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Hello, good evening. Good afternoon. Good day. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom. The past Director of the Faculty of Surgical Trainers for the Royal College, assertions of Edinburgh and a visiting professor at Imperial College. If this is your first time joining the Black Part Academy? Welcome. And I hope that this makes sense. You're joining at the beginning of our Stitching series. But I do advise you look back in the past episodes talking about posture because we'll refer that to that this evening. I'd also like to say thank you very much to the 540 Instagram followers. I'm particularly pleased to announce this evening that the Black Belt Academy of Surgical Skills. Again, one the Exceptional Educator award with Metal. And I'm extremely grateful to Medal for hosting the Blackmailed Academy and to Gabrielle who's in the background as part of the production team. Thank you very much. Indeed. To quote Aristotle Excellence is never an accident. It is always the result of high intentions, sincere effort. And intelligent execution. It represents the wise choice of many alternatives. Choice, not chance determines your destiny. I like that because it highlights in tension and severe effort. And at the Black Belt Academy of Surgical Skills, we are trying to encourage you to home your surgical skills. Now, we delighted to be turning up in person myself, Chris Caddy and John Taylor, fellow census of the Black Belt at the Association Insurgents and training meeting on the 4th and 5th of March. We are supported by B braun and why I'm particularly delighted in that because they've got a campaign at the present moment called Feel the Difference. We've talked before about feeling the instrument and the instruments being an extension of your hand such that you can feel the tissues. I also highlighted that instruments of old were designed by surgeons of a stereotype. Without acknowledgement that 50% of the workforce today, women who have smaller and more slender hands and also 9% of the workforce are left handed. And when you think of sport, particularly golf, you wouldn't ask Rory mcilroy to borrow the club's of Tiger Woods to perform at that level. You need to be familiar and used to your instruments. And that's why the Black Belt Academy is delighted to be working with B braun in looking at how instruments feel and how to optimize the use for better outcomes for the patient. And nothing can be more true done with stitching I collected this feather from the garden from a pheasant and the lightness of touch is important. Even if you're holding a golf club or a sword. It was my pleasure yesterday to be teaching at the Wakefield academy iota. And it stresses although this is a lethal weapon, a sword, you hold it with the lightness of touch and you've got to feel and understand the ergonomics and geometry of it, as I've said before, the art of drawing a sword has been handed down for many generations and prescribed down to the degrees that you hold it, failure to do. That means you failed to progress in the Eido. And was my pleasure to get second down in June of last year. But as I was teaching yesterday, I realized that by teaching, you start to understand even more of the basics than what is required. And I think we fail to describe those basics, particularly when it comes to stitching. And that is what we're going to talk about this evening. So the first thing to understand is that all needles are made from a circle and I'm going to take you to the overhead cam and this is my smiley face demonstrating the needles. Now, whether your needle is a five oh 20 or larger needle, they're all made on a circle, they all fit on a circumference. And the whole idea is to be able to rotate the needle cleanly through the tissue, such that if you took a tan, gentle slice at any point on the passage of the needle through the tissue, you would see a perfect circle if you're clumsy taking the needle into the tissue and taking it out of the tissue, what you have is this elliptical shape where the suture sits in the middle, but there's a space between the suture and the tract that's been described by the passage of the needle. And that certainly is a cardiac surgeon is sweating anastomosis or even a spurt on a two millimeter vessel in a vascular anastomosis. That would be a sweating anastomosis on a bowel anastomosis. That would be a microabscess and why it breaks down at seven days but clumsy carriage of the needle through the tissue actually causes damage because there'd be information all around here and that through the skin would be space for bacteria of the skin and word infection as well. So, clean passage of a needle through the tissue is vital in every aspect of the set of operating and stitching. Now, to do that, we need to understand how to hold a needle holder at the Black Belt Academy. We advocate palm ing the needle holder, which is slang. It flattened the palm of your hand between the index finger and the ring finger. And the access of rotation is between that and the common flexor origin. But like holding a screwdriver, it gives you perfect rotation as I demonstrated last week with a straw at the end. Pro nation, super nation and I almost get 270 degrees. The awesome good thing about it is that you can put your hand out, the instrument gets put in your hand, you