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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm the immediate past president, Director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. I'm a retired cardiac surgeon, but I'm delighted and pleased to be working as the professor in the Medical Education Research and Development Unit in the Faculty of Medicine at the University of Malaya in Kuala Lumpur. And that is where we're coming to you this evening live, supported by ish who is 1/4 year medical student in the Faculty of Medicine who wants to be a pediatric cardiac surgeon and we're gonna certainly help him on his way. And also in the background, fellows, a Chris Caddy who is a plastic surgeon in Sheffield in the United Kingdom. The Black Mo Academy is powered by metal that has enabled us to reach over 100 and 25 countries. And we have 48 registrations this evening from 27 countries from Armenia, Bulgaria, India, Libya, Nigeria, Nepal, Pakistan, Poland, South Africa, Uganda, USA and Zimbabwe to name a few we've also passed more than 4000 registrations for the Black Belt Academy and 41,000 minutes viewed. And during the week, we passed 2000 on Twitter. I'm really delighted, forthcoming. I am doing an online conference for students in Warsaw in Poland. And we've had a conversation talking about the association in Surgeons in training UK annual General meeting in March next year where B BRA are sponsoring the Walk In Black Belt Academy Workshop. Tonight, we're gonna talk about scissors and the basic structure of a pair of scissors consists of two sharpened blades with a pivot rings that haven't changed in size over the years and are remarkable uniformity in size as well. Recognizing that these were designed by men and I understand women might have difficulty with the rings but will come on to the hold. The scissors are held together with a pivot referred to as a fulcrum and this allows the blades to open and close cleanly. And when you listen to a pair of scissors, you should hear it scraping one against the other. There is physics involved. And if I take you over to the top, you will see here that we have a pivot. There you go from the pivot to the tips force times distance equals pivot to the rings four times different distance. So you can imagine with the longer the handle, the less the force and also the greater the force on this end because the distance is smaller. But this design and the placement of the fulcrum affect the ergonomics and functionality of the scissors. But it also enables cutting with precision and comfort. And scissors have honestly stood the test of time. And if you go to your cupboard and it's interesting that I walked around the house looking for scissors and I got a whole range from sewn kit, Balram scissors, professional haircutting scissors that have this nice little bit on the end to hook a finger on kitchen sheer scissors. Then of course, the range of surgical scissors as well. The biggest collection of scissors is by Glib in Germany who's got 7000 different types of scissors that is collected over many years. So they come in a range of sizes in a range of functions or have a purpose of cutting. But the size and shape is determined by what they are cutting. And this is based on the intended application. As I explained, the position of the pivot changes the functionality. No, the symbolism of scissors has extended from ancient art forms from scriptures and paintings, deities and mythological figures because holding scissors has been thought of, of holding power, authority or transformative action. And in ancient mythology, it had significant meanings in a lot of different cultures, representing beginnings, order control, truth, revelation, fate, mortality, or reflecting the role of the scissors for precise cutting and shaping of materials. In the ancient Chinese scissors were often used in rituals associated with birth and marriage. They symbolize the act of cutting away negative energy or influences to bring forth new beginnings. Although in China, it's also superstitious that a woman should, who's pregnant should not hold any scissors because they believe that this could with the cause of a bad thief effect. In ancient China, scissors also held symbolic value associated with wealth and prosperity. And many scissors came highly decorated and a Chinese student of mine gave me a set of scissors. They were manufactured by a family who had been making scissors since 1643. In Japanese mythology, the goddess Amato is depicted using scissors to cut off her brother's unruly hair, which represents chaos. And this act symbolizes control and bringing together of harm in the world. Japan like China have refined the art of paper cutting in Japan. It's called Kurama. And the traditional scissors are called Nigri Sami and likewise s are also made for the Bonzai tree. In Egyptian mythology, scissors were associated with art, the goddess of truth and justice. And she is often depicted holding paras or shears that represent her role in cutting through the lies, to reveal truth. I think we could do it with a lot of scissors in this day and age to cut through and fine truth. In Greek mythology. Atrop was one of the three fates who controlled human destiny and she wielded a