Men: desist from this thing immediately please

Men: desist from this thing immediately please

Imagine the scene, you’re sitting listening to a speaker opine on a topic and when they reach their concluding slide instead of a great slide summing up their message they have a picture of their children. Pause for us all to admire Thomas and Em’s extreme cuteness. Then they make some annoying reference to their progeny being way smarter than they are or some other shitey humble brag. 

A certain subset of men then make reference to their amazing wife (a stay at home mum) who keeps them in clean shirts and feeds everyone. I don’t know how she does it! 

I feel the more kids they have the more likely they are to mention it. 

Why do they do this? Women don’t. Is it to brag about their overall successfulness? “not only have I conducted a randomised controlled trial but I have fathered three children”? It’s vile. If I ever get to the point where I am important enough to be chairing meetings I’ll start telling the offenders that it is pathetic. 

Take the slide of your kids out. Don’t ever make reference to them again in a talk. Nobody cares about your children. 

73 things a surgical trainee should know 

73 things a surgical trainee should know 

1. Be kind to everyone.

2. Look after your mental health.

3. Be honest always.

4. Never put anything in writing you wouldn’t say aloud

5. Don’t trust everyone you meet.

6. Nobody cares about you more than you should care. 

7. Keep fit.

8. Keep a diary of operations and techniques.

9. Organise yourself.

10. Drink enough every day and never miss more than one meal.

11. Remember this is just work.

12. Forgive yourself your small mistakes and forgive others theirs.

13. Don’t walk away from the operating table with any regrets or concerns. Deal with them there and then and walk away happy.

14. People die.

15. The nurses should like you,  but if they all like you all the time you are probably going wrong.

16. You don’t have to justify your choices to anyone. If you walk away from this and do something else or if you decide you want to be professor of surgery, both choices are equally valid and worthwhile.

17. Don’t shit on your doorstep. Take it from me, it never ends well.

18. Your professional reputation will come from what you do and how you do it, it takes time to build but seconds to destroy it.

19. When you need help, ask for help.

20. There is no shame in not knowing something.

21. Always be truthful in your professional life.

22. Consent people with plenty of time and due care, preparing for surgery is important and consent should be done just as well and carefully as the operation is performed.

23. Sometimes your best won’t be good enough.

24. You won’t like all the patients you meet.

25. They won’t all like you either, recognise that when it happens and step back.

26. Be especially kind to yourself, be your own best friend.

27. Find people you admire and watch how they work.

28. Same for people you don’t like, pinpoint what you don’t like and avoid doing that.

29. You can still be you and be a surgeon.

30. Some patients will touch your heart and stay with you forever, remember them and the lessons they teach you.

31. Don’t trust the sigmoid for an anastomosis.

32. Don’t fuck with the pancreas

33. A cut blood vessel has two ends

34. The operation can’t be said to have gone well until the patient is discharged home and you have seen the pathology results.

35. When you feel like crying, have a cry and then wipe the mascara, give yourself a hug and carry on.

36. You are not as good as the last operation you did, so don’t crumble when something goes wrong.

37. The natural history of most things is that they get better with time.

38. Apart from appendicitis, that usually  gets worse.

39. You are more than just your work, don’t let it define you.

40. Be kind and nice to juniors, they might overtake you and anyway they will spread your reputation wherever they go.

41. Don’t dislike pretty female medical students, they are the future and need to feel welcomed.

42. Have a daily routine for where you keep your watch and rings, it’s unprofessional to flap about at work looking for lost jewellery and wastes time when you should be working.

42. Always, always have money on your person to buy food and drink. You don’t know how badly wrong your day can go and having change at 10pm can make or break you.

43. Caffeine. You will need caffeine.

44. Alcohol, this you don’t really need. Never drink when you are sad, or if you are operating next day.

45. You will never stop learning or improving, it’s a lifelong process. Enjoy it.

46. There is always going to be someone better than you.

47. Very few surgeons think that they are average surgeons, half of them are worse than average. Have insight into where you are.

48. Wearing makeup and pretty shoes and reading Grazia as well as the BJS are all perfectly acceptable.

49. Not wearing makeup is also acceptable. Your female surgeon friends should be cherished and respected for who they are.

50. Rise above the stuff that doesn’t matter.

51. You will carry with you and become a product of all of the people who train you and mould you. That’s a gift and a joy to be a part of.

52. Remember that being a trainee is a transitory role, don’t be a dick.

53. Don’t lose your temper, ever, in a professional setting.

54. Hospital politics requires years of practice, listen and watch but stay out of it until you are well established.

55. Organise the rota if you can, it is worth the hassle.

56. Don’t disrespect LTFT trainees or people on maternity/paternal leave, it might be you one day.

57. Stand up for what is right.

58. It should feel good and make you happy at least 50% of the time.

59. The purpose of a ward round is to make the patients feel cared for and safe, not just to ensure they are cared for and safe.

60. When you feel you’ve made a mistake or had a complication do a ward round, it makes everything better.

61. Don’t trust a surgeon who isn’t happy and relaxed in theatre.

62. Don’t trust an anaesthetist who never questions any of your decisions.

63. The anaesthetist is your friend.

64. Lead the team in a way that feels comfortable to you.

65. Don’t try and be someone else.

66. Don’t hide your intraoperative problems from the anaesthetist.

67. Remember that you are lucky to live in this world, in this time, to do this job and be so privileged.

68. Smile and enjoy it. You have worked hard.

69. Foster good relations with other specialists, you never know when you might need them.

70. Don’t do drugs, ever.

72. Treat your seniors with respect, even if you don’t respect them that much.

73. Be prepared to be the subject of gossip, you will be talked about; good and bad, accurate and inaccurate.

Rizzo’s Rule

Rizzo’s Rule

What’s the worst thing I could do?

