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Hello, good evening. Good afternoon. Good day. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon currently in Kuala Lumpur in Malaysia, immediate past director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh, and a visiting professor at Imperial College London. I'd like to thank me for powering the Black Belt Academy because it means that we have reached 1240 people in 94 countries since we joined Metal. And this evening, we have people from 16 countries from Australia, Brazil, Canada, Egypt, Libya, Malaysia, Pakistan, Saudi Arabia, Bulgaria, France, Hungary, Romania, Serbia, and Ukraine. Thank you very much indeed for following and thank you to the Facebook following 4242 Instagram, 707 and Twitter, 1276. I'm delighted this evening to announce that we have another si and doctor Wilson Blo is a cardiac surgeon and an intensive care physician at Sao Paulo Brazil with a career spanning over a decade. Indeed. Wilson, if you're with us this evening. Most welcome since 2020. He's been the CEO of Alpha S medical assistance, a prominent healthcare institution that delivers cutting edge interventions in and intensive medical care. He served as a postdoctoral research associate at Texas Heart Institute and has also done a clinical fellowship in cardiac survey at the University of Beta at the Mesen Cowie Kowski, Alberta Heart Center and at the same did a fellowship completing adult heart and lung transplant ecma and bad support. Between 2012 and 15. He was a resident in cardiovascular surgery in Brazil. And during that time, he was actually Vice president of the Brazilian Association of Cardiovascular Surgery Residence. He is a passionate advocate for martial arts and self defense and has earned a black belt in Aikido. Furthermore, he served as a craft Moger instructor imparting practical self-defense to the community and individuals to enhance their safety and confidence. His passion for martial arts extends beyond the dozer walls. And he founded a charity called Ike Down, which is a nonprofit organization that is teaching AKI O to Children with Down Syndrome. I love this because it embodies a holistic approach to his own personal development and that of martial arts and surgery. And we're delighted to welcome him to the Black Belt Academy. Posture is often assumed to be static. You're just standing there and we're talking about posture. But in fact, it's a dynamic interplay between the skeleton and the muscles and if you get that balance wrong, you injure yourself. But I think from surgery point of view, if you get that balance wrong, you're very likely to actually do damage to the tissues as well. Subtle adjustments are required every day to meet the demands of the environment and the biggest pull, excuse the pun for us is gravity, but at all extends to the table, as we have described in the Black Belt Academy and posture and the equipment that we use, considering that we're going to spend our careers standing. We need to do it correctly and be aware of how we're moving around the table because 27% of surgeons will end up with musculoskeletal dysfunction standing on one leg with the knee locked, for example, causes a hip imbalance. And frequently we see people standing at the table doing this and this means one side of the back is shortened and the other lengthened as we move our chin forward, our shoulders rotate forward, we end up with anterior pelvic tilt, shortened hamstrings. It's important that we maintain a fitness and core strength and muscles. And we know in sport that this is very important and coaches in sport focus on posture all the time. It takes effort and training, but at least it's not reinforcing bad posture, which will result in decreased performance and injury. The thing is is that your trunk and core muscles are linked as we had discussed before with the shoulder. And the combination of a trunk and shoulder movement is why those tennis players can hit extremely powerful forehand and backhand shots. You see them leave the ground and twist. But actually in surgery, as we now been talking about how to use the needle correctly and align the needle small movements of the trunk. If you look at my pen and if I stand on my right leg, it's down on my left leg back and forth. I'm not moving the pen, small movements of my trunk and just changing my posture from right leg to left leg. There is a significant difference and this is important as we will demonstrate in this episode where we now start to build up the complexity of stitching. It's important. I think that we address this in surgical training because this not only will help you in your musculoskeletal health, that will also mean that your stitching becomes more accurate. What's interesting? We spend most of the day sitting down and sleeping and those are not really extending or using the opposite muscles and sports coaches bemoan the fact that gyms like the one downstairs here in the apartment all have you