pair of shears to cut the thread of life when it was time for someone's death. In this respect. The scissors is associated with fate and mortality. When I think of power control fate and mortality in some ways, this is all part of surgical practice or has been to date. And the earliest scissors were actually found in 1500 BC in Egyptian Tombs, consistent, you know, of a single blade wrapped around to form a shear like scissor. And they believed these were used for personal grooming and for crafts. The Romans added the modification of the pivot to make the blades more efficient in crossing each other and cutting. And this, this innovation that actually spread to Europe. But the name came from Caesia, which is Latin meaning cutting instrument. And the old French is and middle English. So became scissors and scissors were widely used throughout the middle ages and like ancient times became symbols of opulence, decorated and adorned with precious metals and jewels, even made of silver and gold and the design of the handle. Sometimes it coats of arms with associated social status, but it was Robert Hinchcliff, a Yorkshire man in Sheffield now or then became the heart of steel making. Patented the scissors in 1761. And from there, scissors became ubiquitously used in the 18 100s. The green fields found its center in Paris in France and in Germany and then was manufacturing in 1887 produced them on an industrial scale and they became worldwide. I didn't know, the Fisker company in Finland, we're the first company to put plastic on the handles to provide lightweight efficient ergotic grips that made scissors more comfortable. So the typical scissors is actually no more than 15 to 20 centimeters any longer. It becomes a set of shares. Scissors like all instruments should be regularly cleaned, particularly the hinges and they should be oiled, two of surgical scissors as well. What's interesting is the largest pair of scissors was actually found in Yorkshire at about 15 m. Interestingly, also the Guinness record for the most high cuts produced in a single day within 24 hours with hair cut scissors. 371 amazing kitchen scissors have been designed. So the handles are offset or gun like to prove their ergonomics and surgeons have lent their names to all different types of scissors over the years depending on their use. Unfortunately, left-handed scissors are still rare. But despite the time and history, the basic concepts of using scissors remain the same. The most expensive pair of scissors made for the Bonzai tree actually cost $35,000. Amazing. So where are we as far as our sisters are concerned? My favorite. And we asked you are the mcindoe scissors named after Archibald mcindoe, the pioneer of reconstructive facial plastic surgery. Famous for his work on fighter plots who were burned during World war two. He established the Guinea Pig Club where he translocated flaps and reconstructed faces but what I liked about him is that he only employed good looking nurses because he wanted to maintain the self esteem of these young men who'd been horrifically disfigured by fire. Apparently, many of them actually ended up getting married and it is said there was Hanky Panky in the broom cupboards at Irus. But adoptions the Mets and bombs are slightly thicker but had the same function. The mayo scissors are stubbier and thicker, still straight and curved. On top of that, there's a special scissors called a little stitch scissor that's got a little hook on the one lip that allows you to lift a stitch up and cut it. At the same time, Iris Scissors and some of the fine commer scissors have gone back to that almost single piece of metal that enabled finger control and improved fidelity toomy scissors, how short and fine tips. Then of course they are the pot scissors that are used for vascular surgery. Somebody mentioned Pierson scissors again and dissection scissors. And then we have the general purpose scissors and the bandage scissors. The important thing about all these scissors is that they need to be an extension of their hand and you got to be able to feel the instrument. So it's how you hold the scissors that is important. And it's interesting looking at photographs of basic surgical skills and watching students pick up scissors and hold them. It's quite interesting that scissor skills were first used and you remember doing them at school because it is the best way to teach coordination. But the scissors need to be held despite the size of the rings, never ever put your fingers through the D IP joints. I can't, my thumb is too big. But even if your fingers are small, the idea behind all surgical instruments is the simple principle that you need to try and maximize the tips of your fingers, touching the instrument. Therefore, even if your fingers are small, you should be able to place them obliquely through the rings. I was taught. And traditionally, surgeons use a ring finger that enables me or enables me as a general surgeon to operate tie knots and like a switchblade, I could bring my scissors out and cut the stitch. Although I would not recommend cutting big stitches with beautiful dissecting forceps. What you need to do is place your fingers obliquely across the rings lightly. I've got my middle finger supporting