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BBASS | Surgery Series: Homing Surgical Skills



This on-demand teaching session, presented by David O'Regan, a retired cardiac surgeon, will teach medical professionals the fundamentals of surgical skills. It will also impart the parallels between martial arts, sports, and surgery, provide insight into the concepts of posture and set-up for a successful procedure, introduce the importance of rhythm, and discuss how to avoid physical strain while operating. Attendees will also have the opportunity to ask questions, receive an attendance certificate upon completion, and interact with other professionals.
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Learning objectives

Learning Objectives: 1. Understand and identify the similarities between martial arts, sports, and surgery. 2. Learn to explain the importance of the diastolic interval in surgery compared to the fixed systole. 3. Practice proper posture and setup for a variety of sports activities. 4. Analyze how posture, set up, and proper posture are essential elements of surgical performance. 5. Demonstrate proper form and technique when using an ironing board.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone and welcome to um our second event today. This is the wonderful David o'regan. He is he champions B bath and surgical skills. He is actually one of my favorite surgeons on the platform. But don't tell him that cos you'll get big headed. Um He is gonna take you through loads of surgical skills. You're gonna learn so much today, but we would love you to type in questions as he's teaching, you type them in. I'll ask him those questions. He can go over things again and again and again, please make him work really, really hard today cos he doesn't do that much. Um So I'm gonna pass this straight up to David right now. Feedback will come after the event which we'd love you to fill out and then your attendance certificate will be on medal. All right. So over to you, David, thank you very much. Su thank you to everybody joining and thank you to all the followers of the Black Academy on Facebook on which they're 4230. And on Instagram, 657 we are on social media. So do follow us and I'm live every Monday evening talking about the details of basic surgical skills. I'll just say in advance that I'm using a yeti microphone outside on a lovely Indian summer afternoon in a caravan park in Yorkshire. You'll hear twitting birds, you'll hear some tractor movement. If it gets too much, I'll have to switch a microphone over to lapel. But Sue will advise me. My name is David o'regan. I'm a retired cardiac surgeon, the immediate past Director of Faculty of Surgical Trainers, and a visiting professor at Imperial College London. I may have 23 letters after my name and degrees and Ph DS and things. But this is the degree that I feel is most important to me. I'm third down in karate. We rou now which I got in September last year and second down in. But I've been teaching basic surgical skills on a cardiac class for 23 years and thought about what I was teaching and thought about my own journey through martial arts. And it's the parallels between martial arts, sport and surgery that I think are underestimated and not realized. The first thing to say if you are familiar with cardiac physiology that there is a systole, which is the contraction of the heart and there's a diastole, which is the reaction. So in the chat room, anybody tell me as the heart gets faster, what changes is it diastole or systole? You've got a 50 50 chance here. What you going to call. So throw it in the chat room so you can call it out. So you're interacting with us. So have we got any answers? Not yet? OK. This is an interactive session. We'll be asking questions as the heart gets faster. It's the diastolic period that shortens the actual action, the squeeze stays fixed. So the rhythm of the heart throughout is regular and all it does is speed up and it speeds up. Not because the systole is short, that's fixed. It's because the diastolic period is shortened. That is important because the time it takes me to do a stitch and the time it takes you to do a stitch is much the same. I wouldn't imagine there's much in the way of difference or range. By the time it takes me to do another stitch, for example, and you to do a stitch, there will be a wide range. And the reason for that is very simply understanding that diastolic interval and that diastolic interval in martial arts and in sport is mindset, preparing and rehearsing and planning what you are going to do. But also in set up. And when you think about it in all sports, swinging a golf club, batting, you set yourself up properly and all sport coaches teach your set up and posture in particular. But we don't seem to do that in surgery, which really surprises me because often the expert trainer said, not like that like this. But what they haven't done is explain this. And the this is more often than not is how you set yourself up. I've had the privilege of recruiting three new sensors for the Black Mail Academy. And per chance they all reached the Olympic level one and weight lifting one in track events and hurdles and another in archery, but also is a black belt in martial arts. And in martial arts, you start off with learning some basic techniques, then you put them into carters, combinations which translate into carters, which then give you the tools to defend yourself. But that's not martial arts. Martial arts is not a sport. It's called a study. Everybody plays sport, but you study martial arts in the same way, you study surgery. So this book is a classic text in the Japanese way of the sword and he was an undefeated samurai warrior in 16 43. I would just like to relate to you the nine principles that he exposes in the book. Yeah, think of what is right and true practice and cultivate the science. Become acquainted with the arts, know the principles of the crafts, understand the harm and benefit in everything. Learn to see everything accurately, become aware of what is not obvious, be careful even in small matters and lastly do not do anything useless. My man surgery has always been no hesitation, deviation, interruption or repetition, which was reducing the diastolic period. But there was a paper produced in the Jama that reached the New York Times that showed an operation laparoscopic. It was to a number of professors who had to rate it according to how smooth the operation was and how it flowed. And this correlated directly with outcome complications. The interesting part is they took the same study and showed it to lay people who rank them the same who can see the deliberate and purposeful movement. And that is it surgery is a deliberate purpose or movement. And as m mutu says, rhythm is something that exists in everything. But rhythms of martial arts in particular are difficult to master our practice. You change the word martial arts surgery, you'll get what I'm talking about. Rhythm is manifested in the world in such things as dance and in music, in pipes and strings. These are all harmonious rhythms and what I like to think that we are teaching the Black Belt Academy is rhythm. But also as I'll explain, there you go. Give you a tickle lightness of touch because we don't explain the why the how and the lightness of touch. So this all comes back to set up. And the first thing we always do in any sport and I'd like you to put in the chat room or the sports that you play or, and two just call out some of the sports for me. This is an interactive session. So hit those buttons and cue them. I'm standing back from the screen so I can't read it. And sue will ask what sports do you play? What hobbies do you have that involve motor skills? So, can you call some out? Yeah. Rink, you says tennis? Good. Anyone else? I think my skill is throwing the ball on the beach for my dogs. Right? But there is a position and a body position that you have to assume for a forehand shot. You're on your right leg or back on your left leg and on a back hand shot, you're on your right leg and that's not too dissimilar in surgery. When you're stitching for forehand and back out. We've got a couple more David. Yes, we've got badminton, uh soda says badminton and Musa says football. Exactly. And with all of those, you need to be balanced and on your right foot. But also with a racket sport as we'll come to later within the racket and the badminton racket, there's a sweet spot. You know, when you hit a bad shot, it hits the wood and it comes off. But without effort, a good shot seems to just happen without effort. And on our power course, we take candidates to a golf lesson afterwards