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Do ask questions and encourage you, ask questions. Hello, good evening. Good day. Good morning. Good afternoon, wherever you are in the world. And thank you very much for joining the Black Belt Academy of Surgical Skills this evening in the UK, it's been raining all day and therefore I've come inside and the studios somewhat smaller. My name is David Regan. I'm a retired cardiac surgeon, the immediate past director, the Faculty of Surgical Trainers and the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. If this is your first time, thank you and welcome. And if you're returning, thank you very much. Indeed. We've got 4230 followers on Facebook and 626 on Instagram. And thanks to your viewing of the Black Belt Academy, we have received exceptional Educator Award for the fourth quarter in a row from medal. And I'd like to thank me for hosting the Black Belt Academy and Gabriel who's in the background producing this event. Please put your questions in the chat, they'll be read out and I'll be happy to answer any and all of them during the session do not hesitate. The Black Belt Academy of Surgical Skills is focused on correctness in getting it right. Because in martial arts, it's technique before power and speed. It's somewhat of an anathema to me. When I look through the photograph of basic surgical skills courses advertised on social media, I looked through 109 of them and found that more than 90% were standing. But then I looked through the same photographs again and identified half of them had photographs where the forceps were visible. And in those 71 forceps were visible. This was in student societies, professional societies and college advertised basic surgical skills courses. And I looked at the hand position and the holding of the forceps and could only identify it being correct. In 32% of cases. In 78% of cases, the forceps were not held at all properly. And in seven, the forceps were actually pinching now with the student surgical societies. And I presume, uh this is being run and overseen by peers with no expert trainer present, but the grip and the hold of the forceps was quite varied. And I brought with me this evening my barbecue tongues because some people hold them as an overhand grip. Literally the hand on the forcep to pick this up. I find this particular movement pretty handy when turning sausages or rolling drumsticks on the barbecue. The other hand movement is the underhand movement and this is pretty good for flipping over steaks and serving salads, but underhand and overhand was predominant in the student basic surgical skills courses. So to my mind, we are not addressing a fundamental issue of how to hold the forceps. Now, the intrinsic muscles of the hand I think are the surgeon's best friend and we should be using them all the time. Why? Because it does that and the muscles that do that and we can't see it there. Let me bring you over to the top and show you from the bottom. The muscles that do the extension of the distal interphalangeal joint are the Lumb course. And the lumbrical arise from the long flexor tendons that run underneath the flexor retinaculum and arise from the medial border from the tendon of the index finger, middle ring and small finger and they inserted and cross the midline of the finger into the extensor retinaculum of the distal interphalangeal joint. And that's exactly what they do. The opponents policies brings the thumb across and brings the palps of your fingers together. And this is as are written on here where you feel the instrument, you feel it with the sin cells, me cells within the palp of your finger. And you have more sensory input from the pulps of your finger to the brain than you do the eyes that movement is extending your finger. And if you're standing properly with the elbow is slightly extended, the hands, palm a flexed, you have effectively isolated the intrinsic muscles of the hand, the forceps therefore sit across at first base and you fold your fingers lightly across the four steps and you bring them together like that. Now, as I was actually thinking about this movement, I was reflecting on the pinch and the pinch is a flexion of the distal interphalangeal joints. And that's done by the flexor poly is longus full of thumb and the digitorum profundus for the other four fingers, the muscles that do that are the two biggest muscles and the deepest and third compartment of the forearm. And that hanging on claw grip is what climbers use to support their body weight. You can imagine the power in that because you are using the major muscles of the hand. So way, by way of example, I was there looking at two bits of Plater with my left hand, I am going to squeeze this uh my fingers extended in my right hand. I'm going to pinch. Now, I challenge you to do the same. That is as much as I can pinch with my left hand. I cannot compress that any further. Whereas if I'm using my right hand, the distal interphalangeal joints, you can see that I've literally squeezed the play do to oblivion. And I can feel my fingernail pressing against the palp on the other side. But no matter how hard I try with my left hand, I cannot squeeze that any further. My point being with extension of the distal interphalangeal joint, you are using these beautiful intrinsic muscles of the hand and therefore you are maximizing the feel and improving your lightness of touch because the forceps when applied poorly cause damage. And you'll see here the tooth marks of the Addison's tooth forceps, these two little rat teeth on that side. Is it possible? And that's the view a little bit David. Yes, of course. Thank you. Is that better? Thank you. So, on this side, this is banana and I've applied tooth forceps and on this side, I have applied non tooth forceps or crushing forceps and I was