the rings and my index finger extended down the instrument. Take it out, put it in, take it out, put it in. I can't do that if my D IP joint is through. But also if it, you can't feel anything beyond the palp of your finger. So practice yourself at home with a pair of scissors no matter the size of your hand, put it in your hand, sitting comfortably and maximize the surface area of the fingers because it is only with the lightest of touch and the maximal surface area that you will be able to feel the tissues. As I said, the first exercise we always did at primary school was to cut out shapes. So cutting out shapes is a good exercise to practice your skills. You can take any shape you like. And this is card rather than paper. So I'm not gonna persist too long with a nice pair of scissors because I haven't been able to find and a few less thick but try practicing cutting out shapes without leaving ragged edges and bits behind. So I asked, how much do you actually open the scissors to cut? I was delighted that nobody went beyond 1.5 centimeters. And in fact, if I did that, I am actually stretching the movement of my hand, I probably never opened them up more than 78 millimeters. But for cutting and developing planes simply 3 to 4 millimeters is enough to enable me two dissect tissue. Now, one of the great things about having scissors that are partially open, it is enable you to develop tissue planes. So I've got here a couple of sausages and you'll appreciate on the sausage. You have got a very fine skin of the top. And what is useful to practice is, can you identify that plane? So you see that I'm using the scissors now as a probe, but also displaying what's above it. And because I can see there's nothing between my scissors in the skin. I can cut with impunity. So the scissors is a tool can be used for blunt dissection and probing and then keeping the blades up. I can run my scissors along this fashion. La confident that I'm not cutting the tissue underneath. This action reminds me of harvesting the long venous vein in order to get clean vein, but also to ensure that you identify all the branches and don't take any extraneous tissue. It is useful to take off this fascial layer on top of vessels. And certainly it's an important skill to do when dissecting and following the anatomy of solid organs where the segments in the anatomy is defined by the vessels. So having confidence, dissecting and removing tissues and thinned membranes like this can be practiced using a sausage without cutting the meat and trying to preserve it at all costs is giving you that lightness of touch. Now, one thing I need to point out is that the line of sight of cutting is with the curve of my wrist, my wrist is curved. The scissors are curved and this way I can see the blades and the tip from holding it upside down. I can see the tip, but I would not be able to see the blade and you'd appreciate. And I'll probably demonstrate here if I was trying to cut this, I would be cutting or potentially cutting the flesh underneath. And I've actually seen that happen with a pulmonary artery with quite a significant bleed. So keep the belly and the tips within the line of sight, it is extremely important. So these are Cumberland sausages. You can get chicken sausages, beef sausages, any sausage, but the smaller the sausage, the thinner the skin. So you start testing your skills in doing this. If you don't want to use meat, there are plenty of other alternatives and I found that the tangerine gives you an excellent opportunity to explore your skills. First of all, one has this rather thick skin. Now, this pair of scissors is a nelson scissors. You can see how long they are for reaching into the chest, but I like them for cortex, dissections in the chest. But I particularly like them because the blades and the points themselves were blunt and was less likely to cause injury. But the thicker the tissue, the thicker the scissors that I'm going to be using to develop the planes. And I'm probably gonna swap scissors the moment because these are for control a little bit too long. So I'm going to go for the heavier mets and scissors to develop this plane. So the first thing to do is think about how you develop pains. If you insert your scissors, open, withdraw, close, insert, open, withdraw, close, never ever ever close. The scissors when you cannot see the tip for in that position, you'll end up causing again, significant damage. So this is the easy part or should be the easy part to remove the skin on top of this tangerine, we are now then going to proceed to try and remove the segment. OK, about forceps and none of these models are supposed to be easy. If they're easy, anybody can do it. What they're supposed to be doing is exercising those skills and your fidelity and practice. So I need to just take the cortex off here and honestly and truly, this is very much like the cortex that I've done had to remove in pericardectomy and pleurectomy. It is all exactly the same. This is all exactly the same. So now I've got a segment, I need to actually dissect out that segment and develop the plane. What I should be able to do is actually open this up carefully and gingerly without cutting the flesh on either side. And sometimes this is extremely difficult. It