- I did the world's first brain surgery in a bear,
in the rainforest, using a mattress pump in an emergency
to complete the operation.
I've anesthetized hundreds of seals,
many of which have tried to commit suicide under anesthesia.
And I did the world's first keyhole appendix removal
in a sick, wild orangutan.
I'm Romain Pizzi and I'm a wildlife veterinarian.
- [Presenter] And Romain has given us unique access
to terabytes worth of his own self-shot footage.
Here we'll be covering three different surgeries.
- Not only were we having to perform
the first brain surgery in a bear,
but it was also in a jungle, in a very undeveloped country,
and having to fit everything we could possibly need
in two suitcases.
Champa was a rescued moon bear in Laos
that was confiscated as a tiny cub.
Now she had quite a swollen head
but she was behaving normally when she was tiny.
- [Presenter] But as she got older,
rescue workers started to suspect
there was something wrong with her brain.
- She stopped being able to see,
she started to have a lot of mucus draining from her nose
and she moved very, very slowly,
and that's when they contacted me.
- [Presenter] Romain thought Champa
might have hydrocephalus,
a condition where fluid builds up inside the skull,
crushing the brain.
- Now there's no MRI in the whole country
when we had this case,
so we had to figure out a different way to do this.
- [Presenter] So 9,000 kilometers away in Scotland,
Romain had to get creative.
- I've got a bear skull and actually took x-rays of it
so I could plan where would be the closest place
that I would be able to access her brain.
So I poured some latex on the inside
and made a mold of what the shape of the brain is
and then planned on the computer
how I would approach the brain
if this was water on the brain hydrocephalus.
Probably the biggest challenge of the whole endeavor
is flying to the other side of the world to do brain surgery
without knowing if you've actually got the diagnosis right.
- [Presenter] His first step was an anesthetizing Champa,
and even that can have catastrophic results.
Too high a dose could be fatal for Champa,
too little could be fatal for Romain.
- I have had a bear wake up on me
on one occasion when I was operating
and I wasn't finished yet,
and it started to shrug itself on the table.
And that can be quite a scary incidence
when you have 150 kilogram, really quite dangerous animal
waking up and you're not finished suturing.
Now Laos is obviously a very underdeveloped country
with limited facilities even for human healthcare.
We're not going to be able to get a vein
and put a little catheter in,
as you could do in a pet or a human patient.
We need to dart our patient.
So the safest place to dart a bear is in the hind muscles,
so the back leg, in the top of the leg.
Basically it's bum.
- [Presenter] With Champa darted and asleep
Romain drilled a tiny hole into her skull,
and the diagnosis was correct, hydrocephalus.
Hydrocephalus is a common condition in human children
and easily treated
by draining the excess fluid down to the abdomen
using a tube.
The body then absorbs the fluid.
- But, obviously, a bear's not like a child
and will climb trees and rub itself, and has sharp claws.
- [Presenter] Sharp claws that could rip the tube out.
- Catastrophically the brain could either collapse on itself
or the shunt could actually block.
So we buried this little shunt
just behind the base of the ear
so it wouldn't be able to get its claws there.
We could make a very big incision and put the tube in,
but then the bear would risk opening this
so we want to do everything by keyhole surgery.
Keyhole surgery is where we use
specialized, very thin instruments
so that we only end up with tiny surgical wounds,
and we use a special surgical telescope
to be able to see inside the body while we do it.
Now the anatomy of a bear skull is really different.
Bears have a big sinus on the top of their head,
that's a big air-filled space.
So where you'd put your tube in an infant
wouldn't work in a bear
because it would disappear into the sinus
on top of their head,
and so we actually had to drill a little hole
much further back.
- [Presenter] With the whole drilled
and the shunt run down to Champas abdomen,
the team were on the home stretch,
until the electricity went out.
- So we borrowed a mattress pump
and what we did is ran that in very short bursts
just to put room air into the abdomen,
just to give us enough space
to do the last bit of the operation,
which we did very quickly, just to make sure
that we don't put too much pressure on the abdomen.
This is an ingenious retractor
which is only five millimeters,
and we can stick down the little tubes
that can go safely in the abdomen.
And then by turning the handle,
it will turn into the surgical equivalent
of a keyhole surgery hand.
- [Presenter] The surgery took six hours.
The next morning, Romain went down to Champas den.
After years of pain and eyesight problems,
Champa woke up and started to look at Romain and the team
in the eyes.
The surgery was a success.
- Every year, all over Europe,
many orphaned grey and harbour seal pups
need rescuing and hand-rearing,
and then they're returned to the world.
Now, one of the most common problems
that I see, as a surgeon,
is actually seals with a ruptured eye.
Now, I've anesthetized hundreds of seals
but they're still a really challenging patient
because they actually
try to commit suicide under anesthesia,
which is a bit nerve-racking and quite frustrating.
Because seals live in water,
we describe them as having something called a dive reflex.
If you hold your breath for a prolonged period of time
you'll feel that you need to take a breath.