Grease is a marvellous movie, I used to know all the words, and the character I wanted to be most of all was chief Pink Lady, Rizzo. Sandy was not for me; she was a saccharine, simpering twit and although she looks fabulous in those black shiny trousers at the end you just know she is a girl who doesn’t know how to have fun.

Rizzo, however, she was a woman of the world and had the best songs of the movie in my opinion. Even her real name, Stockard Channing was great.
As you may know her “Look at me I’m Sandra Dee” is a sort of homage to anaesthetists, but her other song is surely meant for surgeons. There are worse things I could do, lyrics are here, has the brilliant line “that’s the worst thing I could do”.

Before you start every operation and during each stage of an operation you should ask yourself, much like Rizzo does “what’s the worst thing I could do?”

Let’s take a laparoscopic cholecystectomy:

Port insertion: Rizzo says “you could stick it straight on through, pop the colon, spread some poo”

Calot’s triangle: Rizzo has a lot to say here

“You could fuck the CBD,
take the right hepatic artery.
Stick a grasper in the liver,
make it bleed just like a river,
with no IOC to bail you out,
how your boss will scream and shout,

Another way of doing the same thing is by naming and preparing for your enemy. Guddling about under the right colon: the enemy is inadvertent damage to the ureter and duodenum. It’s all the same thing that Rizzo says.

Think about it, then don’t do it. Don’t be scared to do an operation but know what you could do wrong and avoid it. Rizzo wasn’t scared of anything either.


KBW’s Need to know: Whipple’s Operation (read and eat)

KBW’s Need to Know for medical students

(not a how to do it and not comprehensive by any means)

I do like to harp on about Whipple’s operation, it is a lengthy and difficult procedure and even in the best hands and best centres (Bighospital is once such place) has a high rate of complications and death. Even if you survive the operation the outlook can remain poor as the type of cancers that require a Whipple’s are aggressive and deadly (pancreatic cancers, cholangiocarcinoma).

What is a Whipple’s operation?

Professor Allen Whipple was an American (born in Iran) who described the operation of pancreaticoduodenectomy, more widely known by it’s eponymous name and also described Whipple’s triad. He is not the same Whipple as Whipple’s disease but apparently the two were great friends. He modified the operation from his original two stage procedure into the classic operation that we now perform.

The aim of this operation is to remove en bloc the head of pancreas, the duodenum, with attached first part of jejunum and the distal portion of stomach, the common bile duct the surrounding nodes and vessels that are attached and as a separate specimen the gallbladder and cystic duct. Continuity of the bowel and biliary system is then restored via a series of joins called anastomoses. The cut body of pancreas is sutured onto the small intestines (the panreaticojejunostomy) and the top end of resected common bile duct is sutured onto the small intestine (the hepaticojejunostomy) a bit further down stream to restore the flow of bile and pancreatic juices into the gut. Then the stomach is joined onto the small intestines (gastrojejunostomy) to allow food to pass in and finally there is a join between the small intestinal loops (enteroenterostomy) to prevent biliary reflux up into the stomach.

This operation takes about 6hours (on a good day) so make sure you have had your breakfast and make sure you have had a look at your anatomy books.


Image 1: The pancreas

Operative Anatomy

First off you have to get down to the retroperitoneum where the pancreas lies hidden and innocuous looking like cooked cod roe under a layer of fat and peritoneum. To do this you need to make a rooftop incision and then move the right colon away (just like you do for a right hemicolectomy). Then you have to come from the superficial, main abdominal compartment down into the lesser sac onto the pancreas snuggled in the c of the duodenum. The duodenum is freed from the fixed position all plastered down and flipped over (kocherised) to lift all the business up.


Arterial blood supply from coeliac trunk (lienal means splenic)

Then we need to come under the pancreas, we define the vascular anatomy; firstly you find the SMV (superior mesenteric vein). Then the most complex area, a little cube of clockwork known as the porta hepatis. Find the common hepatic and then the GDA (gastroduodenal artery) the right hepatic artery, cystic artery and gallbladder (it is removed). We like to sling the vessels such as the GDA prior to division and also the common bile duct. It should all look rather beautiful and like an anatomy prosection at this point. Then, in order to get on with things you start by dividing the stomach proximal to the pylorus and dividing the jejunum, then you separate the pancreas from its vascular supply (nasty little veins that bleed like stink and you fear for the SMV and the portal vein) you then divide it and remove the specimen with all the lymph nodes and fat.


Image 3: This shows how the anatomy looks in situ

This area of the body has the most complex and difficult anatomy to get your head around, there are also annoyingly, lots of variations of normal. There is no easy way to fix this in your head, it takes lots of study, plenty of time in theatre, time looking at scans and I also think the passage of years to fully grasp. I have not grasped it fully yet and have seen it a fair bit.

This series of intraoperative photographs is fantastic and shows beautifully the operative view that you will see.


After removal of the specimen you join it all back up. Pancreas to jejunum, common bile duct to jejunum, stomach to jejunum and then jejunum to jejunum. We are not routine Roux loopers in Bighospital. Some of the joins can be stapled or hand sewn, it is down to surgeon preference. Every student should watch a Whipple’s as it is truly amazing and inspirational even if you are a career immunologist, just make sure you eat a big breakfast and read your anatomy before hand. I am repeating myself because this part is important, read and eat students, read and eat.

You will not be able to get it all correct here, if you know all this you will please even the most fussy of HPB surgeons; and my god, are they ever fussy.