to reinforce the grip, the address the stance and position, which are intrinsic, set up principles of golf. So the next question is we did a study, I've done a study which submitted to the general surgical education, looking at all the basic surgical skills adverts. And there were 100 and 10 pictures and 100 and nine people are actually sitting down at tables as if to eat. Now, the problem with that is, and I will demonstrate is that the angles are wrong. Very few surgeons sit down to operate neurosurgeons, plastic surgeons, u gynecological surgeons and may be microplastics surgeons. But they usually sit down the stools, they go round and round and up and down. They don't sit at fixed tables. And the thing is when you have a fixed table, your elbow and your wrist at the same level. Yeah, 27% of surgeons going through their careers will end up with musculoskeletal problems. And that's because they are not addressing the posture or the ergonomics of operating. So a question to you again. Now I want you to be quick on the typing in your answers. What table do you use at home? Goes up and down and what function? Oh, domestic chore do you do at home that requires this table? And it's laborious but you do it anyway. Any ideas? Yeah. So any answers? No, but I do know the answer to this one. You do know the I do. I hope you all recognize what this is. Ok if you don't. Um I suggest you do because otherwise we have a very lonely life and everything will be creased. We talk about smooth, we want smooth iron closed, but very simply when you think about it, you don't iron up there. You don't iron down there when you're up here, you have fixed your scapula, fixed your humerus and you're using your trapezius, your pectoralis, your, lets dorsi your supraspinatus muscles involved. You're actually increasing fatigue. When you put it down here, you're losing your lumbar lordosis and you're causing back and neck injury and 27% of people surgery end up with back and neck problems. So any answers yet to the table that goes up and down at home, I've given you a clue. It's your ironing board. You wouldn't set your ironing board up here and you wouldn't sit it down there. Did anybody get that too? Yep, John got it. And rink, you said that she doesn't have an ironing board is hers broke. So she uses the breakfast counter, but that doesn't go up and down. Right. That doesn't go up and down, you know, and ironing board from in the UK from Bilko Argas BS are closing down. So probably giving away ironing boards. That's important. But the relaxed position is from the side. It should be a straight line between the tip of your head, ear, your shoulder, your hip, your ankles for every two centimeters that your chin deviates from the mid line, you're adding two kg to the weight of your head. So when it's eight centimeters from the head, what you're going to have is an extra 19 kg to your 10 kg head, the shoulder zero row forward, the back goes there you lose your lumbar doses and there you go. That's where you got problems. So you do need to stand up, keep your amyloidosis and incline your head. And I came across the prism loops the other day that a periscope, you can look ahead and it's looking down and they're quite innovative because it's maintaining your neck pain and maintaining the neck position. So in this position, we have actually got the shoulders down, our elbows are by our sides, the elbows s like down the hands. Oh Well, what is isolating the intrinsic muscles of the heart? And what do you think are the most intrinsic, most important and most unique intrinsic muscles of the hand? And Nku you cannot answer because you have seen this program before. So in the chat box, so call out, what are the intrinsic muscles? Come on everyone. I'm not medical. So I need your help check is not allowed, is not allowed. But she says she'll get a board, you'll get a board. Yeah, she'll get an ironing board as you're doing that. I'm just going to draw some surface anatomy on my hand to actually help you understand where this is only ring who has responded. Come on somebody. They heard how many people we got on the call? Oh Hang on. We have got, we've got 12 of us on the call, right? OK. I the 12 hang on. I got another one I can see. Uh So when this says, oh, abductor muscle polis, OK. All right. But it's the intrinsic muscles of the hand. So, what muscles am I holding up there? What have I just drawn on my hand? Does anybody recognize those? And green? Those are the lumbrical. And what's unique about the lumbrical is life sperm like is that they're the only muscles in the body without a bony origin or insertion. And the action is simply to do that is to flex the phalangeal carpal joint and extend the two interphalangeal joints and do that. Yeah, you're doing that. That action, which famous cartoon character relies on that action, please. Anybody right. Who does that? Oh, yes, I got it. Is there an audience out there, sir? I think there is anybody it's with the frog? Oh, I was going to say give us some clues, Ham with the frog. Famous. All right, does that and what is unique about that together with the opponent's pollicis which brings the thumb together with the finger. That is what we're looking for in surgery, extension of the interphalangeal joints and bringing the pulps of the fingers together. So you got maximum surface area, you actually get more sensory input from the pulps of your fingers than you to the brain than you do from the eye and the movement you feel, imagine that you're sprink a little bit of salt onto the food and you're doing that, that is all you need. So the posture of standing is actually isolating those muscles and bringing that fingers together and maximizing the seal. And there is the other important part of the Black Belt Academy. And what they don't teach you on basic surgical skills courses is the field, you know, holding the badminton racket, holding the tennis racket. There's a specific grip as well and you don't grip it tightly. You hold it in a particular way and you feel the ball and there is a sweet spot. So the lumbrical high five are the best muscles because the, as soon as you do that and flex them, you're using forearm muscles and we'll come to those when we discuss forceps and I've got a model to show you. So as we go through a number of things this afternoon, I'm giving you a flavor of the basics of what we teach on the Black Weld Academy and hopefully stimulating you to think about how you set yourself up, how you mount your needles and how things work. So the first thing I'm going to do is talk about the needle mount. OK? OK. The needle mount and we're gonna bring it over to the top on the camera and just demonstrate a few important principles. The principle is, and we'll focus on stitching first as in all the needles 50 bit maty, all needles are made on the circumference of a circle And for a stitching point of view, you need to take the needle through the tissue such that if you did a tangle slice at any point on that circumference, you will see a perfect circle and a thread in blue filling that circle. If for any reason you take it through incorrectly entry, exit, pass it through with inadvertent movement, you'll end up with a space between the red and blue and the space here and green. And that space is a spurt and a vascular anastomosis or choses. But also the beginnings of a micro is in surgery. So the important thing is to know how to use your needle holder and how to mount it. So the first point to demonstrate and I'll come up again. Yes, too often or not. When you're past the needle, the needle is mounted like that. Now, when operating at depth, mounting the needle at 90 degrees, the cross there is inappropriate because the needle holder, the wrist are lower than the elbow, if you're sitting at a table doing basic skills, an elbow at the same level. So therefore you can have your needle at 90 degrees. And I'll demons demonstrate this by sound. I've mounted the needle out like that. And too often when you get past the needle, people use this and take it as is to use. But if I'm operating at depth and in a hole, I take it down and I'm hitting a plate, what you have to do is angle it out. Can you see that angle there? That angle is the angle between my forearm and the horizontal. Now, if you draw parallel lines on a diagram, your I GCS E maths on parallel lines and angles prove that that has to be angled out. Now, if I take it down the belly hits the surface instead of the the needle, why this is important? OK. Next question for the box, what is the perfect angle? Can anybody tell me what the perfect angle is? Yeah. Any answers in the box? Not yet. Come on, Pete, what's