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I've got my um blue tops on as well. Yeah. Well, we've had to dash inside cause it's started to oh, getting to rain clean again. Oh dear. OK. 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 O Regan. I'm a retired cardiac surgeon in Yorkshire in the United Kingdom. I am the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. We welcome you to the Black Belt Academy and thank you the 4230 followers on Facebook and the 635 followers on Instagram. Thank you very much indeed. And this is the first time you're joining the Black Belt. Welcome. And I hope you find it informative. One of the first things that you are going to do entering a career in surgery is the assist and good surgeons, make good assistance and good assistants, make good surgeons. And for those of you who have been following me over the past few years on the Black Bar Academy will recognize my son who's going to join me this evening as my assistant. But we're gonna reverse roles. Alistair is going to do the operation and I'm going to assist picking up on the themes that we talked about last week with retraction and holding and following and anticipating an operation using your forceps. What's interesting this evening before the session, Alata was practicing his not time and within half an hour following the not time video and discussion, he was doing the one handed surgeon not and he automatically picked up a needle holder and was using the ratchet and holding it properly with a benediction sign. All that with only a modicum of instruction following the principles that we have been talking about in the Black Belt Academy. So I'd like you to welcome my son to the stage and you will see Alistair is also a third down in karate and we practice drills and techniques in the dojo because the practice of the technique and putting together combinations means that you can translate this into a real fight. Not that karate is about fighting. It's a mindset and it's interesting that it's called a study of karate. Whereas you play golf and play football and play cricket, you study karate and it's the principles of the movement and deconstruction that we have translated into the syllabus for the Black Belt Academy. For those of you who remember Alistair when we first started, here's my shoulder height and now he's well and truly taller than me at six ft three. And what we need to remember is both the surgeon and the assistant need to be working at a comfortable height where your shoulders are down, elbows by the side and your hands palm flex. Because that, as we have said before, isolates the intrinsic muscles of the hand outside. I set up and I had had a step to stand on to take away this difference in shoulder height because the table is at maximum height for Alistair's purpose because he's operating and I'm assisting and I need to stand on the stone, even if he was the trainee and I was assisting, I would still stand on the stone. Now, there's some simple rules in assisting that Alistair is well versed with and we're going to put this band over our heads. And the in the same way we do Q and drills in karate, the movement is equal and opposite in parallel as if we are dancing. So if I move to the right, Alistair's automatically moved to his right. So the midline is between us all the time. So rule number one is you got to keep your shoulders parallel to the surgeon at all stages. And you'll find as we have talked about in the stitching exercise, surgery is a dynamic process and the surgeons gonna move moving all the time that midline needs to be kept between you and the assistant shouldn't reach over because that s the surgeons side, this is my side. The other midline that you don't cross is your own midline. So if you find yourself moving your hand towards the middle, even if you're following a string or holding a forceps, you transfer to the other hand and continue, you never cross the hands this way and you never cross the midline that way. So with the function of an of the assistant is to assist and enable the flow of the operation. And it's very useful to actually understand the steps and the next steps of an operation. So you start anticipating the movement rather being instructed. So if you're watching an operation for the first time from the top end of the table, take note of the different steps and anticipate what is required when a surgeon is going to cut something, you pick up a forceps when a surgeon is ho following, you're stitching, you get to follow and you're going to cut. So you're gonna follow with finger and thumb and a cut with the scissors along the principles we have described. The other very important thing is is that the surgeon, an assistant gives you an equal and opposite perspective. Very simply. If we look at that, I'd say that's a cube and would swear blind as a cube. But if I turn it 90 degrees, you see it as a circle in a similar way when you're looking at the table, Alistair is looking at the table, what number do you see? Alistair? Nine, I see six. It's the same number upside down. Ok. It's the same number six and nine. And it's that ninety-degree perspective that is important. And the surgeon should recognize in the same way that you do 90 degrees on every x-ray A P and lateral joints and chest, et cetera to give you a 3d perception of what's going on. Likewise, in surgery, your assistant is that necessary? 90 degrees opposite. So, Alistair, if you saw me doing something wrong, what would you ask? Could I explain that? Could you explain that, please? And if I persisted with it, what would you ask? I think there is an error here. Certainly you can think there's an error or David, we can't really hear what Alata is saying. So maybe you could just repeat that. I think I, I do not understand what is going on or perhaps you could explain the anatomy further. The next step is most surgeon will say, OK, yes, I understand. I think we, there's an error, I'm concerned there's an error and I hope that the operation stops before that because the two of you are responsible for the safe conduct of an operation. So we are going to go into an operation. Now, I'm gonna move the camera so we can focus on the field in front and note the way I'm moving and Alice is moving and Alice is going to do the operation. I am going to use my forceps to show him the direction but also to help facilitate the operation and make it easier because good surgeons make good assistance. And as I'm doing that with my forceps, I will be explaining the tips and tricks going along. Remember that the movement of the forceps is with the lumbrical with the extended interphalangeal joints because you cannot squeeze hard like that, that your movement is deliberate and precise and it's a lateral hold, maintaining tension. So the operation today is a turkey leg. So forgive me as we're inside, I'm moving the camera and we'll bring it over and focus in on this. And I will explain the movement as we're going along my hands as the an as the assistant are from the left hand side. Ok. So please ask questions and raise any concerns that you have had as an assistant previously and be delighted to answer any questions Gabriel will bring that up. So we are going to try and dissect out the femoral canal in this piece of turkey leg. So would you like to make an incision Alistair through the skin and the muscles down there and we go through? So off you go. Yeah, your yes, your left hand is gonna support the skin and your index fingers down and you're gonna press firmly all the way through and feel the knife going through a bit further. Yeah, do that again and go deeper through the tissues. So I'm going to assist Alistair by holding the tissues apart and I'll focus in a bit further. Good. So there you go, you through the first layer of muscle down to the next layer. So if you want to stroke your knife along that a again, so you're down to that fascial la use your forceps in the other hand because you're gonna hold that bit there. And I'm gonna hold this side and just stroke it down with a blade, not stroke, not the brush stroke and dissection just cut that bit. There you go. I feel it down. Oh, very good. And you can see you're into a fascial layer there. So as a, as the assistant, I am showing Alistair there, a facial layer with my forceps underneath and Alastair now is gonna take a scissors and dissect that fascia lay out. So you can, I can almost cut between the two ends of my scissors. Yeah, that's it. My forceps between the two ends. They go up the middle. There you go. And remember putting an instrument behind enables you to see if there is any tissues in the way. So we're now going to explore it further, pull it across your side. Yeah. And I'm applying countertraction all the time. And what we have dissected out here is really the femoral can canal because the vessels all sitting in the fat that, so Ali's going to get his scissors and developed that pain there. Remember? Nibble, nibble? Put your scissors in, open it up, take it out, open it up. There you go along that plane there. Just nibble. No, you can put your scissors under, open them out. You see that underneath that level there. Yeah. And that's it. Very good. Excellent. I love the bolt. Whoops. Whoops, whoops, there you go. You see, we said whoops, whoops, whoops that there is the vessel. