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Yeah, hello. Good evening. Good day. Good morning. Good afternoon. Wherever you are and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan and the past director of the Faculty of Surgical Trainers for the World Colleges. Thousands of Edinburgh, I'm a retired cardiac surgeon and a visiting professor at Imperial College. E if you're one of the 3230 followers on Facebook, 605 from Instagram. Thank you very much. Indeed. It means a lot. And if this is your first time, welcome to the black belt, carrying this slip briskets. This evening, we're going to explore the blade. And I thought of this a blade of grass. I saw the poplars and green meadows on the other side of the terms, but it did not know that I was looking at them. So I've touched the fingers of the girls hand with a blade of grass and the door was opened in heaven that is from the life and times of ordinary men and the blade of grass is there throughout literature. The mighty desert is burnt for the love of a bladed grass who shakes her head and laughs and flies away. The blade of grass or bit thin has actually got parallel veins. And if you catch it at the wrong angle, equal cultural skin, if you want a good lawn, you need to actually have your lawn blower sharp. So it cuts it clean. So it doesn't damage the fresh and helps photosynthesis and helps it grow again. In the same way, your blade needs to cut through tissue cleanly, meticulously, bloodlessly caressing the tissues as described by Lord. Okay monogram. The thing is that many trainees become a little fearful of a large blade and somewhat hesitant because it's sharp, a clean dissection, the sharp dissection, I would like to encourage you this evening to reflect by the way you use the blade and hold the blade because it is the mightiest too in your surgical tool box and weight to the blade should not be underestimated by the weight of responsibility that coz with the bleed. Because before any incision, there are lots and lots of decisions and having made the incision, we cannot go back and you have left an indelible mark in your patient for the rest of their lives. You might not remember them or the operation, but they will remember you every time they look at that scar, which now becomes your signature on them for life. That is the weight of responsibility and the importance of the blade in surgery. Like all things in martial arts and surgery. We have to actually focus on safety. So I'm gonna take you over so we can look at some of the common blades that we used. And I'd like to thank Swan Morton for their assistance in providing me with blade handles and scalpel blades. I recently had a tour of the factory and I come to my learnings from that in a moment. The common blades you just see here or just want a few of the repertoire found. Give this one more for me, collection of 77 different types of blades. The ones I frequently use and you will probably come across uh the 22 blade, the 10 blade and the 11 blade and they're 15 blade, the 22 blade is the bigger blade and they all come with a patent handle with that. And on the other side, Swan Morton have a very nice rule. Your note as we can focus down on the blade that there is a groove, the thickness of your nail and it's into the groove that the blade slides. This has got to be done with care and deliberately for in the black belt Academy failure to demonstrate safety in mounting the blade will mean you do not pass your black belt the to be picking and for the sharp end can easily be damaged as well by any contact with a metal surface, holding it with a hemostat. The house said likewise align the blade such that the bevel of the blade and the handle online, insinuate the end of the weight, a neck into the slot and pull it home at all times. My hands are resting on the table and ladies pointing into the table such that there is no this movement and the blacks to take it off, you reverse the actions. Lift. Yeah. Under the blade out of the groove slide a slightly long apply. Ahem. A steroid and then gently remove the blade very easy as you see there, bang into the table. And that is why you've got to do it on a surface and cleanly the blade needs to be handled correctly as well. It should not be handled by depend, it needs to be in the palm of your hand and supported between the help of your thumb and the terminal phalanx of your middle finger with your index finger extended down the middle turning over. This actually maintains a perpendicular plane and your index finger is giving you that hectic feedback and feel of the blade. Blade cutting edge no matter the size is all the belly and what blame what operation is entirely up to you. You can do small operations with big blades and big operations for small blades. Suffice to say that a large incision would be better, better off with a bigger blade. But that doesn't mean to say that you should be nervous. I had the privilege of going around the factory and Sheffield down the road that makes these plates and supplies 1.7 million of these blades a day to over 100 countries. They've got their own on site. Cobalt stone lies in plant and I walked around this. I was amazed to see the process. Am I going to show us slide with you? Now that they've said to explain the edge because they didn't quite understand the sharpness of the edge. Which so if you look at at the top, left hand picture, just green, top left and picture that's a electron microscopic picture