sitting down working and ropes and wall bars and balanced beams all seem to have disappeared from the childhood schools, gymnasiums probably over health and safety issues, but it is not doing any good as far as posture. So we're gonna take you overhead and I'm going to run through some bananas. Yes, we are literally going to go bananas as we look at various elements and bring in the movement and change your weight and change your trunk to give you that fine movement, an approach to stitching in more complex situations. So first to remember and reiterate is that we advocate holding the needle holder in the palm and you take the needle on and off by using your thumb and ratchet. And that's the first thing we did in part one. And the alignment is with the pronation super nation of the forearm. Part two was the pickup of the needle. It's gotta be at the tip. So there's no space between the shaft and the needle holder just beyond halfway. And because we are standing up, we angle it out such that and the belly of the needle sits 90 degrees on the surface. And that 90 degrees being the perfect angle as described by Euclid means that all other angles are equal and opposite. We also last week said that the advantage of having the needle on the tip is that you can practice flipping it over forehand and backhand by holding the needle, not on the ratchet but in the jaws. And because of the cuboidal shape of the shaft, it flips naturally into forehand and backhand note that this movement does not require the intervention of forceps. And we don't recommend using forceps to change the needle over because it'll interfere with the rotation to the tissue. So we will come to a straightforward incision. Now, what's interesting today, going to the supermarket, they'd run out of bananas, which surprised me. I've never come across that before, but we use bananas and we were producing a paper looking at the comparison on ct scan of banana and an aorta. Actually bananas softer and learn to stitch the banana properly. You'll find that stitching the aorta becomes very easy. The 90 degree placement is important. And what I've done here on a linear incision is made at one centimeter spaces, a simple ballpoint line to help me align the needle. And I recommend you do this in your practice on a banana. The thing is that you all quite rightly said orientated 90 degrees and you also said standing on your feet depends. You also told me in the feedback that you regularly check the needle. And I'll ask you that again in a moment. So place 90 degrees across what you want to stitch, rotate it back 90 degrees into what you want to stitch and rotate it out. Remembering that the tissue holds the needle in place. You take it out intro, pick it up, grasp it and voila be ready to use it again. But I am again, say to myself, please rotate back point, rotate in a little off center there. And that's the great thing about this is teaching you to be accurate place, rotating back delivering it iterative, picking it up. And then why I'm doing this on the banana as a sequence of movements because this is what you're doing regularly when you do a continuous stitch. And I must ask you again, did you with every stitch you make on a continuous stitch align the needle properly on the place of point. Rotate. Principles. In my honest experience watching trainees, they're more concerned about getting down to the end of the wound with rapid fire movement with very little attention to set up. Now, the banana, as you can see, blackens over time and you can repeat this exercise without the lines and simply put dots either side to side to give you an example of how to practice further on this. I put a dot There and a dot there equidistant opposite. OK. That's what we're looking for for sutures. And also the space from the edge should take into account the lag zone or inflammatory zone of healing at the edges. Remembering that you're going to get edema of the tissues. So when you tie them, you're not gonna tie it tight because you're going to strangulate. So repeat the exercise by simply putting dots and see if you can come out on the dot Opposite, slightly off. OK. Do it again because the whole thing about practice is you practice to, you can't get it wrong, not until you get it right. And there you go. And the daughter now, because the banana goes black. Once you've done this a number of times and happy do it without any locking up and down, up and down. And you'll find that the entry and exit marks of the banana will likewise turn black and that will give you a clue on the orientation. So the first exercise up and down, use a linear incision if we make it complicated a bit further. And we've now got a curved incision on this banana, we align 90 degrees uh cross what we want to stitch. And if I put my needle down at 90 degrees here, and I put my nine needle down at 93 degrees that the ve is drawn from, that there's a 70 degree difference. So I can't just stand in one position as I make a stitch