger in, OK.

Each surgeon places a finger inside the vein -

one from the top, one from the bottom

and gradually release Bob's tumour.

It's... It's free. Ready?

-So that's my finger in.

-I can feel you.

-Fine.

I'm taking it out now.

There we go, it's out.

-OK.

-OK, there is the tumour.

Got it? Keep it together, keep it together.

Lovely. OK.

Not a nice specimen, this one.

The kidney and tumour are out.

Remarkably, it has only taken four minutes.

Now the two surgical teams have just 20 minutes to repair the IVC,

the hole that's been made in the heart's atrium,

and restore Bob's pulse.

Good, OK.

-OK.

-Thank you very much.

-You're welcome.

It's what's known as SLF,

which is "stitch like..."

I won't finish it.

He will close the heart, I will close the big vein.

Can I have a heavy tie, please?

Stephen has finished repairing the hole he made in the heart

to access the tumour.

How're you doing?

-Yeah...

-Halfway there.

You guys have just got to chill out a bit, you know.

You're going to end up in an early grave!

Can I get round to slowly start to fill the patient?

Yes, you can, please.

OK, do you want to start filling the patient?

-Yeah. I can do, yeah.

-So now we're putting his blood back in.

Stephen begins restoring Bob's circulation

to check there are no leaks.

Let's have a look... OK.

-Yeah.

-Crack on.

-Yeah.

Can we turn the timer off, please, Lee?

13 minutes was arrest time.

-How much?

-13.

-One three?

-One three, yeah.

In just under 15 minutes,

the team have removed the tumour

and repaired the incisions.

-Perfect.

-Filled up.

The cava's filling up nicely there.

Start a gentle rewarm, please.

Yeah, can we take the ice off the head, please?

The bypass machine returns gently warmed blood to Bob's body.

His heart is already starting to respond.

As the blood goes back into the patient,

and the patient's heart starts beating again,

well... THAT is a magnificent feeling.

You're really elated, you know at that stage that

the major obstacles, the major pitfalls, are behind you

and that you know that you're probably

starting to look at a success story.

Coming back online?

-Yeah.

-Hello...

INDISTINCT

But I suspect he'll come back into...

Spontaneously come back into an organised rhythm.

Why don't I just tear it off?

Only if you lay your hands on it.

-Say the word.

-Thanks.

-Just get the pump off.

-Thank you.

And shoot.

Stephen shocks the heart to re-establish a normal rhythm.

Despite a period of deep freeze,

Bob is once more displaying all the vital signs of life.

-Yes.

-So, are you happy for us to come off?

I am, gases are good.

And you've not got bleeding going on in the abdomen?

-I'll have a look at it.

-OK. OK, can we get the lungs on, please?

Bob is slowly removed from the bypass machine,

and his heart and lungs take over again.

That's quarter flow.

All right, that looks comfortable.

-Do you want to clamp there, please?

-Thank you.

Clamping venous. Venous is clamped.

That's off bypass, 100 left in the pump.

-Venous pipes out.

-Thank you.

So we're off bypass.

Pump is empty.

Pump is now off.

Are we going to start closing down this end?

-I'm happy.

-Yeah, everyone good?

-Yeah.

After eight hours, Bob's operation is coming to an end.

When surgeries like Bob's go well,

immediately at the end of surgery,

you know, you've had eight, 12 hours

of severe concentration,

you're quite drained. I tend to be quite euphoric after that.

It's just an incredible operation though, isn't it? I love it.

If you think about it, it's quite surreal.

You know, this is a patient

where...they've been frozen...

..where normally that wouldn't be, um, survivable.

And the fact that the Bob before an operation will be the same as,

hopefully, will be the same as the Bob after

as far as brain function,

how he deals with his family,

how the family know what Bob is,

it's incredible that you can do that.

Across the department, the end of an operation brings relief.

I'm just savouring my Hendrick's gin and tonic with cucumber

and a good Fever-Tree tonic water!

I'd just kill a pint of anything!

A pint of that would be fine!

In Theatre 15,

Sam and David are nearing the crunch point of the sarcoma operation.

Oh, God.

Let's get this bastard out.

They've almost detached Jasmine's tumour,

and are preparing to remove it.

See, I'm worried here we're going to go right through her back,

and then onto the operating table.

She's so slim, and we're taking

a muscle at the back to cover the tumour.

If the tumour was breached, then...all is lost.

These types of tumours have a real potential for seeding,

even one or two cells have the potential

to survive and cause tumour recurrence.

So, we need to remove the tumour in its entirety.

And remove it with a healthy cuff of tissue.

Cutter's not quick enough, is it?

-No.

-Right, be careful of this,

-all sorts of stuff here stuck on the back of this lung here.

-Yeah.

As it becomes released,

and you've almost fully mobilised it,

there's a danger that the sheer weight of it

just tends to sort of tear itself out of the abdomen.

Just be careful now. It's OK, we can see, we've got the dome

of the diaphragm... Hm. This lung's stuck to it.

OK, let me see, let me see.

Oh, we're right into the chest here.

Jesus Christ.

-Now, let's just take it steady now.

-Yeah, exactly,

we're about to lose it here.

In every operation, there is a sort of "bugger it" factor.

Which is, just before you finish removing the tumour,

you're getting a little bit cross and a little bit tired,

cos you been going for some hours now

and you know it's going to come out.

And you get to this stage of, "Bugger this, it's coming out!"

And that's when you make a mistake.

Take your time now.

-Trolley for her?

-Trolley behind, please.

-Trolley behind.

-Big swab, please.

Can we just get this off?

Get the bloody tumour out.