of the blade down the middle is the edge that side and that side of the two sides. And you note they're different on the right has smoothed, polished on the left hand, the final bring of the blade is left saturated, it is not smooth or polished. And this is done deliberately to maintain, give you feel that is necessary through the tissues. You can see it's on a metallic surface with the method. And that's why it is very important that treat your blade properly. You're quite right when I thought change the blade, when it feels wrong, when it feels different. And it doesn't matter how much change times you change it genuine operation. If it feels blunt, it is blunt and when it is blunt, you're going to be macerating tissues. So in order to practice, feel the number of things you can do, and I remember doing a cory artery bypass graph and a patient with her protection. Let's see. And the registry decided to put double of song. I asked if he usually use double gloves and the answer was no. And I strongly recommended he did not because he had lose the feel. He ignored my warning and proceeded to harvest radial artery halfway through the Stromboli. I had a plaintiff whale, David and I looked up and the blade had cut straight through the radial artery. We had Hepatitis C infected blood spraying all over theater. So, although the patient Mikey HIV positive Hepatitis C positive, I personally would not recommend loving because you'll lose that field. How do you practice feel at home? Well, I went to the supermarket this afternoon and walked around and thought, what can we play with this evening? And I have here some Tums. It comes in a pack. It was of different layers and this is a great way to start practicing your feel of taking the knife through the cheese and sing if you can cut one layer without actually touching the layer underneath. Core Daniels, that seventies addition would say just like that, but not only comes with experiments, you can feel the blood going tissues and feel it reached the gap underneath. So let's try it again, shall we and see if there wasn't a fluke. This is also a fabulous model to practice cutting in a straight line. There you go. I haven't beneath we also have a question David from Chris. Maybe you could also explain or discuss how human factors can be used to improve on what you explain in like the first part of the session. Yeah. Well, that is a huge question that I've been talking to Professor Paul Barrack about who will be our guest on the 13th of July. The important thing is is that before you make the incision that everybody in the team understands what you're going to do in what order and what things you're going to need. And they're just like, no stopped, take off because there is missing equipment. Like first send this one, I came across as we've been through the briefing had and then I was informed, stop, stop, stop because there's no option. Germany. The ridiculous thing I to you noted by the anesthetist whose daughter pointed it out and everybody said, don't worry about that year. And although they ran out of oxygen, nobody knew there were still three bottles of 2000 liters of liquid oxygen that should we switched over manually when you run out. But nobody knew that where that was. It turned out the oxygen delivery at the hospital was cool Bob from British Oxygen and ask him if he's passing by, could you deliver some off a catastrophic system played from top to bottom? Patient was fine, but it was on the operating table for three hours as we sorted out this debacle. Not a good example. So stop this. We've deviated. I added a few more. Let's see if I can cut through two layers. One, two, nothing. I mean your practice is very simply take a knife through different tissues and feeling your. But we have another example I have here. A stack of cooked hum. And he told me to take away thing applies. Yeah. Now perceived that my knife is feeling somewhat blood just after incisions. There you get, I've cut through and I asked you to see yes, there's any mark on the ham underneath. Remember this is live. I'm not staging it, but that's the level of skill and practice that. I hope of course. Now you can start mixing textures and this is not too dissimilar to making a ham and cheese salmon different layers. And we're now going to cut through the different layers, know that are automatically put my left either side of my as I'll demonstrate in a moment that is important for stabilizing the tissue and maintain the tension, says, deliberate what I like about this cheese and ham model. It tells you if you're cutting straight as well. So let's see if I can go through cheese and ham but not the ham underneath. And to be honest, I'm going to say, I think I should have changed my blade because I'm losing that hectic field back. Take it off. There you go. I think I'm going to quit while I'm willing in there and you can see yourself, I have not cut it underneath. All these things are vitally important in understanding and appreciation of how to use your blade. Mhm hmm I am doing that have only gone through a few layers of cheese and a few layers of ham. And I'm therefore now going to change my blade because my hand and deck feel tells me that it's losing its edge. And the last thing you want from a surgeon is for them to lose the edge. So I'm going to change the blade and move over to a leg of turkey. I've used leg pork belly in the past, but I've concluded that pork belly is now becoming rather