can use it and put it down at no stage is on my fingers through the rings. And certainly, if my fingers are applied to the rings, the distal interphalangeal joint is not through it because that's where it will get stuck. So we recommend that to get the needle holder and practice and to practice putting it on and taking it off. And you can see I'm using my opponents policies to lift it up and put it back on lovely chirping sound. And if I see you in the corridor, the hospital, I'll ask, how are you today and want to see this wonderful chirping sound. But the important thing is, is that because it's on the circle. This now has an important implication is how you're lying your needle. The alignment comes thanks to Euclid, who is it mathematician in geometry? And 330 80. And he learned from Pythagoras and many others. But he's the father of geometry and made a monumental contribution to the field of mathematics. And this is expressed in his books called the elements. And these were used as basic teaching material until the 19th 20th century was the main text book for mathematics. I like his definition align is a length without breath. But he was the said that 90 degrees is the perfect angle because 90 degrees every equal and opposite angle is also 90 of grease in north agonal plane. And he defined this in book one definition term of perpendicular lines. It does not use any numerical degrees of measurement, but rather touch is at the very heart of what the right angle is. Namely two lines intersecting to form to equal and adjacent angles. Thinking about a straight line is 100 and 80 degrees. I said that you got to 90 degrees and 90 degrees. Therefore, is very important. I'm going to deviate a little bit because I personally love geometry and have had the privilege of teaching I GCSE math to my son who is now a college in Malaysia. And we talked about geometry, triangles and lines and this is simple revision nine centimeter nine. I'm going to Bisek this, I'm gonna bisect it using our compass. And when you think that the ancient Greeks didn't have measurements, they and a rope, a piece of string and a marker in the sand. And all I've done is that top and bottom good intersecting circumferences on either side of that line and then join those up. And one of the fantastic thing about this is those two lines joined up by six at nine centimeters into 4.5. And then you have perfect 90 degrees. But you can also put 90 degrees perpendicular on the end of the line, we're gonna draw that it requires a couple of movements for the compass. And I've been drawn, there's a few lines and I can join that point in that point simply with a compass and that is not your degrees. So I hope that you understand that 90 degrees is fourth part of a circle. It's a perfect angle. And if you take any circle whatsoever and you draw a line to the circumference from a diameter will sub tend an angle at the circumference at any point of the circumference of 90 degrees. And that, of course, as part of your circle theorems, what we have deviated a little bit because I do like geometry. We haven't even touched triangles, but let's come down and focus particularly on the anatomy of a needle. Now, the needle anatomy dictates how we pick it up and how we hold. Just put that in the middle. You'll see at one end, we have the suture coming in to this wage. That's a relatively recent edition two needles in the beginning of the 19th century. And Ethicon have now developed a switch that even finer because until to date, that was the thickest and widest point of a needle, the point at this end comes in different forms and different shapes. Bit like my Cortana. Really the Kawasaki, the point is cutting round or blunt. We do not put the needle on that side and we do not put a needle harder on this side. The working angle of the needle is really either side or the midline. And is that what we need to do? Now, there's one other part of the anatomy that is important to recognize is that the middle part, the shaft is not exactly round, it is more cuboidal. And as we come to talk about how to get the needle to work for you, you'll understand why the cuboidal element of the mid part of the needle holder is important. Seven. The idea is we need to take it through at 90 degrees, 90 degrees being fourth part of the circle. But let's just demonstrate why. If I show you this material stretched over light, you can see the wafting we've of this and there is spaces between the fibers, not unlike the collagen of the skin. And if you have stitched a button to a shirt or a piece of cloth, you will know that if you take your needle in obliquely, it is rather difficult to put it through the tissue. The only way to get the needle cleanly through the shirt is to take it through at 90 degrees. And that makes it a lot easier in the same way. When take your needle through the tissue, you need to point your needle 90 degrees into the tissue and then rotate. And that simple rotation ensures that you've got a clean entry and clean exit and we'll be introducing models throughout this series on how to stitch to practice the entry and exit. So it doesn't just end there. I'm afraid it gets a little bit more complicated. And this is where I despair, to be honest because I don't think we are teaching surgical skills correctly. We have and looked at the past four months every surgical society