doing this with a pinched grip, you will see the damage and the full thickness of the banana there all the way through that would apply to bao and the Victoza Histological. The studies have demonstrated significant damage. Imagine if that was the aorta or blood vessel, the endothelium would also be damaged as well because you have gone squeezed the living daylights out of it. And that's not surprising really to introduce a little bit of physics because if pressure equals force over area and the average male applies 25 newtons. And if the surface area at the end of the forceps is taken as five millimeters squared and not as generous translating that to five times 10 to 6 m squared force over area gives you 5 million newtons per meter squared. That is the equivalent of 725 P si or 21 times your normal car pressure or 50 bar. That is huge. That is absolutely huge and would cause significant damage. So part of your learning of your forceps is learning to be gentle. And as we have done with previous sessions, introduce low fidelity models for you to practice and I'll go through each of these models and I'd like you to come up with your own ideas as well. Now, Sura in Baghdad came up with this beautiful model of a boiled new potato. And what you need to do is gently be able to pick the skin off this potato and peel it off in strips. So learning lightness of touch without grabbing the flesh underneath like that, it was quite engaging and mesmerizing and difficult forcep in both hands. You can practice both hands. At the same time, the forceps being blunt can be used to gently tease tissue planes as well. Another easier example perhaps is the skin of a boiled pota tomato. There you go. It's somewhat thicker and see if you can take the skin off this tomato, take it off in strips. Now, if you're taking a dressing of a wound, are you dealing with the infected tissue? My friend Mr Caddy who is actually watching under well, will acknowledge that the bold tomato and the skin is not too dissimilar to infected tissue. I certainly come across that when during endocarditis around the aortic valve. You can spend ages playing around with this model. And what is teaching you is a lightness of touch and accuracy in picking up the edges without picking up the tissue underneath. It is possible to use many different types of layers and examples. This is cooked lasagna. And if I grab it, you can see it breaks off and if I'm drifting or dragging, it has simply using layers of pasta or layers of whatever you like. To be honest, learn to use your forceps without grabbing, without crushing. There you go too hard and a braces. So use your forceps to gently lift the edges and pull it away without breaking or tearing the tissue. I think organic tissue is a lot more representative of real life than any of the plastic models you could possibly play around with. It is totally and utterly unforgiving because there you go, it breaks was an rough touch. So I had some spaghetti left over from our favorite pasta dish this evening. And spaghetti, I thought to myself again, cooked is also extremely delicate and I'll try and put it against a darker background. I'll put it on the table. And my son said to me, can you tie a knot with some spaghetti? So let's get something longer. And I say thank you Alistair for Ch making this challenge. So this is a first live is, is it possible to tie a knot with a piece of spaghetti without breaking it without crushing it as well. There you go. Thank you very much. You pull too hard it breaks. But I think you will agree. We have met the challenge tying or not with a piece of piece of spaghetti. And that's what I want you to do is to have fun and use your imagination and creativity to practice these skills. You do not have to be in a wet lap far from it. All of this is available at home. The thing about these models and not spaghetti time drift or drag, it breaks unforgiving and is focusing your attention on handling gently without crushing the forceps, crushing with your forceps. I must say I like this challenge. Thank you very much. Alastair. You tried to yourself at home. It is not so easy but can you try not with you're spaghetti. There you go. Nor he spaghetti. That's a far. So the ability to pick things up gently and hold them without crushing or grasping or gripping by using the lumbrical is very important. The other thing is, is to practice your accuracy and very simply putting some r on the table, putting some spoons either side and again, with forceps in both hands. If you got a spare of forceps, because you gotta be adapt at operating and using forceps in both hands is pick them up alternative and put the rice into the spoons and that becomes fairly straightforward. But at the ACI conference, we introduced the more difficult model, the more difficult model is turn the brightness down what we have here is four bandi straws at different angles as seen with the shadows. And your challenge is to pick up the rice straw and put it into the straw and drop it in. Now, if I just focus down on this one, in particular, you'll see that the rice diameter is larger than the diameter of the straw. And that means you now have to start manipulating the rice to actually put it in the end of the straws. Our Charli Inna did a beautiful video demonstrating this and he put it to music in a metronome and this will be part of the surgical fitness app that we are developing to help you practice at home. As I said, it is useful to do it with both hands. We ran this competition at the aet meeting in Liverpool in March and people had to put a piece of rice in the end of the straw and go round in a circle and they had to put eight pieces of rice in four straws, two in each. And the fun thing was the fastest time was 15.4 seconds and people came back to do it again and again. Now the thing is