was meant to be difficult and meant to actually test her dissection skills. What I don't want to do is put my scissors in and force them open and break that segment. What I want to be able to do is develop the plane carefully. It's almost like doing a segmentectomy on a solid lesion as far as the organ. Once I've found the plane, I can gently use my forceps to separate. So now I'm getting somewhere, all of these skills you will find will become relevant in theater. Yeah, I have removed the segment. Now, if you want to even go even further as part of this example, you'll find that the segment itself has particularly in oranges and then other citrus feuds. The segment has got usually have quite a thick skin. And what would be try? Nice to try and demonstrate is, can I get into the layer to expose the flesh? This is a finer version, to be honest. And the skin on sausage not having a symptom. Terrific fun. Here. There you go. That's it. There you go. That's it. That's it. I found the letter just requires a little bit of patience and persistence and you can t then dissect of uh this thin layer on top. So you see the tangerine is offering me many examples of cortex separation without breaking the segment and removing this thin segment of skin on top. You can apply the same to any citrus fruit. This has given me an opportunity to practice my fine dissecting skills on a low fidelity model. That of course, at the end of this can be eaten as part of the Blackout Academy sustainable Surgery. I find myself with these models getting totally absorbed in the practice note that I am also using this to gently scrape in a way, gently pressing the tissue away. So the scissors now become extremely useful tool for cutting, separating, displaying and of all the questions that I asked of you beforehand, the scissors have all those functions and you're using them all. At the same time, there's a different way of holding scissors, particularly if you're working in a confined space. Now, imagine you're doing ent surgery and now we have to work down in the nose at the bottom there and you see all the pips. Now, if I took my hand in like that, you can't see, I can't see because my hands in the way. So what it can do is using the similar principle of fingers applied to the instrument obliquely with a thumb and now index finger through the rings, ring finger supporting and the baby finger extended down the shaft. Now, when I got the camera up, you too can see down the scissors and can see me operating and dissecting at depth. And here I'm having fun just gently nibbling off the pips inside this pepper. You can combine this with an exercise and forceps skills to pick up and put in straws on either side. But again, this is enabling me to dissect down as I'm sure you agree a very small space. But my hand moving around like that enables me to see the belly and the tip. As I dissect, you can combine this, as I said with a forcep skill test, picking up the pips and putting them in a straw on a bit of blue tack to the side. But in this case, what I'm doing is I'm using the blade slightly open and I'm scraping these off as well. And when there's a slight resistance, I'm cutting it off, but I would not feel resistance and would not feel any give if I was gripping the set of scissors far from it, I'll be causing damage. Remember? Of course, that even though they're blunt, they can inadvertently be stuck in the tissue and cause damage. So as we look around the kitchen and I walk around g supermarket this evening, I look for all sorts of things that would enable me to actually practice my dissection skills and highlight the the functions of the scissors. So I found this bit of fish. I haven't dissected this fish before, but I thought, oh, look at this, a whole lot of planes here that I could perhaps explore. How can I go about doing this? Take any organic material you like and from the supermarket, fish or meat and just feel and practice with your instruments. I think that is a bit of cartilage or bone there. This is a bit of a skate. Can I just take it off? This again is gonna be used in a fish stock tomorrow. So don't worry, it's not going to waste, but it's rather fun to actually look out for different materials when going around the supermarket thinking could we actually cut the burns out cartilage out? Where did you get? My, the principle is simply find anything you like in the supermarket, take your scissors to it and begin to feel your way through and cutting out the bones and fileting a fish, take it out without much in the way of fish flesh on it. Great, practice good fun. Even a chicken thigh. Now, I was asked and as we have demonstrated before, when do you use scissors? And when do you actually use a knife? Well, to be honest, the answer to that is, is depending on the area, the depth and what you're using it for. So I'm using the scissors here to develop a plane. And I've demonstrated there's nothing underneath because I can put my scissors underneath and probe. And I like using it as a probe because it's usually got a blunt end. And I can count that I don't advocate ever cutting skin with scissors because I don't think it gives you a clean cut and would never cut a skin with scissors. But the principle of scraping and