in this position which we'll come to in a moment is stitching towards my right shoulder, which is the most difficult stitch for a righthanded surgeon. But again, the exercise for this is exactly the same. I'm not wanting you to be fast. I want you to be careful and deliberate in the rotation of your needle because just being careful and deliberate, you see, and I can immediately see I was offline because I let go of the needle there. So these models are giving you an opportunity to self correct yourself every time and use the lines until you are confident picking the needle up. Now note that I have actually changed the needle position somewhat but moved my arm as well. And I'm standing predominantly on my right leg. The present moment, an acne equal distance from the edges and coming out perpendicularly 90 degrees across. And another thing coming around this side, I'm changing my weight now, c both right and my left feet are equally bearing the weight and my alignment is to the edge at each and every part of this incision. If you don't go with your stitches parallel, because that will not bring the edges together because you can see between there and there you got 70 degrees. No. What happens if you've got an irregular wound. Now, many people working in A&E will be familiar with a jagged wound caused by a bottle there, slice through the skin there. And that's what happens when skin has been sliced, it lifts and blackens and this is a jagged wound again, 90 degrees across what you want to stitch place, rotate back and rotate forward. What I'm going to do also do in this is I'm sticking to the healthy skin edges and bringing them together and I'm not going to attempt and it would be folly to try and stitch this bacon sliced bitter skin here because that's already devascularized, it'll tear out and you'll make matters worse. So either side of that accurate apposition, accurate placement of your sutures, 90 degrees cross towards a stitch, bringing it together will enable it to heal that diver vascularise, put the skin there, maybe a bit of steri strip to hold it in place. But that will act as a dressing to enable healing underneath from there to there. Note that I'm always my body position is dictated bye the alignment of 90 degrees of the needle to the edges. Now, all these edges so far have been together next to each other. So therefore, I can take my seat needle through both. Confidently knowing that I am going to come out exactly opposite. That is the idea the problem is is that some wounds, one, not now, this uh the wounds are separated. Now, if I try and, and line my needle up does across both but not quite. But I could try and pull it together on a single stitch. Yeah. But in this position, it would be folly for me to take the needle through here and then try and force it across the other side because it'll tear w if the edges are separated by distance like this, it is very important that you do each side in turn and you do it in two, do not try and force the rotation through both sides. And this is what this banana is teaching me to do is to do it each side. In inter for the plastic surgeons and my colleagues, Mr Caddy might be online and watching you would not use forceps on these skin edges, but you'd use a skin hook to lift it up. And really what you want to do is make sure your needle comes through 90 degrees from the inside. Yeah, to bring you together. So there we have got different types of strange straight wounds, but we need to progress further because when we are joining things together and we'll continue the story next week. In part four, we are looking at moving things around a circle. I've put a clock on here deliberately, cos not many people wear watches nowadays and the watches mostly are digital. So it's a polite reminder of what a clock looks like, forgive me. So if I take my needle around this clock and we will be coming to the clock and the hours of the clock, your alignment is 90 degrees to the edge and 90 degrees to the edge is a tangent at a radius that is the radius, uh uh the diamond across there, it is 90 degrees. There you go. And your alignment is always 90 degrees. So as we go around this clock, we must be careful to think of the radius hitting the circumference and being 90 degrees. So as I start this, I'll start at eight o'clock, I'll come to seven and you do it yourself. I'm standing on my right leg. I come to six o'clock and then I come to five o'clock and at five o'clock, I am now stitching into my shoulder and that is becoming very uncomfortable because I can't bend or contort to get past five o'clock. And it's in that position that I now change my body weight to my left foot. I flipped my needle over since backhand and I now can go back hand and on the radius each time I'm 90 degrees to the circumference. And as they're coming around, my weight is going from my left foot cross the midline when I'm balanced on right and left foot. And I'm now coming across to 11 o'clock, which you can see is