the perfect angle? Just look around you and no matter where you are, you are staring at the perfect A as we speak. What is that angle? Look at the door, look at the picture frame. And who described that angle? I have 3 60 I've got 90. Well, it goes to the 90 degrees, 90 is the perfect angle and it's the fourth part of the circle. Why that is important? Because how we got geometry where you got to take a needle through the tissue, it's gotta go through on a circle, it's gotta go through perfectly. You got a curve needle. So how do you set it up? You set it up and making sure that you are 90 degrees across what you want to stitch and then 90 degrees into what you want to stitch and why 90 degrees is important? Because every angle opposite is 90 degrees. And when I showed you that belly bounce just by putting it at the tip of the needle, angling it out, the belly's there, you can see the belly hitting the plate and in sagittal plane is 90 degrees to the tissue. OK? And the sale minus 90 degrees. So the simple role in stitching to get it 90 degrees is you place your needle and your alignment is 90 degrees across what you want to stitch. So no matter how big, how small microvascular macrovascular aorta coronary vessel, your knee or big the needle is, your needle is 90 degrees across what you want to stitch and you place your needle down to show that it is 90 degrees across what you want to stitch. This is a setup. So golfers would line things across the plane, they were going to stitch 90 degrees. All right. And that alignment allows you then to think about your body posture. So with the badminton and with the tennis, you now got to think where it is and how you are going to take this through. So I can deviate slightly and just give an example. Well, we like our domestic engineering classes here. I've got a reg nole does everybody still on buttons? I hope that's a thumbs up. Use thumbs up in the box, please because everybody's still on buttons, lots of thumbs up. So I hope not as many as I'd like to see. Oh Yeah. Yeah. So we, we all use Velcro jelly. But the thing is, there's a and left with material like that and you know, if you try and take a needle across the tissue, like stitching on the button, it doesn't go. Whereas if you stick it in at 90 degrees, it goes easily through the wa and left that is the same with the tissues and going through at 90 degrees. So, not only is it going through easily through the tissue, but your alignment is that, which enables you to take this further. So there you got it, then you got, all you got to do is put your needle down. Is it 90 degrees? So there's three parts to the pickup. Often people let the, let the needle drift and I'll focus down. Often people let the needle drift. OK? And this is very important is this pick up and there's a simple rule of 12 and three. OK. I know before somebody even makes a stitch, whether this is gonna be good or not because of how they mounted the needle. The wa shaft of the needle is the middle bit here. You never put it near the point and you never put it near the way. And your pickup is just after halfway, just after halfway there and it ought to be at the tip. So just after halfway at the tip and it's at the tip. So there's no space between the shaft of the needle and your finger. And no, you will never stab yourself. And if you're mounting a needle again and correcting it, put it against the palp of your finger and come in at that angle and you set up properly, there's no space and there you go. That's the angle. So it's one just beyond the halfway two in the sweet spot as in the racket at badminton just down there and three angled out and there you go. I've got a sagittal plane and I know you see the belly of this is pushing the cloth in the table away. And that I actually use the belly in coronary vessels because I can use the belly to push the wall away. The thing about this is that as people are stitching, you will find that this migrates and does that and people forget to address the angle. So now I want to tell you why it is important that you got to hold your needle holder in a particular way. Does that make sense? So there you go some geography for you. So we advocate in the black val calamine to hold your needle holder correctly and then holding it correctly to you, hold it correctly. So you can affect the perfect rotation. And the rotation of the forearm is around pronation, supination, which is from the common flexor origin to the point between the index finger and the middle finger where the radius folds over the ulnar. Now, if you actually put your fingers through this and I'll demonstrate the rotations I put in the straw on there and hold it towards you my wrist and elbow at the same level. So I can make it 90 degrees, but I'm going to rotate it back, that's pronation and you can see the angle there and I'm gonna supinate all the way around to that angle and it's probably about 200 or at best 100 and 90 to 200 degrees. Ok. At best, what we recommend is that you palm your needle holder, so you place it in your hand, fold your ring finger and baby finger over the needle holder, extend the index finger down. Now you've got a palm and you automatically do this, then you're using a screwdriver. Ok? So now if I show you pronation, supination and I think you will agree that I'm getting almost 240 degrees there. All right. And the tip of the needle holder is staying steady. So how do you practice this? Do you need a needle holder? Place it in your hand and you use your abductor pollicis to take it on and off. So, what I want to hear from you is I take it on and off and that takes weeks of skill, but that's giving you that extra, extra feel and process and anybody with any size hand can do that. The thing is that many people actually stick the dip joints through the holes and that not only is limiting the movement but, um, you see, now it's stuck in my hand and I can't get rid of it or put it down where I'm holding it like that and you put it down and I can pick it up with ease and we're ready to go. So how can we actually practice these principles at home and reinforce what's involved? Mhm OK. Behold the potato. He just said a man who likes potatoes must be a jolly good fellow. I think Ts Elliot said that this is a microwave rotator. You microwave it until it's soft. You can see the skin is soft. All right. And then I'm going to actually put it in a pudding basin. The ridiculous thing is with much of what we do in surgery is we operate in depth, but I'm sure you have probably found the basic skills courses that you're sitting down and the food is on a plate in front of you as if to eat. But we're always operating in depth. Now, health warning, microwave, potatoes are awfully hot. Do not burn yourself, make sure you put it down. But now let me show you something to actually help you with this practice. So I've put the potato in the dish. All right, I am now working at depth here. I'm working at depth. All right. And I'll use the bigger needle. So you can see it or focus down even further. And I've drawn some lines and why not to help me align 90 degrees across what I want to stitch. I'm rotating back. So I say place 90 degrees across what I want to stitch. I am now gonna pronate and rotate this back and in doing so I'm using my abductor poly to unlock the needle holder and I'm now pointing into what I want to stitch and uh continue to rotate around. And the rotation is iterative. And what I should be able to do is come out in the, the opposite. So if the view is not good, I'm watching the model, you can watch the screen and advise please but notice the rotation's good because the needle has actually come out of the tissue ready to pick up again. And I can use the forceps to deliver it just be un healthy, pick it up and Walla I'm ready to do it again, but I've lost the angle. So I need to angle it out. The thing about the potato is if I do it badly, it actually tears out. OK. If I just do it badly and pull it, it tears the skin. What's nice about the potato is the hemisphere you get that side, that side, turning it around to do it this side. This is the angle of sorrow in cardiac surgery and to take it out and what you're finding you're having to do is if you place your needle 90 degrees and I'll mark it. You have to adjust your body position to know that can happen. David, could you bring your bowl down a little bit towards that the other way? Yeah, that's per, that's a better. Yeah. All right. So there's another model to use. Ok, because I'm conscious of the time and we're going to be moving on. So, my favorite model here is the banana. What I like about the banana. Is it totally different to