across the globe that I can see, retrieved 96 photographs of basic skills courses and everybody at those courses are sitting down at tables on chairs that do not move. Now, there's a problem. There's a serious problem with that because all our operating is standing up. And as we've described in our previous lectures, posture is important but also having the correct posture and correct position for your arms is of significant importance in reducing the muscular skeletal injury that has an incidence of 27% amongst practicing surgeons and getting worse. So that's why we need to stand properly, but standing properly with arms extended releases all the major muscles of the shoulder girdle and upper arm and focuses the function on the hand and the opposition of the parts of the fingers. So the problem is, when were you given a needle is often passed to us with a needle, not at the tip and at 90 degrees. And that has a problem I'll demonstrated by sound. First of all, because demonstrated by sound because I hope you hear the difference and I'll show you why we'll come to the other head again. So you may indeed be presented it with a needle that is mounted at 90 degrees and it's not at the tip. Now, if I was sitting down my wrist and elbow would be at the right level and therefore 90 degrees to the needle holder would be correct. However, look what happens if I go to a standing position. As soon as I go to a standing position, I lose the sagittal plane. There was no longer 90 degrees, put it on the table plate that is no longer 90 degrees. It's drifted off line and that drift or flying from 90 degrees there, it means that it's not going to pass through the tissue correctly. Now, if I open the angle up just beyond halfway, my needle, now the belly of the needle is bouncing on the plate as opposed to and there's a difference and that bell you bounce, I describe means the sagittal plane to the tissue is correct. So when picking up the needle, it's, it's vital that you check each and every time you pick the needle up and I'll pick it up with a bigger needle. So you can see it more clearly. That is just beyond halfway. There is no space between the tip of the needle holder and three, it is angled out. Now, that is sitting perfectly across in the central plain, 90 degrees. And that is your alignment, really, you need to be thinking of this alignment each and every time you practice. So what we're going to do is use one of my splash models. Now, if you think of the Olympic diver diving into the pool, the perfect dive has no splash whatsoever. They enter the water without any ripple effect, know over, not under were perfectly in. And that is the idea behind these models that we're going to be producing. And what I have here is a microwave potato is cut in half and to mimic operating a depth, we would advocate using a glass bowl because very sounder. Are we sitting down at a table? Except for my neurological neurological gynecological ophthalmological and micro surgeons who sit on stores and go up and down. Most of us are operating at depth. So to practice these, I'd advocate putting in a basin to mimic the angles. And you can see now if I mount my needle at 90 degrees, the sagittal plane is completely off. Whereas a angle it out which is equal to the angle between my forearm and the horizontal, the belly of the needle is bouncing on that and all I got to do is align it at 90 degrees. Now, why? 90 degrees is a fantastic angle? Not only because nuclear described it and it is the perfect angle but for you and me, we are surrounded by 90 degrees every day, just look around you and you count surroundings, the window, the door, the cupboard, the picture frame is all 90 degrees hardwired. And if you want to test that online, we have got a PDF file where you can try and spot the 90 degrees. What we determined in the study is that 95% of people picked out the 2, 90 degrees after 20 slides between 86 94. So therefore, for you to think 90 degrees each and every time you align your needle is important. So it's 90 degrees across what we want to stitch. I've demonstrated with the material, it's got to be 90 degrees thing to what you want to stitch. And therefore, we need to rotate the needle back. So it's pointing into what we want to stitch and simply rotate the needle forward. And this is an intuitive process, delivering it carefully on the curve of the needle until you have just passed halfway and then you pick it up again. I'm using a rather large needle there to demonstrate it. But if I used a regular sized needle into not going to disrupt the tissue on the potato. 