cutting you can appreciate by looking at is connected tissue adhesions do not ever tear in adhesion. Adhesions are usually a lot stronger than the tissue itself. And therefore it's better to nibble them. So yes, I can tease it and feel as I'm doing that feeling how thick these tissues are, I'm gonna focus down. And obviously, if it's very thick, I need to make it particularly as I'm dissecting a judgment is that a vessel or nerve or an adhesion, a condensation of tissue. And that's essentially why you need to hold scissors, the lightest of touches to enable you to feel the planes as you're dissecting. Um trying to see if there's a plane down here. So once you got on the plane a bit like I with the tangerine, I can open my scissors up to separate the layers sometimes and no is clear and require a little bit more sharp dissection or persuasion with what I call a scraping motion. And I'm gonna cut through that muscle there because that's where I want to be. I separating these two muscles. Sometimes the planes are not so obvious and you have to develop them and taken educated, not guess feel or where the separation is going to be anatomically because the planes are not always going to be perfect. So therefore, your dissection needs to be versatile and you need to actually have all these skills at hand in here. I've got potentially, I feel perhaps a neurovascular bundle there that I can use my scissors. Just lift it forward to help me demonstrate if it is not and it is not. So I can continue to cut. Oh what we have here there, I think we're down to bone. But on that fascia layer, I see a layer of blue and I think that it's down to the bone, the periosteum. I was wondering if that was a vessel there. I don't cut across it. I follow the vessel along its line and you can see. Now, scissors become extremely useful when the deeper you go and the smaller the space. So that's down to the bone. Now, I was hoping to actually find a vascular bundle for you in the slot, but I have not got the thigh, the leg. So I'm using a whole lot of actions here to develop planes and separate. When I know there's no vessel around, I can cut boldly and develop. So I was fileting this chicken leg here, chicken thigh again, as I said, I find myself getting totally absorbed in these models for dissection. There you go, separated that muscle off down to the bone and I could continue happily for hours having fun in dissecting of these lands. Again, I'm using my scissors as a probe, feeling my way through the tissues. I can use the scissors to bring something forward to have a look at it and decide if I can cut it or not. It's only with practice when you get to actually feel or understand the use of your scissors. So any comments from you ish and from my fellow sense, Mister Cady. Oh, there we go. There we go. There, we got a blood vessel. All right, there's a blood vessel. You can see a vascular bundle there. And what I wanted to do is just demonstrate this because I can actually use ay to grab a suture and pull it round. I don't actually have to use another instrument. So rather than cut it. There you go. And I've pulled the scissor, use the scissors to catch my suture to take it around. I can cut it but I didn't. So having done that I can tie and set you off and demonstrate I was able to flick process is interaction. Yeah. So there you have it. I think the scissors are the most versatile tool in the surgical box. You can use anything in the supermarket. And I really enjoy walking around the supermarket and I bumped into Lawrence this evening. He said, what are you operating on this evening, David? And I showed him the basket of chicken, fish, peppers, oranges, tangerines, all organic material. The reason why we use organic material is to be honest, in 35 years of surgery, I have not come across any synthetic material that resembles the real thing, but you can find it in the supermarket and I'll put these straight back in the fridge when I'm finished and they'll be used for cooking in tomorrow's menu in tomorrow's dinner, low fidelity models, homing your surgical skills and having fun. What more do you want? Any questions vanish or any observations, Chris at, I've, I've had to dilate on one platform and back in on another, but really enjoyed that. Um When you are a plastic surgeon into microsurgery, you use in particularly hand surgery, you do a lot of fine dissection. I presume you use a lot of scissors in your dissection. Do they have rings or are they fingertip held scissors? No, they, they're a bit like your cast of the age. Um, scissors, they're either straight or curved at the tip, but they're very fine and you control them with your thumb, controlling them like that. Yeah. Yeah. Yeah. Literally like that. So again, this is scissors designed and the principal way to get maximum amount of fingertips applied to the instrument and it's not much movement is required at a micro level to get significant movement. What is your favorite dissecting scissors? Well, it's, it's probably um medicine bombs, but we, we us, we usually use uh Steven's tono scissors for finer dissection. Mhm. Um So you need to be, have a number of instruments in your, in your repertoire and choose the right instrument for the right case at the right time. So indeed