expensive. And of course, in some parts of the world, pork belly cannot be found. So a much cheaper cut of meat is a turkey leg and we're going to have a little fun now with a bit of turkey leg and damaging some further skills for a knife. And I'm just going to amount this plate and we'll move the other, come back over. Now, there's something quintessentially English going on in the background of brass band music. I'm not sure if they've got a live brass banning somewhere from the park, but it sounds quite familiar and on the summer evening with tweeting beds, that's quintessentially in addition. So this is a five of a turkey. It's an amazingly big bird, but I want you to use this to demonstrate something because you can see here, the skin is not too dissimilar to skin that you'll find operating. And the important thing is when an incision is to support the skin, either side with your hand all the way down your incision, the blade has been 90 degrees at each stage because the last thing you want to do is to bake and slice. And I can demonstrate that with an orange that is effectively bacon slicing. And you can see you leave a very thin piece of orange there with the same with the skin and that wouldn't be crows and result in a bad wound. That is why the blade has it at 90 degrees to the skin throughout. Trick them is that's fine of his five centimeters. That's all right. But can you do it over 20 centimeters? Everybody used to laugh at cardiac surgeons and say it's only one incision, but you try 20 centimeters straight down the middle without turning around your hip. Because after 10 centimeters, the only way to keep going straight is to abduct their arm and be conscious that you're not turning your body as the knife curves around there. You see, I've supported throughout and cut it cleanly down the side. Now, at this end of the wound, I'd want to point out something awesome. When doing an incision. You need to make sure you use the full length of the wound. You do not leave bits because you'll find as you go deeper and deeper. If you do not use the full length of the wound, your whole you're looking at gets smaller and smaller. So think of your wound as an inverted pyramid. The skin is the smallest part of the incision. Everything else underneath can be big. And of course, the skin can move over and move around. Suffice to say that if you put retractors in and hold them in for too long, that area there becomes aske emmick and again, it would ruin your incision. So blade, I'm count Lee using is a 22 blade. My original trainer and surgery, Mr William Water Frederick Southward. He was Zorro with a blade and was able to do a gastrectomy in 20 minutes and open up a redo abdomen with this blade as it whipped through the tissues he had was a master of control even on these tissues. Simply each layer supporting and feeling your way through as part of your dissection and part of the layers. Yeah. And each layer should be cut with a knife. Unfortunately, today, there's a tendency for people to make the skin incision, pick up the diathermy and then for great all the tissues underneath thinking that it's stopping bleeding. Well, it might stop bleeding. But the two things that are happening, one, you're burning and destroying the tissues. Two, the smoke from diathermy is actually carcinogenic. And unless you doesn't extract her at hand, not only are you doing a patient at the service? You're doing yourself a disservice. Note that I'm not pressing very hard as I dissect down the layers here. And as I found a layer, I can extend my incision to develop that plane further. And there you go all the way deep tissues. And I'm using, trying to use the full length of the incision. When it comes to bone, the blade can be used as a scraping tool to take the tissue off the bone and their origins to expose this an orthopedic surgery and the periosteum and get round in a bloodless plane. See that I have now exposed the bone and all the way down. I've kept sharp dissection and respected the tissues. Please do not die thymine these layers because it's blood and a little bit of bleeding that is absolutely necessary to enable you to bring the tissues together in a good way. The other way to hold the blade for dissection is to use it and think of it as a brush that you're brushing is dissecting edge away with the blade itself. You're not cutting into the gap and I'll try and demonstrate that to you here and try and separate you see there, that little bit of muscle from the one underneath. So I'm going to gently hold it up in your system for there. And now I have opened the blade out to the base of my fingers and gently holding it and literally brushing the surface like that. And it's the sharpness of the blade that is enabling me to develop this plane. And as you get used to this technique, this becomes a very, very effective way of developing tissue planes. As part of your dissection was brushing, brushing it through. And what I commend you do, this is a turkey leg. Uh I've got two big pieces for five lbs from morrisons. As long as using style instruments, you can cut and fill it this and then use it at cooking at home. This is what I call sustainable green surgery and change it into a dish but have fun just practicing with the knife and getting the feel. And once you more confident, you can be bold with your strokes. I'm going to be a little bit bored deliberately. Now to show you that I'm being bold with my strokes to actually get into the plane