90 degrees across what I want to stitch, I'll come down, closer, rotated back. And this is where people often get it wrong is the rotation is not complete on the backswing, take it through. And you can see if you're clumsy, they're big needle tears the potato and it gives you feedback. That's the splash. I'll just move off center of it. I'll draw another line on there and it's useful to use it pen on your potato to align. That's what they're doing. Golf and many other disciplines. And certainly with my sword, I was standing in front of a window using the window panes in the diagonals to perfect and practice my sword strokes, said they're perfectly straight. And what they do in I do is cut bamboo and look that the leaving edge and the following edge are perfectly aligned. In other words, the sword has gone through the perfect rotation. And at the present moment, I'm slightly off. But as I pick it up, you see, I've gone back to 90 degrees. And that's the problem until you're practiced. You will find as you repeat the exercise that you lose the 90 degrees and what you need to do each and every time is make sure your needle is 90 degrees and this simple exercise is practicing that 90 degrees will come to you later on with the potato. Other exercise is what I've done with this hemisphere is marked 90 degrees away from me, the site towards me to my dominant hand and my non dominant hand. And if the alignment is always at 90 degrees across what you want to stitch, then you need to think yourself, what is my body position and my arm position going to be to enable me to be at 90 degrees. Now, in this position here, my wrist and elbow are aligned in the same position and therefore my needle mountain is at 90 degrees because my elbows in the air and, and rotating around, you know, this by using a screwdriver, an odd angles and there you go and pick it up on the opposite side. Again, I got to think what position do I need to be in? Right. Like I've got the cameras in the way here, but I've got my elbow up in the air and we're taking the new through the side nearest me is a common place for stitching. Put problems with aortic valve replacement. This is what I call the angle of sorrow, which is between the superior vena cava and the right atrium and the aorta and the roof of the left atrium. And it's in this angle. One almost does the screwdriver stretch. Again. You see it mounted backhand 90 degrees because my album wrist at the same level and rotating it I/O of the potato that way. And if you tear it out there, you can see your splash mark as I dragged the needle out. This takes practice, takes time, takes patient takes intent as Aristotle said, and that is important. These models are not meant to be easy, they're meant to be difficult. So how do we practice this for continuous suture? Because too often I find when people are doing a continuous suture, that simple alignment of the needle is lost taking the ball away and adjusting the height of the table. So it's more functional. Your needle's got to be 90 degrees across what you want to stitch and please only go through both sides if they're sitting together and your needle is 90 degrees across both otherwise good independently. And we'll come to that in on it. Next presentation. So you can practice on the banana is at 90 degrees. And all I've done is your one centimeter lines on the banana. And I'm going to try and take it I/O of the banana and pick it up. And each time I'm checking my alignment, I'm also gonna angle it out my position. 123 align, the needle were taking it back and rotating it out. And what I've get trainees to say in this exercise is place 90 degrees across what you want to stitch 0.90 degrees into what you want to stitch and rotate. And that's simple place point routine. If you say that yourself each and every time you're stitching and verbalize it quietly or in your mind, you will be focusing and concentrating on ensuring that your needle goes perfectly through both sides and at 90 degrees. So half this banana, I've made tracks and the other half of banana, I've now just put a simple point of entry and accent. And my idea in practicing is to try and get it across exactly through the point as I have there are slightly off that side, just a fraction off there too. And why should models bit and easy that you can see yourself in the simple practice. Are you a lining your needle perfectly every time? And I bet when you're doing a continuous suture to close the tissues in the fashion layers, you're just cobbling them up, focusing on getting the needle I/O of the tissue as quickly as you can without paying attention to the fact that has got to rotate properly. Now, when you're first starting out this, you might find and think to yourself is going to make for a very long operation because it's going to slow you down. Yes, it might indeed slow you down in the beginning. But what it's doing is reinforcing the accuracy and precision with which you're going to do it. What you noticed here had a curve and each time I'm going 90 degrees perfectly across. What we should have started with was the straight line. So straight lining with potato banana and simply rotate your needle I/O. Note that the tissue holds the needle for you. You do not need the needle holder to support the needle or to deliver it. If you do that, I believe you are going to ruin the rotation of the needle and it's not going to be clean. So in the Black Belt Academy, we would not advocate using your needle hoarder at any stage in this process whatsoever. And I've noticed as I'm coming through, I am slightly off to my left hand side coming out and I'm thinking of my rotation. Yeah, I/O exactly where I wanted it each time. Please pointed to the doctor and rotate it out. I am not using my forceps to deliver. I'm using the tissue and in taking it out, picking the needle up just beyond the halfway, maintaining the angle each and every time. And when you practice, that becomes automatic. But that doesn't mean to say you do not keep an eye on that alignment each and every time when you've practiced enough, this will become second turned nature. But I do recommend I've stopped myself