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Hello, good evening. Good day. Good afternoon. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon, immediate past director, Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh, and a visiting professor at Imperial College London. Thank you very much indeed to the 4230 Facebook followers and the 653 followers on Instagram. And thank you for joining this evening, Riu. Hello and I believe Alice, you're joining us for the first time. Greetings. And if you are joining us for the first time, welcome. And I hope you spread the word. The Black Mount Academy is focused on technique. I don't teach speed. But if everything is technique and even with the blade, there is technique, what intrigues me is that since the 16 hundreds, the art of Yao has been refined, described and prescribed the way you stand the container, the way you draw it and the way you put it back in or all part of a ritual and routine that forms the art of the idea Yes, my blade is a live blade. It is razor sharp. And because I'm registered with the International Martial Arts Committee and I, the second down in United I'm entitled to use and practice the blade, but I cannot take it along the street native like this and of course, have to have it in the bag. The thing is what amazes me is that we've been using scalpels since Egyptian times. Scopus is a Roman term. And until the 19 hundreds, the scalpel was a single piece of ivory or wood that was used as sharpened too. Of course, caveman used flint for scraping hides and dividing skins. It was the razor people who picked up on using razor blades and scalpels and King Gile was one of the people involved. The new and early scalpels progressed to be one piece of metal, but of course, this had to be sterilized and sterilizing it. It became blunt and there was an increasing demand for a technician to sit in theater in the corner to sharpen the blade. What's interesting the art to sharpening the katana. And there's a lovely video on it takes months of artistry care is shaping the blaze. And because this was a problem, Morgan Parker in 1915 decided to actually produce a handle with separate attachable blades. He numbered his handles 1 to 9 and this bleeds 10 to 20. And whenever the blade became blunt, it was detached and replaced with a fresh one, they were later acquired by Becton Dixon, but the patent expired in 1935. And that's where Swan Morton and Feathers together, they now produce 1.7 million blades a day. They, they sent or under the close and they're based in the center of Sheffield. I have the privilege of going around the factory and they kindly supply me with scalpel blades. We're going to do a special video to show you more about the production of the blade. The important thing is like the katana, it is sharp and safety is up high. And that's why Swan Morton have progressed to actually produce disposable blades, but a blade with a sheath that covers it at disposal. And they've recently sent me a special box putting your blades in and disposing of them. The point being is that the blade needs to be respected and they passed from one person to another. It needs to be passed, handle first, lay down and away. But that's old fashioned. We should always pass your blade in a kidney dish because that avoids injury. And I know to the questions that some of you have cut yourself and because it's so sharp, you don't notice you've cut yourself until it starts bleeding profusely. So the first part of the Black Belt Academy and as in martial arts, there are some basic rules that if you fail to adhere to them, you would fail you blackout graduation, same, you know, I do. They're a little bit more particular. I do. If they see the ball of your foot as you're moving around, you will be fed. So let's come over and look at the blade and reinforce blade safety. We have a number of models for you this evening and I had fun walking around Morrison's looking for material to practice it. I've upgraded my lights and I was informed that these Phillips lights would not give the flicker. I plugged, put plugs on them this evening, plugged it in. And unfortunately, I see that we have a flicker. I will 10 to that later date. So the blade taking off, you lift it out, you groove, apply a hemostat to the non sharp edge. And literally we draw the blade only one hand is moving and at all times the blade is actually pointed into the table. And how these blades work is that there's a groove we'll focus on this groove. You can see there, there's a little groove that takes your fingernail and that is the groove the blade sits in. So to put it on a note, a wide bit and a thin bit. He put the scalpel in and he started advancing it into that groove, keeping it pointed into the table and push it home, take it off, lift off the edge, how your hemostat pointing to the table and gently remove the blade. This is a one handed process, one hand stays stable and still you do not ever use two hands. Otherwise the blade goes flying off. Now, just as in the katana, which is described as one body, two body, three body, we best five body katanas, the five body katana in theory, can slice through five bodies in one go. And it's the point of the guitar there, it