all other tissues? Is the fact that it gives you the feel. But also when you've got a problem, it actually shows up. So there's a linear incision. I am drawing lines across the banana with a bit pra OK? And 90 degrees across 11 stitch, I rotate it back and I make sure that I come out at the same point. And you can do this as a number of lines to simulate, continue stitching. I'm ready there for my next stitch. I picked it up and the angle was correct. And in doing so you see, I've just reduced the diastolic pill because with practice all I'm doing and I'm rehs on the angles. I know the set up slightly off from that point. OK? And take it out. That is not going to work for me. I've changed the needle position so I can get pronation and supination correct in and out and you can practice a continuous suture on a banana and because the two layers are together, I can do it in one once you've got practice doing that and you can see your alignment with respect to the line. Put a dot Either side, see if you can hit the dot And I've gone there, I've gone in the dot And not the dot Take it up, pick the needle up ready to use again. And am I actually hitting the dot Each time? Ok. And you can go up and down this each time and practice because if I focus in closer and I'll bring, come back to this, you can see the exit wounds where it comes out. So the banana actually goes black at that point. So you can almost play doubts. I've gone through exactly the same point last time or slightly off. That's better. That's right on the line. And as I'm practicing this exercise, I'm actually saying to myself and lying on the place point, rotate, it can go up and down. Yeah, you try it yourself. And for some reason, I'm just missing the line there. So I know I have to think harder in practicing. That's skill. But I hope you can see the exit mark is clearly delineated by the banana going from yellow to black. So that's a linear continuous suture because what happens is that the angle when stitching of the needle holder changes and it goes back to that. So what do we do for going round in the circle. Well, think about a clock in all anastomosis. We talk about a clock and to be 90 degrees when stitching around in a circle, you do need to make sure that you are on the right, correct position. So I'm standing at six o'clock, that's 12 o'clock, three o'clock, nine o'clock. So geometry again, the radius touches a tangent and 90 degrees at all parts of the circle. And you've got to ensure that your knee is actually all the way at 90 degrees. But as you're coming around here, you'll suddenly realize in this position for me. So it operating between four and five o'clock, about half past four, I'll put that across there. I am now stitching towards my shoulder and this is the most difficult stitch you could possibly do in surgery, stitching towards your shoulder in this position. I find myself in the right hand stitching into my right shoulder. I now I have to go back out. So I switched my weight to a solution to my back foot, my left foot, and I'm going backhand and now I can go backhand and my weight now goes from left foot, changing weight all the way round 50 50 weight distribution towards the right foot and always diagon the opposite. That becomes a difficult backhand stitch again and have to change the position. And what I've just seen if you're watching closely is demonstrated that angle is also very useful to actually practice what's called sexy moves. I'm moving my needle forehand and back out. So it's literally dancing. So I can pro with the needle at the top forehand and back out and maintain that position at no stage. In this process, I'm actually using forceps to deliver the needle. So let's take that further, coming back to my banana model again. So now I've taken Apple co stand up to the banana and taken out a section and you can do the same exercise as we do with the straight line is a line or needle 90 degrees across what you want a stitch and take it through each time, pick it up 90 degrees, place it back and you point it in such, your needle is going into the lumen. It is not, you're not dropping the needle holder into the banana. So there I'm going to come to my back hand stitch change position and I've come to the back hand stitch here and take it out. Now, you don't need lots of sutures to do this. You just need a needle. All right. So this is low fidelity models cost friendly and yes, at the end of this, you'll feel hungry. You can eat the banana as they do between tennis matches just to maintain their strength and practice going round and round the banana to ensure that your alignment is correct. Your rotation is correct. You're not tearing the banana, you're delivering the needle each time I'm not using forceps. Yeah. Ok. And I'm not actually mushing the banana. So I have a scoring system on this and I've tried this skill at every level and it is extremely good feedback and determining how good your stitching is. Right thing is also you can feel the banana and as you go round and round, you can see the exit points, the exit points will come right down so you can see the exit points. You can see the exit points at the end of the line or where the needles come out. So you got feedback all the time on how that is working. So we are forceps. OK. Let's just come back a bit. We're going to come on to the next bit of forceps. So the forceps are there for a specific purpose. The forceps are there to help and excuse me, as a chat can set up at the same time, I turn to my side, a lot of models uh to help practice the forceps are there to hold and retract tissue and to expose tissue, but they are never there at work. Deliver the needle because that ruins the rotation. And I hope you appreciate the mathematics involved. So here this is what I'm talking about. I made an incision in the banana area. And along the lower edge here, you will see the bites of tooth forceps and on the top of it, you will see that's non tooth forceps that you would probably think are not causing any damage. But if you think again of physics, the pressure equals force of the area. The average pinched pressure of a person, there's about 25 newtons up to 30 newtons. And you're using that, you see, I'm now flexing my distal interphalangeal joints. So the cartoon character that has the biggest forearms, this Popeye and he's got the biggest forearms because the biggest muscle is in the forearms is the flexor digitorum profundus. And the flexor pollicis Longus that sits in the deepest compartment of the forearm and they flex the D IP joints. Those are the joints and that flexion that hold cliff climbers to the wall, it can hold your body weight. But you can imagine if you pinch like that and I'll show you pinch, you can see my fingernails blanch. I can even see that through gloves. As soon as you flex your dip joint, you start pinching and you get 25 newtons and that 25 newtons over an area which is the end of the forcep. And let me get a smaller forcep. I'll take the end of that forcep area that I'm holding. That area is at best five millimeter squared, which is five times 10 to the minus six m squared into 25 newtons gives you 5 million newtons per meter squared pressure. And if you look at this, you can see on the banana on the skin full thickness crush, you will do that to barrel to blood vessels and cause a total massacre of endothelium by crushing this. And that has been shown histologically, the problem with the forceps is that people often grab them and pinch them and hold them like pens. Sometimes they hold them like solid servers. The way to hold the forceps is to balance it in the first Interros space and then fold your fingers around and then folding your fingers around the, extending the dip joints and bringing the pulps together. That is what is required to do the job no more and no less but it needs precision and control. So our next exercise I'll bring you over is very simply this and you can make Friday night games out of this and competitions. It is rather fun. I have got here some bendy straws mounted with a blue blue tack on a plate. I have a question and yes, rink you asks um forceps. One plastic surgeon suggests to use one part of the tooth forcep to just retract the dermis and not touch or pinch the e that is exactly correct because in fact, what plastic surgeons do is use a hook and they lift up the edge. You just use the tooth forcep, literally lift the edge up as you quite rightly point out is that's the tooth forcep. I'll focus in on that. You can see there's a little tooth there, the rat's tooth and it interdigitate with the tooth, the other side that literally is biting and that's what you saw is that