What function does the appendix serve?

Great question, we have no idea!

So, the appendix is about a couple of centimetres. It sits on the end of your cecum - which is the first part of your large bowel, where your large bowel connects to your small bowel, in the right lower side of your abdomen. It's cheeky, and it causes problems in people. 

We think it was a bit of a remnant stomach or something from the olden days, that then got really small, and is useless. So, there are people who are rarely born without an appendix. We've never proved what it can do, but there is quite interesting evidence that if you have inflammatory bowel disease - so something like Crohn's or ulcerative colitis - if you have your appendix still in, sometimes you respond better to different medications, and you do better. That's really weird and no one knows why. 

But, the appendix currently serves no function that we can use other than to be annoying. 

How long does recovery typically take after surgery?

It is very dependent on the operation. So, people can go home from an operation the same day. If you've had a little lump removed under a local anaesthetic, you can literally walk out of the recovery room and just go home. If you've had a laparotomy - which is a big open cut in the abdomen, where we go inside and ferret around to get your bowels out and things, that can take a good couple of weeks. 

We try to keep people in hospital for as little time as possible. So, even after a really big sort of esophagectomy, which is where you have to go in the tummy and in the chest, two big cuts, and take a big portion of your oesophagus - which is your food pipe out - and join everything back together. It's very high risk. You can, in theory, go home as soon as day eight or nine after the operation, but that doesn't mean you're fully recovered. So, getting to go home doesn't mean the recovery is over. It just means we are trying to reduce the complications we can give people in hospital. 

When you're at home, you can get much better walking around in your own environment. You encourage people to walk, so people in hospitals think they should be in bed all the time - definitely not. You're at less risk of hospital acquired infections, and other complications of being in hospital, blood clots and things like that. So, we always try and get people home as soon as we can, or we can send them to somewhere like a rehab place in the meantime, if they're sort of older and more frail, so that they're in a less high -risk hospital environment but getting more physio support. 

After say a bowel cancer operation, in theory if it's robotic and it's simple, sometimes you can go home after two days - but it can be sort of eight or nine days, depending if you have a complication after surgery or if you're in a lot of pain. 

So, the recovery is definitely based on the operation, the type of operation, and what happens. Keyhole operations and robotic operations - you are much more likely to go home earlier if you don't have a complication than an open operation, and that's mainly pain related, as well as sort of complication related. 

What is the difference between operating on a child and an adult?

The parents are 100% the difference. So, you need the parents' consent and that can be tricky if parents disagree. You only need one parent to consent for an operation that has parental responsibility, so it's on the birth certificate of the child. But, you can get problems with parents disagreeing about whether they need an operation or not. That's one of the first steps - the consent process. 

Children are smaller, which is one fundamental thing. That doesn't mean you have to do things differently,  so you can still do a keyhole operation down to about a two year old - is the youngest I've seen someone do a keyhole operation on. But under five, it's much more risky, and much more complicated. So, in a general hospital that doesn't have paediatric surgeons, or children's surgeons, will normally do appendix operations on children who are five or above.

In under fives, they'll normally go to a specialist paediatric surgery unit because they're better able to deal with the complications of operating on a really small child, and their anaesthetists will be able to cope with very small children. You have to be really careful going into their abdomen because they have much less fat, so everything is very close together, and you don't have very much space. So, you have to be very careful when you're putting in your first port around the belly button. So, when you're first accessing the abdomen, you're doing it without being able to see what's underneath -so you have to go very carefully, and there's different manoeuvres that you can do. You can sort of pick up their abdominal wall, in order to very carefully go in so that you don't damage the other structures around it. 

Children have bigger bladders as well, in comparison to the size of their abdomen. So, we always tell people for an appendix operation to go for a wee beforehand, so the bladder is out of the way. But children, you can't rely on them to do that. Sometimes you have to put a catheter tube in their bladder just before the operation, to make sure that their bladder is out of the way. If you have a bladder injury in a child, it's obviously quite significant and they'll have to go to a specialist unit. So, you have to be really careful where you put your ports, where you put your instruments. 

It can make it easier, so there's less fat and stuff inside the abdomen, so it's easier to see things. But, you've also got to be really careful because any complications are much more severe for a child. So damage to a child's bowel is extremely serious. Often, if they're very, very small, we mainly do it on the height and weight - so if they're very small for a child, then we will do it as an open operation, rather than a keyhole - because an open operation is much easier, and with a child can go right over the appendix, as there's not other stuff in the way and you can do it much simpler. So, if they're really small and very young, we will do it as a planned open operation, rather than starting with a keyhole. But, it's mainly about there not being as much stuff in the way - so you just have to be very careful. 

Adults can be tricky as well. So, you can get really thin, small adults, and you can get really big adults, and getting into the tummy of someone who's over 100 kilograms, who's really big - is a different type of challenge. So those are the main differences. 

What does the belly button do?

So when you are a baby, before you come out, your belly button is where your main blood vessels go from the placenta of your mother and they carry oxygen and nutrients through the belly button into the foetus. So their lungs aren't functional yet, so they're not breathing, they're just surrounded by fluid. 

In order to get oxygen and sugar and everything from the placenta and from the mother, the blood vessels run through where your belly button is. When you are born, you can breathe and you can take things orally. So you don't need the belly button to do this anymore. So the belly button, where the umbilical cord is, that's clamped off and cut when you are born. Those blood vessels are still there, but then they sort of shrink away because you don't need them. The umbilical sort of stalk falls off this little remnant after the cord's cut and you're left with this little usually inner or outy. 