is called the Kasai. But the shy here, the sharp bit here that is the curve is the slicing bit. And this blade is particularly good at slicing. When I first started, I was at a competition and I inadvertently took it out and I didn't notice it until there was blood on the do that. But the way you hold the blade gives you that feel and the field comes, as we have described before by ensuring that you got a maximum application of the pulps of your fingers to the blade. You hold the blade like a knife with the handles buried in the palm. I'm holding the sagittal plane between my thumb and the side of my middle finger. And I've got my index finger extended down the shaft and it's the sagittal plane of field. It, it maintains the 90 degrees to the tissue and my index finger gives me direction and proprioception. Now, when you are cutting, it is important to support the tissue with the opposite hand and you're applying traction with the opposite hand all the way down the incision. That's yours. People have often joked as a cardiac surgeon, you only make one incision. True. I replied, but can you make 22 centimeters perfectly straight down the middle? Because what happens is that for five centimeter cut that we ask you to do at the beginning of the black belt, that's relatively straightforward, a 10 centimeter cut you should be able to do it. But as soon as you get beyond 10 centimeters, what happens is that people turn around the hip and shoulder and you end up curving your incision, not only that you lose the sagittal plane and the blade actually comes out. So a 22 centimeter incision requires that we stroke down. And as I'm coming down beyond 10 centimeters, I'm beginning to abduct my arm and maintain it straight. Remember as you're doing an incision, incisions are according to bony landmarks too often, I've seen trainees being distracted because the drapes are being put on and they think they're parallel to the patient, but also in putting on the drapes, what happens? It pulls the fat across the body. So when you're putting a drape taken from top down or bottom up, say you remove that lateral pull of the skin and the fat over the abdomen, leg or body, your incisions are always planned to bony landmarks because you remember know how big or small you are, the skeleton is approximately the same and the bony landmarks are directly related to anatomical positions. So part of the field. And one of the exercises we ask you to do in the Black Rot Academy is, can you feel your blade through the skin of an orange all the way through the skin of an orange? I'm rotating those straight, but I'm using the curved, not using the tip. I'm using the curve to cut. And if you cut through the orange, you can see my cut there and I squeeze it. If I've cut into the flesh, you will see drips of juice into that dish. And part of your practice and field is to take any material, any fruit. And can you take your knife through the skin without cut in the flesh? So let's have a look, shall we? And the other important thing about this is in cutting it. I want to actually see that I've cut perfectly through the skin stuff because that is bacon slices is when you lose the sagittal plane, does that effectively to the skin that becomes very difficult to actually stitch. But also this thin bit of skin will become de vascularized. And Nero's the exception to the rule on holding it like a knife and not like a pen comes if you're using a 15 blade. And thanks to my fellow, since then Chris Cody, he's a plastic surgeon in Sheffield sent me this barren blade and the barren blade. You can see his octagonal. It's more like your pencil. Now, certainly you can hold this blade as a pencil and it gives you that fine movement of rotating the blade, which you note that is again, my application of my thumb, my index finger and my middle finger supporting it and the support is also cradled with the first dors of to. So one of the common things that we are asked to do, certainly in one's general practice and minor surgery is excise a lesion and there you go, that's a lesion and we need to excise it, to excise it. You need to do a fusiform incision and the fusiform incision is taking around the lesion and they need to be longer than the diameter. And the reason for this is is that you then can bring two edges together in linear closure. And I've just drifted off there. I can see that and feel that drifted off there, massage it little the plane and it's particularly in microsurgery to get a perfectly perpendicular incision on a fusiform incision is rather difficult, but it is absolutely necessary to enable the two edges to come together. There are many ways of actually practicing the field of tissue. And if you go to the supermarket, you'll see packets, cheese packets, meat. You can make it up yourself previously. I used bits of pasta. But even after that short dissection with that blade, I'm taking another one because it is now blunt in this exercise, I want to try and cut through each layer of this Montet cheese without cutting the layer underneath. This Monterey Jack cheese that I used to put on the hamburgers that we put on the barbecue this evening. That's through one layer and it's the lightest of touches as you stroke