there for two reasons. One and beyond the working area or at the limit of the working over the needle is beyond the halfway my needles, not at the tip and it's at 90 degrees. Stop reposition your needle realign it and make sure there you go, please point rotate. Now, as I've described at the beginning, the whole thing about surgery is feel I was taking Sam through an aortic valve one day and he did a beautiful job of taking the valve route, stitching it and stitching the any water and he stitched it perfectly from what I could see as for perfectly meted Sitges literally every 54 millimeters long, four by four by four. And it looked beautiful. We can't started to come off bypass and they also started to unzip and I couldn't understand why something stitched so beautifully could unzip until I picked up the needle holder. And I took my needle through the tissue. And the thing is I could not feel a single thing. In other words, my needle was like a hot knife going through butter. What I've done here with this model is bottle of potato and I've cut it such that there is a segment standing up in the middle. And what I'm doing is a feeling the needle go through the tissue. So I cut it at the center peter. Let's see if it stands up for doing it the smaller thickness because if I'm clumsy is going to tear out to the potato and it'll tear off a segment. And this is a, an adoption of my potato exercise that is measuring your ability to take a needle cleaning through the tissue with his minimal trauma as possible. Like much of these exercises, this is extremely difficult. And I would like to know for those of you tried, how thin can you cut this potato without tearing it? Thinking of butter and hot knife through butter. I thought to myself. Mm. I wonder what butter feels like with a needle going through it. And I've cut a wedge of butter here and I put it on a plate and I would commend you to take a needle on a needle holder and try yourself what it feels like what I quite like about this where you butter on the plate. It has also given me some feedback on the rotation and there's a delicacy that's needed as you can see that. Well, focus down on that. I hope you can see the exit wounds and the entrance wounds, all that bit of butter. I'd like to know from you what materials you've tried at home to practice your skills, an appreciation of the feel of tissues too often today, people are sending out plastic suture pads. Gels. To be honest, in my 35 years of surgery, I have not come across any synthetic material as a kin to the ones that I'm offering you. These are cheap, easy to access that they use a bit of fat or lard. You can see if you're clumsy, really clumsy. You will tear this out the edge to make it more difficult for yourself. Maybe we heat the needle or you just melt the button a little bit to make it softer. But I want you to feel your needle going through that and you can only feel if you're holding your instrument as light as that feather that I had in my hand. I'd love to hear from you on what models and what examples that you've got at home. I've seen some fabulous examples from you. I'd like to see more and let's have some fun. I don't believe you need to be in a wet lab. I do not believe that you need fancy material to practice these basics. And remember mastery and it counts by focusing and attending to the basics. And that's what essentially martial arts is about because without technique, power and speed will not come. But above all in. Sadly, the lightness of touch, feathers on the floor, the lightness of touch, caressing the tissue as described by Lloyd Barclay Monaghan means the tissues will look after you more likely to heal less damage, less trauma, less bleeding. And we all know that contributes two ruin infection. So I'd like to conclude with a Euclid say he came up with Q E D quad area. It demonstrated. I hope the Black Belt Academy is making it Q E D for you. I like the fact that the laws of nature are but the mathematical thoughts of God. That's what you kids said. I like geometry. The circle of the needle of what we need to do is respect that circle in our stitching. Now, you know how to align it at 90 degrees each and every time and attend to your pick up each and every time and next time you're frantically doing a continuous suture. Take note that your needle alignment will drift stop real line and start again with practice. You'll find in the end you don't have to thank you indeed for watching the Black Belt Academy of Surgical Skills. I look forward to seeing you next week. And do pass the word around. We are joined by a global speaker which Deveny, he's an ex Commander of Navy Seals. And we were talking about attributes because when I read his book on attributes to be a Navy, see, oh, I wondered about those attributes and how they applied. Two surgeons do join us next week as we explore this fascinating topic and we'll continue, our story are rhythm and flow in two weeks, time attending to the angles and reinforcing the principles defined by Euclid. When I say Namaste, er I do this also reinforcing the fact that you do not ever put a needle through both sides of a wound or tissue unless the two edges are together. And that is my plea, the mestre. Thank you very much for joining the Black Belt Academy of Surgical Skills and we'll see you next week. Good day, goodnight, good evening and be well.