bite mark there. So when you're using a tooth forcep, particularly so in the skin, just use it as one sided as a plastic surgeon would use the hook. And thank you for that prompt Winkle. I was coming to that. There you go. So you're not actually crushing it. The problem is when people are using and focusing on stitching, the left hand grabs drifts and drags. So I've got a number of exercises. If you look online on the metal platform and Blackout Academy, it can show you how to practice, but you're using the forces just to lift the edges, never ever grab it, the, grabbing his bow. And I looked again in those pictures and in 59 pictures, I could see forceps, 73 of them were holding forceps and 30% of them were pinching and these were sessions even run by a professional societies. And I think we are not teaching the basics of surgery correctly. I, I worry and that is why we've got the Black Belt Academy. See here, I've got rice grains. You see the rice grain, the length of it is longer than the diameter at the end of this bendy drawer. So I'm gonna have to move my hand around to pick it up and drop it in. They had this competition at the aet meeting. They invited people to come in and had four stores like this. Eight grains of rice against the clock. They had to put in rice grain into each drawer. The fastest, I don't teach speed because it's accuracy and precision. The fastest was 15.4 seconds, eight grains of rice into the straws. Remember your Forceps skills has to be right hand and left hand and simply doing this is improving your accuracy and precision. We can go further. And I'd like to have examples from you wherever you are in the world and how to use different material. So we can make it easy by pulling spoons out and simply putting it out into spoon, one a two. But you've got some fennel, some mustard, some pepper and coriander seeds here. And you can put a forcep in both hands and do it at the same time. Pepper seed and some pepper. PNL seed and fey mustard seed. These are very tricky and small and coriander seeds. Yeah. Final seats go to the left side. And the general principle in surgery, you shouldn't be crossing your Me M line and must it CS come to my left. You can see they're tricky little things pepper to my right and coriander to my right. And again, this is actually helping you with precision in pickup because if you grab them, these go flying across the dish become very difficult to hold and use. So I'm conscious that we are actually time is flying as we're having lots of fun and introduce you to the other because very often we are actually working in depth. So just taking a pepper and look at all these seeds here, picking them out, gently picking these seeds out. And you can put a straw either side and again, right hand and left hand, pick each seed up and drop it in the straw on either side. Again, you are practicing your fine control Sura in Baghdad after this model and I've overcooked it. This is a boiled potato and often in surgery. What we are doing is having to lift layers off. So this is teaching you lightness of touch and peeling layers of potato broth without actually tearing it. Can you actually peel the layers of this boiled potatoes without crushing or tearing the skin. And thank you Sirrah and Baghdad for this model. I think it's wonderful. It is difficult and challenging but surgical low fidelity models need to be difficult and challenging if we are going to master our skills. Note that I've always got for trying to maintain extension of the dip joints. If I don't pick it up properly, I ain't gonna be picking up potato. Again, this is accuracy and precision practice pulling layers of a microwave potato. So, forceps are very useful as well, particularly for an assistant you can use as a fog to hold and support if you are coming into a surgical environment with an instrument and you feel your hands are unsteady, take a forceps on the other hand and use it to balance sense, which brings me on to the next siss. Well, this is an example of the Japanese art of cutting with a pair of scissors. We cut pieces of paper when we at nursery school in the kindergarten. But can you cut like that? The important thing is is that we actually think about how we hold the disease of aci it should be placed in the hand and I put my ring finger, thumb, middle finger, the index finger extended. Now note that my fingers are placed obliquely across the holes so I can feel it. I've got maximum pulp of my fingertips. 1234, the direction is controlled with my thumb with my index finger. And as I'm looking down my index finger because that's where I'm working. I'm looking a ro with the curve at the point. If I hold it the other way around the curve up, I can see the point but I can't see the belly. So as we hold this, I hope your homework, please and you, this is your homework for today's lesson. You're gonna find out who does anybody know the name of this person who made these scissors? Just put it in the chat room. Now any answers, Sirri, you, you can't answer no, no answers yet. No answers there. All right, ma and do so your homework, please to find out who Mac do is and having found out who Mac and do is from now on, you're gonna seriously respect the surgery and in doing so, flu tips of fingers, index finger down. So a simple trick that we also have in the black again, nothing complicated but awfully difficult because I've got different black and white shapes on paper and I gotta use the scissors and you never open up the scissors any further than necessary to do the job. And you need curve says is in a straight line to, can you take that perfectly down the line without leaving any white bits on, focus down. It gives you immediate feedback. You can see the white bit down or black on the other side. You can do the same the black circles and we had this in our scissors competition as well at the Acid meeting in Liverpool. And thank you to B BRA for their support and they actually printed out all this paper I'm still using for March. So the idea again is, can you, yeah, with accuracy and precision cut around the shape? Sure. That should accurately not leaving any black on one side and not leaving any white on the other side a bit. Can I ask a question now? I'm not medical but well and rink was asked one too. I'm gonna ask mine first. Sorry, Rinky. Um Why this is his curve? Because obviously Curves is a far harder to navigate because one of the movements of dissection is actually as we'll show you is developing planes, but you can scrape tissue towards you and it gives you that sort of gathering action. Yeah, because you scraping it towards you. You wouldn't be able to do that. You curva your wrist and curva that brings my scissors perfectly in line with the tissues there and you can scrape tissues and develop planes. So it matches the angle of the wrist and the angle of the forearm and the working posture that you are using. That is an excellent question that I haven't asked Mac do himself. All right. So I have a question from Rinky. What is the difference between? Oh Mac Makindo and Meen, I'm sure she just wanted me to try and pronounce words that I couldn't pronounce. But me and B can you see the difference? Can you see the difference? One's Makan one's mat BM. That's Mesen B that me do. And one slightly chunkier, the thing about all these surgeons at the time, they all actually lent their names to instruments. And so they should because they're actually amazing surgeons. So the difference is literally that the one I use, I like the dissection of these, the Nelson. This is yeah, much longer, same principle, reaching into the chest and they are great. The great thing is they got round tips and usually because they're not often used in theater, they are very sharp I use them for dissection on frequent occasions. So another two models to actually test your scissor skills. This is bought today from Morrison's and just a chita sausage. The thing about this chita sausage, it has got a skin and as that skin is actually represents, the fascia is, is that you'll find over the vessels had this out and I think it's been drying a little bit in the sun because I can feel it. But what you got to be able to do is insinuate your scissors along there. All right, I can see that underneath, develop a plane and you can cut once you're in the right plane, you're not actually cutting the sausage meat underneath. I can take my scissors off and a bit like cutting Christmas paper mu is, is a long tissue plane as I've done there just come out a little bit because so you should be prompting. Yes. So in doing so, then I can also use the lovely blunt end that I have with scissors, teas, sausage