the knife down through each of these layers, two layers. And I've said previously a sustainable surgery, this cheese is gonna go back in the fridge, a sandwich but also a treat for our dogs. Nothing goes to waste when it comes to the last letter, I've got a slice of bread underneath and that's exactly what we can do. You can think of this as a sandwich. Now, can I actually cut through that layer and you can see how easily you go straight into the bread. So let's try that again. Tried to go through just the cheese without scratching the bread underneath and that's better. And this is giving you a feedback of the depth and appreciation of the tissues that you're working on. Whether it's just cheese or whether using a slice of ham and these are thin slices of ham again and should be out here, practice literally the weight of the blade. He's taking me to that ha. There's a little scratch at this side. You might not be able to see it, but I can see it here, but I have not gone through the challenge that I wonder if I can go through two lens in once the third. Uh OK. Here we go not promising. But these are, these are the exercises that I use to challenge my skills. One, two, there you go. I've now cut the two layers without touching the third layer at the bottom. And this is all with the application and understanding of the depth of the field that we're using and applying at every stage. There you go. Monterey Jack ham. There's a slice of bread there, put that on top, voa bit of let lettuce some mayo and you have one handover ham and cheese sandwich. There you go. The other function of the blade is not only understanding the dissection and sharp dissection is ski dissection because it doesn't macerate tissue. When you start macerating tissue, there's a propensity for bleeding and the bleeding will lead to scarring edema and reduced function. That's why clean dissection, a sharp dissection. So I have a salmon silk fillet here and we're now going to change the way we hold the blade from the standard way of the index finger down and between finger and thumb. I'm now going to move it out a little bit because I'm using that blade now to stroke along the surface. And the idea behind that is that you are developing a plane and removing it. So last time we used scissors and the scissors were very useful in situations where you've got a short area and you are de but if you got a long plane, you working over a large area then the best thing to use is Alade. And the idea behind this, as you see, chefs in the kitchen is to try and take the skin off this without tearing the flesh underneath. Now, the difficulty here is I have no assistant to see me and that means that I don't have anybody to hold that air it and hold that bit as I go. So in some respects, I'm actually operating with my hand behind my back. You see now I am now brushing, I bleed, not against the flesh but against the skin. You never actually take your blade into the space between the flesh and what you're taking off because in doing so, you are going to cause damage. So I'm using, I bleed to develop a plane by brushing a blade against the skin to dissect this off. You're working over a broad surface and it's not supposed to be easy. These models have been deliberately chosen to test anybody at every level on their skills. Some might actually say and laugh because, oh, that's too easy. Well, you tried yourself and the next person is stops, invite them to try it as well. I can assure you they will certainly change their mind once they start because it all requires the lightness touch. I'm finding that blade is actually getting blunt and I'm therefore going to come to another blade. And how often do you change the blade? You change it whenever you think it's getting blunt, at least we don't have to pass it to a technician in the corner, the theater to sharpen it and sterilize it again. And thanks to S Morton, we have an endless supply of carbon still leads. I think they've got 73 different types of rates. But I, the common ones that we use are the 22 the 10 15 and D 11. Now the 11 blade requires special attention and discussion because the 11 blade is used to incise or puncture, pointing abscesses. In this case, I'm not using the blade to dissect. There's a point because it's got no belly. I'm using it to insinuate the blade into something. And in cardiac surgery, I'm using this to actually do my aortotomy to put the arterial pipes in and in doing so to control the depth note that I've put it against the palp of my finger. And therefore I've got a clean feel of the depth I'm using this and your finger can determine the depth. So if that, I think that's probably the depth of the orange skin. Let's have a look. Yeah, that's the depth of the orange skin. Well, come over here, I can sign it. Nothing comes out. What about on my banana skin? Can I actually make a stab incision into the banana without going through? I'll have a look at that because we now we going to try incise the banana skin and feel your way through. However, I cut the flesh underneath. There you go. And if you look on the other side, I've actually gone through the banana skin with a lemon blade and I have not cut the banana. There you go. Slight, a little crease