and develop it further. It's a very, very effective way of developing tissue planes that only comes with feel if you can't use a bit of meat, then I suggest something very simple for the fish. Any fish will do any idea or you switch to fish. David have just another question from Chris. Um Could you expand on the carcinogenic effects on the diet thermic blue? And what steps can the surgeon take to ensure that he's not exposed well or she to these gasses? Thank you very much Chris. The simple thing is reduce your diet. Stomach diathermy should be used as a pinpoint diathermy on vessels only. And they should be used on small arteries with large thick walls of probably less than a millimeter. Veins do not diathermy because they're not muscular and veins and any veins and tissues need to be tied. So, die theory is not the answer to good. He was stasis until she handling. I would actually, if I smell a lot of diathermy smoke in theater with a trainee, I discussed with them the, the fact that they're damaging tissue, but also the smoke itself. If not extracted with a fan or preferably uh extraction sucker near your wound, you'll be exposed to it and everybody else will as well. It is an unreal. It is a poorly reported phenomenon and I think people should become more aware of it, but you can mitigate it by focusing on your tissue handling and reduce the need for your diathermy. Anyway, of course, bipolar diathermy is a lot kinder to the tissues. And my colleague, Mr Carrey is a plastic surgeon has been doing lumps and bumps lists and you'll probably say that he is a big advocate for bipolar diathermy, which is fabulous for small wounds, small operations in small areas and it respects the tissue because it just deals with what you pick up between the forceps. The idea behind this fish model is very simply again to use this brushing technique as I've described against the scales and try and take it off such that you don't have any fish on the skin and you haven't macerated the tissue underneath. I am thinking to myself that this blade is actually getting rather blunt because I've used it for something else at the present and at this point, I would not have any hesitation in changing the blade. Now, the other thing which I haven't mentioned is changing the blade means passing the blade in a kidney dish. But if you have to pass the blade, it's handled first laid down directly looking at the person watching the hand them taking it never snatching it. The safest way is to pass the blade in a kidney dash. But as you put it in the kidney dish, remember that microscope picture if you drop it in there or the other instruments in the dish, metal on metal, on metal, on plastic of the kidney dish can even blunt the edge itself. So there you go another little model to practice. So now let's come to the smaller incision and the 15 blade I've made Allegiant on this orange. And to take this lesion out, I need to do a fusiform incision. I can I and it needs to be long enough such that when I pull this together, it comes with our tension, but you have already determined preoperatively that this fits with Langdon's lines. Remember Langer was that Austrian anatomist who described Lange's lines by using ice pick and going around making multiple holes in cadavers and noticing that some holes were remained open and as others closed. And in doing so, he mapped the body where the tensions across incision's naturally brought them together. And other places like that, it is useful to understand how these language lines go around the body to help you with your incision and excision. So this is a different blade handle and this is called a barren blade handle. And you were sent to me by Sensei Christopher Keady. Your note that it's not unlike a pencil that has got an octagonal handle that enables you to roll the blade in your fingertips. And in such, you can hold this blade as you would hold a pen. It gives you the finer control. The important thing is is that you are able to make an elliptical incision and with this fusiform sorry Mr Kaddoumi fusiform incision. And at each stage, you are certain that your blade is perpendicular to the skin. The great thing about this orange. Now, as I can't see where my incision is the other side there it is. And I'm keeping he played as I'm going around perpendicular to the skin. And what I like about this orange model, let you see in a moment again, it's an unforgiving model as far as perpendicular to the skin is concerned. I think I've got it and try and lift this out. Um really, I'll have to have a nerve hook probably. But let's look at that marvelous and why I've just torn off the edge off, but completed here and there's a full length of my decision. And again, this is another lovely practice model because try doing an excising a lesion on a knowledge. And now the two things about this one, I've excised it, as you can see within the 11 blade are going to test it. Now, I'll put my clean cloth underneath. I'm gonna squeeze it there, no drips, no juices. So you're satisfied that I have not actually cut the skin underneath. But the other important thing is if we look at that now zoom down. So you can look at the excision and this is important for all your lumps and bumps. If you look at that excision, the edge itself is perpendicular throughout the fusiform incision perpendicular to the edge, you can see that if you look at the other piece, it's a clean cut. So it's not too difficult to imagine that interrupted