But because of where those blood vessels used to be and where they go away, that is the quickest point of access into the abdomen because that was where things went into your tummy. So when we use it for keyhole surgery, we know that the little stalk connects to the sort of muscles and the layers of the abdominal wall.

So it's the point where everything else is usually out of the way and it's the easiest point to get into the tummy. People can get little hernias through the belly button because there was a weakness there, they're sort of closed up. So babies can have those when they're born. It's normal to have those when you're born and normally they go away and by the time you're about two or three, but sometimes they don't go away. And then we have to fix them, which is fun. But that's what we use it for - it's a physiological use up until you're born and then we use it as a bit of a bit of a cheat to get into the tummy. 

How do you prepare for surgery?

It's important for both us and the patients to prepare for surgery. So, part of us preparing for surgery is when you see someone in a clinic, if it's an elective operation, you have to think about the approach of what you're going to do. So, part of preparing for surgery is definitely deciding if it needs doing - because any surgery presents risks to people. You have to talk through the risks and benefits with the patient, as part of what's called the informed consent process. They have to know all of the risks, all of the benefits, and want to have it done. 

We can make our recommendations, but ultimately the patient has to decide if they're happy to go ahead with the surgery if they are able to do so. If it's an emergency operation, or an operation that's for cancer, or something very severe, and the person isn't able to give their consent and able to say what they want, because they have problems such as learning difficulties, or if they have dementia, or cognitive impairment - then we have like an MDT process. Which is getting everyone involved and deciding what's in the best interest for the patient. 

Personally, before you go into an operation, you have to get them to sign the consent form, and in doing so, you have to say what you're going to do. You have to know what you're going to do - are you going to do an open operation? Are you going to do a keyhole operation? What are you going to do and what are the things that you might have to do?

If you're doing something simple, you will generally put what you're going to do. If you're going to do it as a keyhole operation, you always have to prepare for it to become an open operation, because you can't always do a keyhole. Then you have to figure out what you might have to do if things go wrong. So, depending which part of the body you're going into, you have to think about the steps of the operation. So before I go in, and start an operation, I'll walk through the steps right from where I position myself around the patient, which side am I going to be on, because you think about which dominant hand you use. If you're doing a keyhole operation, you think where you're going to stand, and where there has to be a screen. You have to be able to see the screen best to be able to coordinate with your hands. 

Then you go through each of the steps of the operation, what you need to ask for at each step, because some things need to get ready. So, if you need to put clips on something, some point you need to think when am I going to need to do that, when do I need to ask the nurse who's giving you the equipment to do that, and how am I going to approach this depending on what information I've got about the patient, whether you've got scans, what the patient's pathology is, what you're doing, and then you walk through the steps. 

Before I scrub up, before I get ready for the patient, I'll go through every step of the operation and then as you're going in often you verbalise what you're doing as you're going along, even if you're the most senior person in the room, just to sort of make sure you're doing everything at every step. Patients prepare for surgery as well, so especially big surgeries. They go to things like surgery school, so that they're at the fittest they can be beforehand. It's a process, we'll get it right first time, which means if a person is as optimised, and as informed as they can be at the time of surgery and everyone's the most prepared - it's less likely to go wrong. 

How do surgeons and anaesthetists work together?

It's very important for the surgeons and the anaesthetists to work together. There is always a little bit of friendly banter between the two. They are saying that they're not putting them to sleep quick enough, and them saying we're not operating quick enough. But when you have a really good surgeon anaesthetic team, when you work together and communicate, it makes everything run so much better. 

So, the anesthetists, we ask them if they will put patients to sleep. So if it's an emergency setting and someone's a bit older, more complicated, we work with them to say, this is what we want to do. Are you able to put them to sleep for us to do that? Sometimes they'll say no, and then we'll say, OK, so we can't do that operation. Then we have to make a decision about what the best thing to do is. Often they'll say we can do it, but it's really risky, in which case then it helps us to counsel the patient. But then they can establish the best way to put them to sleep. They're really important for pain management, so they can do procedures before they go to sleep, or while they're asleep, or after they wake up. In terms of they can put what's called an epidural in, or a spinal anaesthetic in which gives better pain relief for big operations afterwards. So we need to think about that. We need to tell them what they're going to do so they can try and anticipate what to do from that perspective. 

They can also suggest to us that we can do operations that aren't putting people to sleep, so we can put them under a different type of anaesthetic whether awake but paralysed, or under a local anaesthetic for higher risk patients if they are more likely to have problems with the general anaesthetic. Then during the operation, they tell us if they're concerned, if something we're doing is causing their heart rate to go up, or their blood pressure to go down, then we have to speak to each other to try and make sure that the risks to the patient are as low as possible throughout. 

We also, we work together electively before the operation and especially in emergency settings when the anaesthetists are covering different specialties, we have to communicate with them to make sure that their patients are coming, and getting prepared as quickly as possible to reduce the time between operations that people are sitting around waiting for things to happen. 

So when you have a good anaesthetist and a good surgeon that work together very well, it's great. If there's a little bit of animosity, then it doesn't work quite so well. But it's nice in the elective setting often for a list on say a specific day of the week, it'll be the same surgeons, and the same anaesthetists, and they've seen the patients beforehand. So, that's much better. That's more common with sort of cancer lists and big case lists. With day cases and smaller lists, then you often get a bit of a mismatch in difference, because those patients are high turnover. But we love our anaesthetists, and hopefully they love us as well.