there maybe, but I haven't cut it. And I felt my blade all the way through. Do not ever be hesitant with the scalpel, clean dissection, a sharp dissection and learn to feel the death. Now, the other story I have, when I say feel you do need to actually have your fingers applied and understand the different pressures as the blade goes through. We have a question from Chris. Yes, of course. Why are you using non tooth forceps to demonstrate the technique? Because that was at the top of the box and I left it there for you to point out Mr Caddy. I quite agree uh tooth force and you should also do as a plastic surgeon. You do not use tooth forceps of the skin, you would actually use a skin hook to hold, but I did not actually grab the banana with the forceps, but I could actually have used and prefer to have used two forceps on the fish skin. Certainly. So in this particular case, the patient required coronary artery bypass grafts and was hepatitis C positive but was a young person. And therefore, I elected to use arterial grafts and internal mammary artery and a couple of radial artery jump grafts. The reg who is quite proficient at taking the regular artery decided to put on double gloves because the patient was hepatitis C positive. And I strongly recommend that they didn't because they don't usually wear double gloves when operating. But he insisted and I proceeded to the chest and he proceeded to work on the arm on the opposite side of the table. Haven't got to the d there's this pl of voice that they said yes. And I looked up, but what he had done with his blade has gone through the skin and straight through the radial artery in one fast swoop. So we had hepatitis C blood spray all over theater as a result because he ignored the fact that double gloving would have turn his appreciation and feel of the tissues and the knife. Everything we want to teach you in a black cat simply comes down to fear and that is the application of one p against another pal, which is unique to the human hand to be able to extend the interphalangeal joints. And with the opponents policies, bring the two together. We ran the tic course at the weekend and a lot of members and I think Alice is on the co had a house as they suddenly realized. In fact, it is a and the metaphor I was using at the weekend. If you imagine rubbing a little bit of salt to flavor the food, we take it with the soup salt, a little rub of salt and it's that movement and that feel that is required. Remember that you get a bigger sensory input from your fingers to the brain, then you do from the eyes to the brain. I'd like very happy to take questions and answer any questions or demonstrate anything else to you this evening, Gabrielle. Do we have any questions? Not at the moment. However, I encourage people to put them in the chat if they have. And I'd also invite you to send in pictures of models that you have dr up at home. So we could share it with the global audience. We're going to announce a competition and the winners will receive their own set of. So we are looking for the most innovative models that you're using at home to improve your skills. And we have a question from Nicole. What do you think about robotic surgery that removes this feeling as well? That's very interesting. I totally agree with you there. And I think it is, it i it is interesting. It is interesting because I've used a robotic survey and you totally remove the haptics. But then I also think of the electric toothbrush. I use that when you're pressing too hard, it actually flashes red so you can build into these instruments, some sort of feedback on pressure and feel the difficulty I have with this is as we become more specialized in robotics. And yes, the demand is there is the old added in surgery, the smaller than the incision, the bigger the mistake you might call me old fashioned. But that is true because one of the things that happens when people run into difficulty is because they haven't set themselves up properly and it's access table height, lighting, rotation, positioning. All that is there in robotic surgery. If there's a problem, one's gonna have to open. And I sincerely hope that the use of the hands and surgical skills doesn't disappear. I see it as an adjunct and a useful adjunct to the advancement of surgery, but I do not see it as a complete replacement as yet. Certainly machines and robots are learning haptics and do give you some feedback. But I have not felt anything as yet. Although I was delighted to see on social media, somebody peeling a banana and stitching a grape using robotic surgery and they were sitting at a console 5000 miles away. So you never say never. And everything is possible, but the haptics are certainly going to be important. And the other thing is I would like to actually salute all my female colleagues because you're quite right. The journal of American Medical Association published a very good paper that demonstrated that women are actually better than men at surgery. And the reason I think that is is because they focus on the technique. There's no rush, there's no brute force and you're gently caressing the tissues. I think the other one is the smaller hands. You perhaps got more maneuverability, particularly