if you drop it, you stop the clock and you start again and you have to think that some of these bendy draws about the orientation as well. And if you pick it up too hard, it drops away. The next model again, using the same principle is using a collection of seeds and these of seeds are different sizes and shapes. And if you grip it too hard, the seeds will go flying off. And it's all variations are on the same theme. To be honest, I have coriander HEPA senol, a mustard seeds. So the mustard seeds are the smallest ones. There you go. We'll focus down on that. Very small and you need it again. Pick them out, pepper, coriander ones, zebra colored ones. My forceps are a little bit sticky from the potato and the pasta and the fe seats. That's sorry. That was the, that was the Coriander seeds. The f there you go and the final seats. Uh, the other ones, you can make a game of this yourself at home. And if somebody's playing with you, they can call out the different colors and you need to put it the different seeds and you need to put them in the respect of spoons. So the pepper coriander mustard and well, we got it and the, and I'm using both hands each time because I need to keep both hands in practice. It's these little mustard seeds you can see are the most awkward as they very round, very hard and skid off across all of these can be translated into competitive games at home. So that is one lot of seeds. It was not really a depth. What we can do now is move over to removing seeds from inside of pepper. This is kind of fun too because we're going to have on the port side, a red straw and on the starboard side, a green straw. And after two forceps, we need to actually pick off the seats on the right side, try and put it in the end. So, oh I think these seeds, I'm not going to go into this because they are quite, oh yeah, just, just make it, make it off with the other side and drop it in again. Test yourself. How many seeds can you pick up? Put in? That is just at the limit of the diameter at the end of the straw. See if it works, it's not gonna go in that one. All of these are deliberate now, although we're doing it against the clock in competitions and go, you can see it only just goes in the end. That's the seed sitting in the top of that straw and then he just goes in. But all these should be done deliberately and purposely because it's important to be able to bring your forceps into the surgical field, deliberately, pick up, pick it up and deliberately move it away. And a little trick to use in the circumstance to help you with stability. You'll note that that my little finger has come out the side as a form of scaffold and I can use that to steady my hand and to make it more deliberate. And that's quite an order if necessary, use another Forceps to hold your instrument to pick it up. But at all times you've got the di IP joint extended. So the idea behind forceps is lightness of touch, accuracy in pre precision and to hold. And in hoarding by way of an example, I've got a piece of cloth here with a triangle on it. And when you're holding and assisting, really, you want to be able to straighten the edges. So if that was the suture, you're following your forceps are holding the edges, so it is straight. So if the surgeon was stitching down the black line, I'm following, I'm holding that. If they're dissecting, I'm holding that and basically, I'm maintaining a triangle of tension and a lateral hold and not a pull to enable access, expose the tissues and expose the area that you're working on. An intuitive assistant will be following the surgeon and anticipate where they're going to move and would therefore move their forceps accordingly. If you're following a suture, when the surgeon goes to the other side, you're swapping hands, note finger and thumb, holding the suture and note finger and thumb, holding the forceps. If the following goes the other side, I'm swapping my forceps over, never crossing the midline and continuing my hold finger and thumb, finger and thumb, all the time you're actually using these beautiful muscles called the lumbrical and extending the D IP joint to bring the palp of this finger into the contact with a palp with that finger. By doing that, you have the maximal surface area and thereby realize the feel of the tissue itself. Remember that the pinch causes damage and I can see the pinch bring to you true the gloves of an operating surgeon because you see that the fingernails blanche and I can see the pinching through the gloves with the blanching of the fingernails. I hope this makes sense to you seem to have gone into darkness. It's gone dark outside. And I think probably as the evenings get shorter, I need to consider extra lighting in the studio. Do send me examples of your practice at home. Remember that is a movement. I want to see both right and left hands actually doing that. Reminds me of that silly is an eighties song I could do. I think they did that or Chi chi cheap, cheap, but that dates me, doesn't it? Thank you very much indeed for joining the Black Belt Academy of Surgical Skills. I'll be pleased to take any questions. I see Gabrielle has prompted you to ask questions. I hope you have a better understanding of the reason we hold the forceps the way we do. And it might indeed feel a bit awkward to do that in the first place. But I can promise you, as demonstrated by my two bits of plasticine and Plato, it makes a significant difference and you'll realize the lightness of touch. Beco S Lloyd Barkley One A Ns. And we need to be able to caress the tissues and not the mere cures of flesh. Thank you very much. Indeed. Next week, my son's going to join me as we talk about assisting. This is his last black belt Academy of Surgical Skills appearance before he goes back to school in Malaysia. Thank you. Wish you well and see you next week.