diagonally opposite five. And in this position here I find that I can't do any more backhand stitches without getting into a contorted position to get me to that position. All I've done is changed my weight distribution from my left leg to the right leg. But here I now have to flip my needle over again and I can continue down beforehand on my left leg, coming around to my right leg can stitch in my shoulder. I flip the needle over and now I'm on my left leg continuing round. So all the way around and it's, it's a subtle movement. It's a subtle movement that doesn't require your elbow to leave your side. So this is where taking an apple cora, you can get them at most Diy supermarkets to a banana and taking out that bit of skin and just like the clock. I have got radial markings to help me work out where I am and what I'm doing. So, let's try. Shall we, sir? I'm starting here, eight o'clock, 90 degrees. I'm gonna rotate it back and I'm taking the needle into the lumen. I'm rotating it out. Ok. Now, this is important because the needle going into the lumen, the needle holder is not going into the lumen. The needle is, and you deliberately coming out at each point, note that the needle is held in position and I can take it along to just be on the halfway and I'm ready to go again. And here we go five o'clock and this is now becoming difficult because it's into my shoulder. And while it's in that position, I'm going to swap over to my left leg, continue to deliver this and I can pick it up and I'm ready to go again. Now, the banana is actually very soft and is totally unforgiving as far as rotation is concerned. And this is why I think that this is a fabulous model to use to practice on at no stage in this procedure. Have I actually used the forceps? The forceps would be retracting or holding tissue ate to enable me to make the accurate ditch. So here we go, it's directly opposite. At 11 o'clock, I could probably get that in if it feels uncomfortable, try switching to beforehand beforehand. Now you see that it was uncomfortable for me and my needle holder dropped into the lumen and guess what, I've mushed the banana, haven't I? Your needle holder should not be dropping into the lumen and mushing the banana. You should be able to go round and maintain clean banana all the way as I went off the side. You probably noticed that I did that move to switch the needle across. Now, a common error when stitching around in circles and stitching lumens, I'll show you people push the needle into the lumen and they're s mushing the banana. And you already see, I'm getting lots of banana on my needle holder and it's now becoming more like e banana mash. And the other reason for holding it at the tips, I'll demonstrate as well because if I don't hold it at the tips and I don't have to line properly, I am going to end up with my needle holder mushing the banana as well. So it's an exercise that's reinforcing, not only your needle control, but reinforcing the fact that you keep the needle at the tip because that is where you get the most control. That is where you can flip it forehand and backhand and place, rotate it back and lock it, put point the needle in and by pointing, it gives you the accuracy and precision. You're putting it there, not somewhere and rotate. So an extension of a circle would be an ellipse. And this is really the basis of any sort of vascular surgery because if the blood flow was actually flowing that direction, you'll have a heel there and the toe there, heel and toe, the blood is flowing that way. Heel and toe. Now, the important thing to look at this again is 90 degrees at every point as we go round. Now, 90 degrees at the hill and 90 degrees at the toe is essentially aligning your needle parallel to the two walls because it's actually at the tip. Yeah. So I can take my suture and put a stitch at the heel there. My neck stitch is a tr application like this and it needs to be fairly close because if it's wide apart, what happens that you'll pinch the heel and toe and in a vascular anastomosis and in chorea anastomosis, that is the worst thing you can do. So, 90 degrees is among that trajectory because you can see it's curving in at that side. So I need to come closer to align it, please and point and rotate. And as I come along the side, there's a subtle change in the position of the needle as it becomes more directed towards me. Now, whether it's on a small scale or large scale carotid endarterectomy or coronary anastomosis, the principle is exactly the same. No, as I described the five o'clock position for you, it might be different. It depends on your body habitus, but get a clock and you try yourself and work out if it's five o'clock, half past four or four o'clock where you need to change from forehand to backhand. So now I'm on my right leg. This is right at the limit perhaps of my stitching into my right shoulder. So I am going to turn round and come backwards on this bit because it gives me a better. Ok, see I have to play