what you're teaching are principles, but you then need to apply those principles with correct, with collecting the right instrument, correct. So, you know, you wouldn't do a dissection with hairdressing scissors. Those blades are far too long. They're extremely sharp. What I like about them. They've got that lovely sort of s slicing, hissing sound as you cut. It was interesting. The hairdresser I went to in ate, he had a pair of Japanese scissors, Japanese steel and sharpness and renowned and it cost him, I think 900 lbs for a pair of hairdressing scissors like this. But he was a master with these scissors really quite a master. But he had a, a unique, um, field on which to, to practice his a, yeah. Well, yeah, he didn't, he didn't do 300 haircuts in 24 hours. But again, if you look at the way they hold scissors too, note that the fingers are not through the rings, but look at how many fingers are actually applied to that hairdressing of scissors. And again, his art is in the field, the only times that you put your fingers through and this comes down to the plastic handles. You can see these scissors are heavy duty and they have got a function which is now a grip. You don't need to feel this, you need to cut heavy sinews, kitchen scissors and you need to be able to grip what's interesting watching some people pick up scissors and basic skills. They hold scissors like they did at kindergarten in a sort of pterodactyl pincer movement with D IP joints through it and c like that. Um Quite, quite remarkable. I'd see that in, in kindergarten schools and how to use scissors. And actually the use of scissors in developing coordination skills is recognized in the educational field amongst Children as a good indicative of coordination. The fact that I stick my finger down to stabilize my surgical instruments has been pointed out when I am practicing uh Joe, which is really a long broom handle that some of my movements. I've got my fingers extended and the sense has pointed out that I've got my fingers extended with that weapon and with my katana is likely to be cut off. It's funny how years of holding instruments and keeping my index finger extended down the instrument has crept into the way I, I'm using weapons in martial arts and I have to unlearn extending my finger in that regard. Finish any observations from your side. Yeah, I think there was a wonderful session prof you know, as usual and uh definitely something I need to try at home because I have not done much with the seizures other than cut sutures. Yeah. Which is, and, and the other thing, even when you're cutting sutures, that's a common thing you're going to be asked to do in an operation is cut sutures. So you might be given some mado to cut sutures. And I think if it's a AAA 40 or 30 at the maximum, you're welcome to cut with a mado. But if it's any more than that, please use some proper curve ma scissors. But when you're taking an instrument into the chest, please take your instrument into the chest carefully. Open the scissors up no more than necessary to do the job. All right, cut and then withdraw, please don't come in with the scissors wide open like that from the theater light and out. Again, if you have difficulty with keeping the scissors stable use a pair of forceps. In the other hand, as a fog to stabilize your scissors, bring it in open up no more than necessary to do the job cut and withdraw. Do not ever open the scissors up more than that. Certainly, when you enter the tissues, open, withdraw, close, enter open withdrawal, close simple principles in handling the scissors obviously going into the thorax greater depth. But even this is feeling the index finger down at the extreme of cutting. But that's probably why you've got laparoscopic instruments now because they can do a depth without having these rather compass and things. Thank you very much indeed for joining the Black Belt Academy this evening. Do send me comments and pictures of your practice do recommend vegetables, fruits, whatever you have in your part of the world, that could be good models for practice. My favorite I think is the tangerine because you can take off the cortex, take out a segment and then dissect off the thin layer of skin that is holding the flesh. I think there's a three in one model to use for practice organic material is always better enjoy your practice. I personally find these sessions fun and could spend all evening snipping away and enjoying this because I find myself getting totally engrossed. Thank you very much to finish for hosting. Thank you, Mr Carry for your insights and thank you for joining the Black Belt Academy. We will see you next week. What we're going to be doing next week is talking about closing wounds and particularly focusing on different types of sutures and different ways of closing wounds as well. So we'll cover the basics of sushi and also the basics of continuous stitch, subcuticular stitch, mattress, sutures, and instrument tying as well. Thank you very much indeed for joining us. Do spread the word and we hope to see you next week. Thank you, Chris. Thank you and thank you too. To me, please fill in your feedback form and collect your CPD points. We are a credited by the Royal College of Surgeons of Edinburgh. Thank you.