meat off that skin or something. And it's helping me develop that plane. I can use it as a, a fabulous object for blunt dissection. Now, there's an important principle here in, in using scissors and dissection, I can use the scissors underneath. And if you look carefully, I'll come down closer, our scissors is passing underneath it. You can see there's nothing between the fascia lay and sausage meat and that layer I haven't got any vessels or nerves traversing that. And as you're developing fascial layers, this is a good way of determining if you have any blood vessels or nerves crossing over. Well, you should know the anatomy anyway, but veins are usually don't adhere to perfect anatomy and a lot of variation and cut veins bleeded and don't die the and you have to tie them, putting your scissors underneath one of these, you can see it clearly, you can isolate it and tired, but I can never level and confidently develop the plane. So if you want to know how to practice your scissor skills and dissection skills and exposed vessels and tissue layers, take a sausage, anything similar to the skin and the the the layers. So the other part of the sci is the ability to separate and then separate. You worry when you open up, you are not tearing or breaking the tissues as you open and sometimes tissues are very hard. So here, could you bring the, by the way? Yes. Thank you. Yeah. So here the curb is going to help me feel my way around this tangerine. OK. The idea is to develop the plane without cutting the flesh underneath, got a little bit of blue underneath. But if it's coming off the blue, it just hold it differently. And my assistant would be retracting this, of course track as well. But I can use this to develop play. You see, I'm opening it up and developing the plane as a technology, you see the little adhesions of tissue adhesions as this is coming off, my assistant will be holding this and enable me to develop. You can now see you asked about the curve. The curve allows me to dissect around objects that the curve since we've got bow and tubes and everything else in the body, this now becomes very useful. Yeah, it would come all the way around and any questions from anybody so far, you're all awfully quiet. Any questions? No, no questions. I think we're all just captivated by these different things that you can do at home. Yeah. Well, these and I find myself actually forgetting you there and getting totally immersed in this. So I've exposed a segment, a segment of that tangerine but not unlike many solid organs, bronchopulmonary segment or liver segment. The segments are a bit like the segments of an orange oil thing. So I want to actually develop this plan. Notice I'm opening it up, taking it out, opening it up and taking it out, opening it up and taking it out and what I'm doing, I'm doing a segmentectomy. We do segment empathic segmentectomy, kidney segment type to us, David. How do you know when you, how do you know when you're doing that? That when you're pushing your scissors down and in, you're not actually scraping something with the curve of them because I'm holding my scissors with the lightest of touches and my scissors are an extension of my fingers. So it's like me feeling my way down and you'll only get this and appreciate this. If you hold your scissors properly and hold them with the lightness of touch. And when you start holding your instruments for the lightness of touch, then you start feeling the tissues and I can use the scissors to ex probe and explore. I'm using the separation technique there and I'm trying not to actually damage or in segment and rising it apart and learning to feel. And what I've got with all these models and my thinking behind all of these models is to actually get you to learn to feel. Yeah. And the great thing about these models, they get major surgery on a tangerine live on my Black belt Academy Segmentectomy. And the thing is if I was rough and it would be rough just to show you see that I start macerating the tissues there. You get all the bleeding and you're not respecting the tissues. Lloyd Bar May Mohan coined the phrase Eyes of an Eagle Heart of a Lie hands of a lady. And in fact, ladies salute to you because we now have a paper that has been published that proves beyond a doubt that you are far superior to all male surgeons because you have a better lightness of touch and your technique is better, but we all can practice the technique. So There you go, pat yourselves on the back, please salute you are. Fabulous. Brilliant. We need more women in surgery. Segmentectomy. So, the last scissor thing to demonstrate to you is the ent section is holding the scissors upside down. Can you give that? I've inverted the scissors. There you go. I've got it between my thumb, my middle finger and my baby finger is down there. So let's imagine that this is a nasal cavity and I'm stitching down the nose. I can see and you can see the tips of my scissors and you can see the belly as well and I can nibble. There you go. The pepper again, nibble off the pips. And in fact, if I keep the tips of my scissors just open, I can use that see that to scrape the pips off as well. So that's your scraping action. So all the functions of the scissor in one and being in a deep dark circle, I can get to the different angles. I can see the tips and see the points simply by rotating my, this. There you go. Isn't that fabulous? This is great fun. I can scream all of that off and that's the scraping action that you can use as well and dissect out. I just scissors. Ok. So now we come on to the ninth. OK. The blade, ah, there's a hesitancy, the big blades. This is the 22 blade. That's an 11 blade. We will come to, that's a 10 blade and that's the 15 blade and you see it on a different angle. First thing about blades is knowing how to take them off and take them, put them on safely. So we always have our hands resting on a surface. And thanks to Swan Morton for supplying the handles and blades and keeping me in stock. I lift the edge up, slide it along. So disengage it from the slot, apply a hemostat to the blunt end, hold it and one hand only slide it off. All right, it comes off with a jerk as you saw there. But if my hands weren't actually on a table, it would have actually flown off and a one handed thing pointing into the table. So in the Black Bar Academy, if you don't demonstrate blade safety, you fail. So to put it on, we're gonna have the bevel measured to the bevel we insinuate. You see, there's a little groove that mits thumb on that side. You've gotta put la into the groove and slide it on and click into place, please. When passing your blade, put it in a kidney dish. But if you don't have one pass it lay down and handle first and look at the person, you're passing it. So we'll try and practice and see if you can remember what is the perfect angle for cutting anybody. The perfect angle is 90 degrees. But we get that by holding the blade properly, you hold the blade like a knife, it is buried in the palm, my thumb and the side of my ring finger. I maintaining that sagittal plane of 90 degrees, my index finger is extended down, the blade is providing proprioception and it is actually acting as a cane. So why 90 degrees is important as I demonstrate in the sponge and I've colored the edge. If you go through 90 degrees, you should have a fine white line as in that part of the wound and the wound actually heals properly. The wound healing starts with the incision if you're not 90 degree, but you bake and slice the skin like that. It means that these edges are going to the cruise and the wound healing and scar is gonna be poor. So you can see that that is a perfect incision that's got worn over time, but that is baca. So how do you know you've got a perfect incision? Well, again, this comes down to a feel introducing an orange. What you've got to be able to do is feel your blade through the skin. You can try anything and everything. The orange is a challenging one because it's a very thick skin. But I'm trying to feel as I'm taking this blade through in 90 degrees trying to feel it through the skin. So I'm not cutting the flesh. I I'll actually feel it give. All right. Let's come down this side and see. And I am actually moving the orange and cutting this to demonstrate the feel. But there's another important principle on in demonstrating the moment and what's great about this. I've got to see if I cut it, cut all the way through or if there's any juice. So I'm gonna squeeze the orange, squeeze it tight. If I hit the orange, I'm gonna get juice coming off the bottom and I haven't got juice, so I haven't gone through. But the important thing is if you look at that