sutures from either end will bring that together. As a perfect incision. You have respected the tissues. You have used your blade at 90 degrees. You have felt the blade go through each of the layers, you're caressing the tissues. This is what surgery is all about. I had another model here as well. I've never tried this before, but this is a, I'll probably get a clean blue for this. Before we do that, I just want to explain the 11 blade, the 11 blade is for stabbing. And as you quite rightly answered, and all the questions usually for incising and drainage of abscesses or I use an 11 blade in creating an aortotomy for 10 Eurasian for cardiac surgery. Hold the adventitia scrape it, insinuate the blade, hold the adventitia over and then put the cannula in all by field. The thing about this blade is the depth can only be controlled with your finger on this side. So the death of my incision is maximum between the tip of my finger and the blade. And if I wanted less, I take my finger further down the bled. So if that's the thickness of the skin, I can literally judge the thickness of my incision because my fingers on the side of the blade and I cannot push it in any further. Let's have a look. And this way you can control and be very delivered about your cuts. These are perpendicular cuts. You see that and I actually haven't gone full thickness through the orange. As you can see the pith is still there. So the control of the 11 blade. There you go. Yeah. The control of the 11th grade is achieved by putting against the top of your finger. There's no way that I can stab that orange if my fingers there take it away free form, of course, and there stabbed and problematic. So all of this really and truly comes with a volume of experience. And as you do more and as you practice more, you become one with the blade, you'll understand how it's working for you and you appreciate that haptic feedback and now appreciate the design. That's one Morton put in that blade to have one side, slightly rough and the other side shiny. This helps them to be honest with their quality control. And what was remarkable to see these ladies doing quality control on a band of 250 surgical blades picking them up and opening them up and finding them out like a pack of cars for what they were doing is they're so sharp, they're doing it under light that the blades do not reflect the life back. So when they look at a pack of 250 blades under a light, they get no shining back because the blade is sharp, that one side slightly rough in the other side is polished smooth. If they get a glimpse of light as they flick through those 250 blades, they know that that blade has been damaged, it has taken out and was put back for recycling. So the glint of the blade, as you note in the photographs that I put up, there was a glint on the blade. The glint in the blade did not show it was a perfect blade. The glint on the blade showed that the edge had been damaged and you can do that simply by putting it in indiscriminately on a tree, a kidney dish or shaking it around without the instruments. The surgical blade coz a heavy weight of responsibility. And is your duty is training surgeons to become comfortable with the essential tool of the surgeon. The scalpel blade have his wives emblematic of the association of surgeons and training before you pick up the blade, you could be certain of what you're doing and why. But as Chris said, from a human factors point of view, everybody on the team needs to be with you too. And I'm delighted in two weeks that Paul Barrack will be joining me on the 13th of July to discuss human factors and explore as we're going to call the blood brain barrier. Next week, I'm going to start the basics of stitching. I'm gonna put up some pictures for you in the questions session beforehand and ask you to list all the things that you think could be wrong with the picture and we'll discuss those elements next week as we begin our series on Stitching. I'm very happy to take in questions, observations from anybody. I would like to thank Gabrielle for her production and wish you well in her exams. She got three exams this week. It's still has found the time to join us an offer. Excellent production. Thank you Gabrielle. Good luck in your exams. And thank you med or any questions. Yes, we have a question about the stitching session, uh, date next week. Uh, on Monday evenings, always on Monday evenings at eight o'clock. Same thing. I'm sorry, I've been a little tidy and actually putting those up because I've been chasing down special gas appearances and I wanted to interdigitate them with the program of stitching. But we're going to be gave through the basics of stitching for the next month with a few exciting speakers talking about human factors and what it means to be a surgeon in between. I'm also hoping to be joined by sushi chef to talk about the blade as well. And scalpel skills if you really want to see an artist did wreck, you should look at what some of the sushi chefs do in their restaurants. Thank you very much. Any other questions? Nope, not at the moment. Thank you very much. Indeed. Wish you all well look forward to seeing you next week and I hope this has made sense. Do fill in the feedback form. It's useful for us and it helps us develop the sessions and develop the learning. Mr Cuddy. Would you like to come back in and make some observations, please? It might not be there. Thanks Gabrielle. Oh, yes, he is. Oh, yes, he is. Oh, yes, he is.