with it. Is it better forehand or is it better backhand? I can get it for her. But of course, now my toe, it is down the middle and I've swapped to back hand. Now a little secret about holding it at the tip and holding it just on the halfway. You know, we did this is it 90 degrees because the belly bounces on the surface. Everybody, particularly cardiac surgeons learning to stitch are so terrified that the needle will pick up the posterior wall a little trick. These are smaller needles, but even on vascular surgery and bigger vessels, you can use the belly of this to push the posterior wall away and allow your needle to bounce up through the anterior surface. And that way you are never going to worry about picking up the posterior wall because you're using the belly to push it away. And that's another advantage to that. It's not working on the banana cos, I'm mushing the banana. But again, tr look at the angle there compared to there, it's tucked in to make a little tr there and we continue around. So in each of these models in our bunch of bananas and getting bananas today. I hope that I've demonstrated to you that with simple practice and simple fruits and the banana. I love, you can practice and hone your surgical skills. You don't need a thread, you need a needle holder and a needle and a banana. And we're not stitching fast. But what you notice as I'm doing this, I'm actually not wasting time on my alignment. All right. I am not wasting any time thinking about my alignment. Yes, I've, I've drawn the vectors on the edges, but that is helping me think about my alignment of the tissues as I'm going round. And that's the whole thing about surgery. And I think what people do forget when stitching, you don't have to stitch fast. And that's what was going round there. I was not stitching fast. I was deliberately and purposely place point, rotate, consciously, making an effort to be 90 degrees at every single vector on every single shape. Controlling the needle means that I don't have to get my forceps in the way, controlling my posture. And thinking about my upper limb means that I can rotate the needle, it comes out of the tissue ready to be picked up again. What we're rehearsing in these models is all about set up and this is why I call it diastolic learning because the heart systole is fixed, diastole shortens as the heart rate speeds up. But the lovely rhythm of the heart and the chest does not change just because you speed it up. What you have done is removed or unnecessary movement by paying attention to the smallest things. And those of you who have seen the previous series will know that's exactly what Miyamura Masashi said in his book of Five Rings. He was the undefeated Samurai warrior of 1642. Surgery is the same by attending to these low fidelity models. Thinking about your set up, thinking about your posture, drawing the lines that are practicing them regularly, get the needle to work for you. You'll find that the lightness of touch and the rhythm of surgery will come. More importantly, you will not be stressed. You will not be exerting extra energy contorting yourself into difficult positions. Cos you have now understood how the needle works and how subtle body movement can change right leg, left leg, right leg, left leg. Look at that difference and I haven't actually begun to move my shoulder because as we have pointed out, moving your shoulder involves 20 different muscles, holding it in that position is when you get fatigue. I sincerely hope this has made sense. I'll be delighted to answer any questions if you have any. And Gabrielle, do we have any questions before we go there and sign off? Also, it's to reiterate that we are having a competition and we'll put the URL on the chat room as well. We want to know what you are doing to hone your skills would like your email, a photograph and a short description of something innovative and different to hone your skills. That is the the competition there. The top three will get their own set of Black Belt Academy Instruments so you can continue to hone your skills. Thank you for your attention. Part four. Next week is taking this from a two D dimension as we've seen now to 3D and how you work, not with it in one direction by bringing different tubes together and how you orientate your sutures, your placements. But guess what? You're quite correct that 90 degree alignment to the tissue is inviable, that dictates how you stand and where you start. Thank you, Gabrielle. Any questions? Not at the moment, but if anyone has any questions, then I do encourage you to just pop them in the chest and also like you, we, we do value your feedback and pay attention and we will take a moment to fill in the feedback form, which will also be in the chat room if this has made sense to you, um, do pass on to others encourage them to watch. Look back at the other parts if you haven't seen them as yet and I look forward to seeing you next week and wish you well. Thank you very much. Indeed.