edge, it's perpendicular. Because if I come through at an angle, that is what I call a bacon slice. Yeah, that's bacon slice in the skin that's not gonna heal properly. So the important thing is, is to maintain that 90 degrees. And if I was excising a lesion and some of you probably are gonna be excising a lesion, let's put a lesion on my orange that I need to excise. And what we need now is a fusiform incision and this is a barren blade holder. And in this case, it is an octagonal pencil like and you hold it like a pencil because it's for fine cutting and fine dissection and I can hold and maintain the angles by simply rolling the barrel. So I need a fusiform incision around this and in excising it, I must keep 90 degrees to the skin all the time, making sure that I'm not actually baking, slicing it, trying to keep it perpendicular. A great thing again about the orange bottle, we'll have a look. The thing about doing these things live is that you can't cheat, can you? But you can see there, I've gone straight through, I'm gone, I'm, I'm perpendicular to the skin. And if I cut it at an angle, I'll be saying something like that. Instead you should see that. OK. So that's teaching you to keep that sagittal plane. One of the biggest problems with a knife is cutting in a straight line. As a cardiac surgeon, many people say, oh, it's one incision, I say yes, it is, but it's 23 centimeters. You try and do that perfectly down the middle. So in the Black Belt Academy, we say five centimeters and note my left hand is parting the tissues and maintain it under tissue tension as I'm taking this down and supporting all the way beyond five centimeters. I have to start abducting my arm to maintain it going straight because too often and with a long incision, people pivot around the hip and they do that and that becomes problematic. So we've got a couple of other wonderful things to practice on for feel. And here we got a pack of ham and you notice that or ma material is friendly and, and if I don't put it in a sandwich, my dogs certainly love the treat. So I'm gonna take some ham, take your thyroid medicine. Ok? I'll put that on the plate, I'm gonna use a fresh blade. So you change your blade. And when you can practice with using the blade, you rapidly realize that they get blunt very quickly. So the challenge here is to cut through each layer without cutting the layers times. So let's have a look, shall we? It's very soft, so naturally supporting it either side. Let's a look look. Yeah, there's no cheating on this. OK. And in fact, what I should do be useful. Let's pick it all up a little bit because this is les, pick it up with my forceps, pick it up with my forceps without tearing it. Have a cut layer underneath. Ah LA just to prove that I haven't, I'll pick up the nail underneath so you can see it has not cut. All right. And that is what you can do in your surgery. So that's one layer. The challenge I think is actually, can you actually feel it through two legs? This is very difficult. Indeed. The thing, the blade is blunt, even when the first incision was started to maac and we're going through two layers. Let's do two lays there. Let's have a look. Yeah. And all of this is done through field. You see one, 22 layers. I said I didn't quite feel it through at that point, but my LA, is there anything underneath? No, there's not. So all of these things are very useful and I won't open this because we're going to run out of time. But there you go, slices of cheese do the same. So anything with the skin on can be very useful for practicing simple dissection techniques. And that is to feel the last bit of this, see, organic material again, I've got some fish. Now, the interesting thing is when you're watching chefs and watching people in kitchens, they're all very adapt. And don't worry, this fish is not going to waste it been I used it on Monday, but it's not gonna be good food consumption or, but the dogs are absolutely love it. And the omega three is good for their coat. So you're gonna be feeding the dogs some fish. So the idea now is the other part of life skills is what I call dissection skills of tissue planes. So when you've got a small space as tight to usually scissors, if you got a, a large area, you use your blade. And now I've opened the blade up across my fingers and I'm going to use the blade a bit like a brush and brush the layers off and I, and it's feeling and brushing the tissue away. So the idea behind this is to develop an edge. Yeah, and I'm brushing, using my blade to develop without playing again. This is very difficult, to be honest, without an assistant holding it the other side, I'm proud to see that my blade is in line with the tissue So I'm not cutting directly into the plane between the flesh and the skin. I'm brushing it against the skin and allowing my blade to feel its way in that gap. And this is a lovely way of actually developing tissue planes. And when you get bold, you can try and feel it, feel, feel it yourself. And that's the thing about noel models, you can try rough, you can try smooth, but I want you to appreciate the feel and the feedback that you get from the tissues as you're doing this, the assistant would be holding it as well. Any questions su oh I think everyone's just mesmerizing what you're doing. It's just like we're just watching away. It's incredible. It really is. All right. So there you go. And this is what's really fun about surgical dissection is you can do this and we have got all the models here and developing this plane. Ideally, as I said, I'd like an assistant for this bit, but um to hold it so I can actually retract the tissue, but I want to do it without macerating the flesh underneath and I'm just brushing against the edges there. So again, the seal using the blade, how to do an elliptical incision, how to brush this off. See, I, I can, I'm going to be brave now. And as I'm feeling this, it's requiring me to be a little bit braver with my life. Literally, you might hear it and it's getting blunt. So I'm gonna pick up another one like this strong at me. So, how often do you change the blade as soon as you feel it is blunt and that's why holding it properly and appreciating that haptic is important. It takes time dissecting and with time I'll easily dissect them off and I can find myself totally engrossed in this exercise and having fun. Yeah. Two. Yeah, I'm developing the pain change. Right. So, I think you have got an idea on what that is all about and how to actually practice and skip it home. So how it comes down to and we've got a video which I hope will be made available to you. Knots. Ok. So what knot do you tie on a regular basis on a daily basis? That actually is the most important not of the day. Anybody are you want to about your shoes, David? Yes. Thank you very much. Your shoelaces. I can explain to you why your shoelaces come undone. All right. The commonest knot. Does anybody know what this knot is? No answers yet? They got to be quick off the mark. That's a ref knot. All right. Let me see if I put my fingers in that and pull it. It doesn't, it itself locks. That is a reef knot. You see it sits flat on the table. It's otherwise called uncrossed or flat knot. Reef knot that you can see is not sitting flat on the table. And if I put my fingers in there and work it and work it and work it, it comes undone. And that is why your shoelace is come undone. If you did your shoelaces, we'll pop a roof knot. You'll find that the bows come out across the coronal plane of your shoe. If you put a granny knot, cross knot off the bows, go down the sagittal plane of the shoe and that is wrong. So let me just explain to you something about tying a knot. And of course, we've been tying not forever in surgery ever since hemp and twine were used and animal skin from the early days, one had to actually secure one end to another. The one handed surgeon's knot is useful for surgery to be able to put the knots down. And it's something that requires practice. Basically, you've got, you create a loop and with that loop, you got to get your finger through the loop. There you go. And you've got to flick the short hand there through the loop. And as you do that, you catch it. All right, just to show you that again. And it's that process of flicking it through the loop and catching it that many of our surgical knot tying things on does not describe. So there's a loop, there's a hole. I put my index middle finger through. I'm flicking that through the loop and I'm catching it. I'm doing it like that and that is important and I'll show you why it is important. Now, come back over to my rig and you don't need an eon and everybody produces these