So, you've got the cava. You have the cava there.

I've got the cava on my side. OK, where's the aorta?

The aorta is...

-Not a million miles away.

-Not a million miles away.

-My finger's on the aorta.

-OK.

Fuck.

-There's a hole there, there's a big hole in something.

-Sucker, please.

There's a bleed,

but until they take out the tumour, they can't see where it is.

Just take it, just bloody take it.

Let's go. Go, go, go.

Oh, got it! Got it, don't worry. Got it.

Jesus Christ!

-I've got it, don't worry, I've got it.

-Big ones, please.

Phew!

Although the tumour's out,

they can't relax until they stem the bleed.

Open the packs up, please.

Come on. Suction.

It's OK, we don't need it. It's packing. Just packing.

-Thank you.

-Thank you.

Open it up!

OK, right, let's all relax for a moment.

It's taken seven hours,

but it's finally done.

All right?

Lifting the tumour out is fantastic.

It's a combination of relief...

..and elation.

Well done, well done!

-Thank you, thanks!

-Well done.

I think it's officially plus size.

That is absolutely enormous!

-Pretty much 60...

-70.

She's going to feel very, very different when she wakes up.

She'll have to buy a new wardrobe.

How on earth she'd been able to carry that around

for months is anybody's guess.

I think I get first guess.

Get out of it. 18!

18. Small, small, small, small.

Prof, write Prof next.

15.

-Damien?

-22.

During the operation,

the atmosphere in a theatre can become quite tense

and challenging at times.

And in order to lift our spirits somewhat,

we like to run a sweepstake and guess the weight of the tumour.

I never seem to win,

even though I've actually had the tumour in my arms beforehand.

Go on, don't keep us in suspenders.

19 and a half.

-James it is, then!

-Well done, James.

So you get to buy the first round at the Plough, that's great!

Quite a case.

That's why we come here, isn't it?

We're done, we're about to close.

We're going to zip this one nicely up.

-Hell of a tummy tuck.

-Mm-hm.

-Yes.

Oh, she'll be light on her feet now, like a spring chicken.

Despite all their worries, it seems the operation has been a success.

It's been a long day.

We're in the speciality because we enjoy it.

We enjoy the surgery, we enjoy each other's company,

and we enjoy the whole spirit of the theatre and the spirit of adventure

that this sort of surgery brings.

Good job.

-Yeah, great. Thanks very much.

-I haven't done anything.

I'm only here for you.

This is an exceptional case.

And so, it comes as no surprise

that we would wish to pit our wits against the tumour,

and have it out and take it out.

That's what drives us really.

Sheer arrogance!

Look at you tuckered up, lovely.

All right, lovely, we're going over.

Let's go.

When I got home, having operated on Mrs Harkness,

I was putting my son to bed and he likes me to carry him up the stairs.

And I lifted him up and I thought, "Gosh, he's a heavy boy.

"I'll just put him on the scales to see how heavy he actually is."

And, oddly enough, he weighed exactly 20kg.

So Mrs Harkness's tumour,

weighs the same amount as a five-year-old boy.

Two days after his operation,

Bob is recovering in intensive care.

It was my Cup Final, this one.

And I thought to myself, "I've seen big players in the Cup Finals

"dragged down, you know - they haven't performed."

I've won my cup final, definitely.

OK, how are you doing, Mr Moran?

You're making pretty good progress.

Yeah, it's going very well indeed.

We'll keep a pretty close eye on you.

I can only thank you.

Can't do no more. You've made me a very happy man.

And my family.

I just can't thank you enough.

I believed you from the first day I met you

and I said I'd try and be a good patient.

I'm all right now...

Just so...

I'm not upset, I'm thrilled.

Just emotion, that's all.

Yeah, I know. That's always going to happen.

Where we are in 2017 with the NHS,

the complaints come thick and fast,

so it's quite nice to hear that.

Nowadays, people generally expect treatment.

OK, whether that's surgery or surgery with other things,

and they're more demanding as far as what they expect from surgery.

It's only human nature.

But it does put a lot of pressure onto surgeons, and surgical teams,

to keep pushing the boundary and to keep...

..getting good results.

Back in hospital,

Jasmine is starting to recover

and is adjusting to life without her tumour.

I feel much better now than I did.

And it's nice to be on the mend.

It's nice, it's like a miracle, really,

that you've got a second chance.

-Knock, knock. Hello, Jasmine!

-Hello!

I feel as if I could float.

It's like a cloud, you know,

somebody's taken the worry out of you, out of your mind and you can

just float on air.

That's the feeling you get.

OK, how was that?

-Fine.

-Yeah? So these ones are a little bit steep.

I quite often ask my junior doctors

what the most important gland in the body is

and they say the pancreas, or the thyroid, or something like that.

And actually the most important gland in the body

is the up-for-it gland, "Are you up for it?"

If that's working well,

you can do things to people that you wouldn't be able to do to a patient

who was struggling with motivation.

I thought she put up an extraordinary effort

-to get through that sort of surgery.

-I feel all right.

-Yeah? Do you want to turn around and we'll have a look...?

-Yes.

I mean as recently as, certainly ten years ago,

it would be very unlikely that someone

in her reduced condition with this massive tumour

and poor physiological reserve would be offered

this sort of surgery.

What's changed in recent years?

We just got a bit braver, I think.

Next time...surgeons put experimental techniques to the test.

Gene therapy trial. Everyone's eyes should be covered.

I'm taking a high-speed drill and making my way inside the skull.

There are huge risks...

The liver might not function at all.

..and rewards.

If this works, I shall feel marvellous.

Today's research is tomorrow's standard of care.