You cannot make yourself unconscious by holding your breath.
As soon as you're gonna lose consciousness,
you will actually, your brain will make you take a breath.
Now that doesn't work with seals
because if you're diving under water
and you feel like you're building up carbon dioxide
or running low on oxygen,
the worst thing you can do is take a breath
'cause you'll drown.
So they have a whole range of different adaptations
that their body uses to try and get around this.
It slows their heart down and it changes the blood flow
through different blood vessels.
It'll dilate the blood vessels to the heart
and the brain and the kidneys, those vital organs,
but it will constrict blood vessels
to either non-vital organs.
Now the problem is, under anesthesia it can be difficult
to recognize and understand what's happening,
and the seal might go into these dive reflexes
and as we try and wake it up
and it runs a little bit low on oxygen
and a bit high on carbon oxide,
it actually slows its heart down and circulates worse,
and it dies.
And so these are things that we have to be very aware of
with how we anesthetize seals
and how we monitor them during anesthesia.
The simplest solution to preventing this whole dive reflex
is to actually breathe really well for our seals.
And all we need to do
is regularly squeeze the Ambu bag that we're using
to give oxygen and anesthetic gases to our patient
regularly throughout the anesthesia,
and that will prevent any of these reflexes from happening.
- [Presenter] With the seal safely sedated,
Romain must remove the ruptured eye.
- Once you take the eyeball out, what could happen
is their skin can heal down into the socket
and it'll end up with a little cavity.
Now that could accumulate little sea creatures
and all sorts of debris
if that animal goes back to the wild,
and we can't let that happen.
So to solve that, once we've taken the eyeball out
and before we close the skin,
we make a mesh of stitches across that orbit
so that when the skin starts to sink down,
it hits that mesh.
Now I can use the thermal camera
to judge how the eye's healing
and to tell if there's any infection,
because the blubber heals very differently.
So this is what my eye would look like.
Now you'll actually see
that my glasses will reflect infrared from the light,
but a seals eye can look quite different
especially if there's an injury around the eye,
or the eye has been partly punctured.
It'll radiate a lot less heat
because it's actually a smaller structure.
But I also have to be really careful
on how I suture this closed
so that it's watertight very soon
and the seal can go back into water
a day or two after its operation.
So Myria was a very specific case.
She'd been confiscated from a farmer
because she'd been raiding his fruit trees
and he put her in a wooden crate
and kept her like that for two years.
So she'd gone to one of the rescue centers
and she was doing really well
when she suddenly got very severely ill,
so they rushed her into the clinic and took some x-rays
and this is when they saw the nail.
This was a large metal nail
and no one could figure out where it was.
It looked like it might be just up her bottom
and she was going to poo it out, but the nail never passed,
and that's when I got involved.
Now, orangutans have quite a long appendix,
a lot longer than ours, and little heavy things like stones
and, in this case, the nail, will typically get lodged there
and they can cause a problem and appendicitis
and either puncture their appendix
or the appendix can rupture.
So now we know what the problem is, but our challenge is
how to do surgery so it doesn't turn into a disaster
because orangutans are probably the most intelligent
of all the great apes.
And that's really interesting,
although we may be more closely related to chimpanzees,
chimpanzees learn in a group
whereas orangutans learn on their own.
And so the youngsters will spend much longer with their mom
learning all the life skills
and they have a very problem-solving way
of thinking about the world.
But when I do surgery,
or anyone else does something like it
and they've got a little bit of discomfort,
their first inclination is to open any wound
and try and explore that.
Now that can be an absolute disaster
if you open up the abdomen
because if they open the wound and play with the intestines,
that will be fatal,
and that's why keyhole surgery is so vital in orangutans.
To make the tiny incisions that we are going
to stick our keyhole surgery instruments through
really taxes one's eyesight,
and that's why I use magnifying loops
to have a look at what I'm doing.
And that just allows me to see and keep sterile
without having my face right against the orangutan,
the tiny area that I'm working in.
- [Presenter] Orangutan's appendix surgery
is the same as human appendix surgery,
but Romain has to use even smaller incisions.
- In Myria's case, an orangutan, because she's so clever
and we were worried she'd open those holes,
I used even smaller instruments.
So these are even just three millimeters in diameter,
barely larger than a microchip needle,
and those tiny holes don't even really need stitches
and there's no chance that she'd be able to open them
or even poke a grass blade inside
to interfere with the operation after I'm finished.
Now, Myria had a really good outcome.
She were recover really quickly,
she almost didn't notice she'd had surgery
because those wounds were so tiny.
She was eating an hour after she woke up.
A couple of months later
when they were preparing to get her ready
to go back to the wild,
they actually managed to foster a small baby onto her,
and she was great and she took this little baby
and looked after it and started to teach her things
and when they released Myria back to the forest
she took the baby with her.
And they've been monitoring her the last few years
and it's almost five years now
that she and her now quite large infant that she's adopted
are doing really well.
So that is something really deeply satisfying
that the operation
actually resulted in such a happy outcome.