knot tying stations. You do not need a knot tying station. All you need is a rubber band, a book, a brick or whatever. So, online on metal, you'll find a not tying video that's gonna describe it. Does anybody know what the end of suture of the shoestrings called an alert? And there's a patent on the Agli I think his name was Robert Harrison. He came up and held the end together. So short and towards you holding your finger and thumb, I'm gonna supinate my hand to hold the short end out. I'm gonna take the long end across the short and I'm going to take my middle finger that's through the loop, flick it around to catch the short end to deliver it through and I'm gonna take it away and take it away. I'm taking it away between those two fingers and catching it again and securing the eyelet. This is my little finger and my thumb and I've taken that down flat. Then my index will be extended. I'm gonna scoop it out, turn it in, hold the short hand out, hold the long over the short and my index finger is now gonna do the flicking through. I'm going to flick it through, lost it there. Index finger. It's amazing once you when you lose it, you totally lose it. That would be going through so we can try that again. It's interesting with the training knots. When you get into a rhythm, it's easy through. Take it away, rotate around, hold it out. You use index finger to flick that through me and then I'll bring it towards me in doing so I hope you'll see that. What you're looking at. There is a wee note. Now, the important thing is is that you can dry it with all sorts of material on it and all sorts of material. Our way of selection. It's here. So string dental floss, cat gut, which is like proline or cat gut. This, this fishing line which is like proline. No, no, no. So clothes. Our next models, I want you to know how to do those is can you tie to a pencil at the bottom of a cup that is held on a plate and this is the black belt level. If you watched the Ninja Warrior Mount Maradona is actually a three fngd. So you can try the one P fenix two Phenix three fngd. OK. And a simple trick to pass something through li ring just right on lay. He Roberts, pass it below what you want to tie release and pick up. Great thing about this. One exercises is you need to be able to tie and this is cotton. It breaks easily if you do not put your finger on the knot. Yeah. If my finger is going on the knot and my finger stays on the knot to make sure it beds down. If you look at our ro time videos, we explain how you get to this level. I shouldn't have the string. Ask me. So if I've done it properly, that's always the fun thing about doing it live. Yes. If I've done a proper because you will see if I haven't, I should be able to get a hold of that piece of string. So there you go. My thread does not move along the pencil. Yeah. In fact, I'm gonna move the cup. So your challenge is when you're not tying is can you get it down? So the secret there was, I threw two throws the same direction, right? If you noticed. So once you've practiced, you cross. Not so 22 throws the same direction. So I've effectively got a slip knot. But the important thing is your fingers on the knot to make sure it beds down. So you're pulling across the knot. All right, you're pulling across the knot and one way of practicing all these things is take a short Tanger and start off with a bit of string. And what you're going to do is now 23 is the same direction you be able to come down a little bit, David. Yeah. Come down, focus down towards a plate a little bit. Yeah. There you go. And tie the knot without lifting that off the surface. All right. Let me just move things out to the head. Getting kind of full on the table here and I need to just de class. Excuse me. Just a moment. Demonstrate that again. No, that way. Oh, my was actually rather busy. Huh? There you go. This 23 is the same direction to make sure that's down and then you can, it's moving. We've got to make sure it doesn't move. So one way you can practice that also. Yes. And I did this earlier with a piece of string and a bit of hosepipe, which is a bit like a chest drin ti such, it does not move because your drains have to lose the cube at the end of your parties. We have balloons to take away. So here's your takeaway balloon for this party. And thank you very much indeed for joining us today. The take away and again, red, it's full of blood. Of course, we're gonna tie off the neck of this balloon. Have to do so. And this is what you need to practice as well. A little, a bit of cotton without breaking it and making sure that cotton is Ben down and that to not lifting off the table. Let's see, this is, uh, very tricky because it moves around a lot. There you go. But I need now, if you can tie balloons off with a bit of cotton accurately. So, that they don't come undone. You're now beginning to appreciate what time. So, ladies and gentlemen, we've had a tour de force this afternoon. Here's your party balloon for you to take away. Thank you very much for joining the Black Part Academy. I hope I've demonstrated running through all these skills that it's technique is more important than anything else. Bruce Lee said he's not worried about a person who's got a repertoire of 10,000 kicks is more worried about somebody who's done one kick 10,000 times. And I use the word 10,000 because said that expertise comes through practice and talks about the 10,000 hours, but 10,000 hours would be totally wasted if it was not deliberate and purposeful. And that deliberate and purposeful comes by attending to what I described in the beginning as the diastolic element of it. It is not the action, it just the set up. It's the technique and above all the feel because the human hand can do something beautiful pose, fingers and bring the palps together. So unless it is 90 degrees across both as in the master, you have to take it in 2 90 degrees through that 1 90 degrees through that two layers together, then you can bring the two together in one stitch. There are no shortcuts, you cannot compromise them in the set up, you cannot compromise in alignment. And with that, I'd like to say the master. Thank you. So much. Thank you so much, David. Um, you can see why David is one of my favorites. He really does teach the basics there and, and it's really, really, super interesting. You can catch David on a Monday night on Medal. He has his own organization. I've put the link in the chat. It's called V bas. He put it on at eight o'clock, er, UK time, isn't it, David? That's right, isn't it? Yes. And you, and on this Monday, um, we're going to be talking about a history and examination. Has it forgotten? Not because everybody thinks about surgery as the actual operating part of it. But that's the easiest part of it. You do not ever make an incision or operate unless you got the right person at the right time for the right reason and the right diagnosis and the patient wants it. So it's decisions before incisions. So please join me Monday evening. As we go through decisions before incisions, there's a lot more to surgery than just operating. And as part of that is the mindset, set up crew resource management, situation awareness and how you act with other people in the team. Perfect, can say it better myself. So you will get a feedback form. Please fill it out. I will pass those on to David so that he can see what teaching what, you know, your feedback, how it went down, that kind of thing. No teaching. I would like to see you stitch that David without it going down. Well, um, there's a simple thing when you got a balloon and you got a needle. Yeah, I thought you were better than that. Thank you. The way you can treat that if you want to actually impress people is put a bit of cello tape on the balloon at that point and then take a needle through the cell. You should know and ball go together might be on another one of your shows. E maybe. Anyway, thank you everyone very much for joining us. There's more, er, events on tomorrow on the m er, medical education platform. And like I said, you can catch David on Monday night, 8 p.m. UK time and you can catch all of his catch up. Everything comes with feedback and certificate. It's really, really good stuff that he produces. Alright round. Um, and I've been doing martial arts now for nine years. I'm third down, but I've been doing surgery for 35 years. A black belt is only, is a white belt is put in practice. There's no difference and the difference between me and you is simply that I've been longer on the road and I love the Japanese term sense. It be the same, but I've got more stories to tell. So join me on Monday evenings. Thank you. Perfect. See you all soon.