in deeper spaces, but either which way salute you get better results. And I think men could, should stop and think and focus on the technique more. That's my reply to the German people. Thank you for sharing that. Um Now the other question we have from re is what are the uses of size 22 and 50? Thank you. Re well, what's interesting is that you're actually cutting with a curve of the blade as I'm cutting with a curve in the katana. And if you look at the curve, they're much the same and your knife is coming in at sort of 45 degrees. So you can optimize the blade the same with the 22 blade. The actual curve area, the cutting area is much the same. There seems to be a hesitancy using 22 blades and for dissection, I really personally love the 22 blade. And I suppose it goes back to my training, Mr William Walter Frederick. So who watch pocket coat tie, morning suit trousers, use the 22 blade, but he could open up a redo abdomen like Zorro, I could, his knife skills were super high. And I think despite the blade, the size, if you're confident with your technique and you've got a good feel, I think in that section, the 22 blade will enable you to make more progress than a 15 blade. A 15 blade is extremely good for framework. And in that situation, the 15 blade on this iron we hold, it held like a pen gives you the skill to maintain 90 degrees with your incision and small incision. It's also very good for micro dissections in small areas. So I'd say it depends on the anatomy, but the principles are the same and you need to understand the feel and that is the important thing. You can use anything. Absolutely anything as you walk around. I was looking at the avocados, I looking at the peaches, looking at the groups, all elements to actually practice and understand that the simple lightness of touch and a stroke and the blade would do it for you as were all the instruments, any other questions? Um I'm not sure if that's a question from Chris or comment. Uh He says your comments are relevant to how we use knots as part of presence in the operating theater, my or ss surgery, you need stillness of mind. And I like the Japanese term mao Ku mind like water and only with stillness of mind. Are you able to focus on what you're doing? What was interesting on the park course, we took everybody off to play golf at the end of this and the group addressed dance position and set up is just as important in golf as setup is in all surgery, but it's also the mindset. If you have a troubled mind and not focusing, you're not going to be at one with the instrument. The word used to describe the art of drawing the sword. The ido is serenity. One starts in the Caesar position, breathing quietly gathering your thoughts before you draw the sword. You never ever draw the sword in anger, yo body language, communication and frustration will ripple across the waters of theater and be felt and seen by absolutely everybody and the temperature of the water and the temperature of theater will go up. We know from human factors that the cognitive abilities fall in those circumstances. That's why another reason for you to practice till you can't get it wrong because there will be circumstances in your career where you are faced with catastrophic or difficult circumstances. But if your technique is good, you can always rely on it and thinking critically under pressure. It is always there for you and it's the same in martial arts, same in sports and same with everything else. The Japanese call it Shin or Kar. And then five elements to that which we'll discuss at a later date. But paying attention to the smallest of things the red Indians call it our eyes, being able to see everything and in the US Navy seals, it is being able to see at a distance. It called sp rides to see everything, but also focus at the same time. And different disciplines, sport sales or train this and recognize this, but we are very poor at explaining it in surgery and that's why we're trying to highlight these parallels with the Black Academy of Surgical Skills. Any other questions? No, it looks like that was everything. Well, I'd like to thank you very much indeed for joining us and Gabrielle. Thank you very much indeed for producing and being behind the scenes. Next week, we are going to talk about history and examination because it's incisions before incisions if you're uncertain. So I have any doubt, I'm not quite sure who do not have enough information. You do not make an incision is now Ghani, our guest speaker and airline pilot, he would not take off if you had any doubt. So in surgery, it's much the same. You have to have all the information to hand to make the right decision to make a good incision and we'll discuss that in detail next week. And at the end of the, my fellow says, Chris Carry and Tim Terry will talk about k reflection and mindset in more detail and the need to actually have a mentor and coach to maintain the right mindset and surgery and maintain your mental status because the two good together. Thank you very much for joining the Black Academy. I wish you well, we'll see you next week. Do fill in the feedback forms, do send in suggestions and please send me photographs of your practice at home. Thank you and goodbye.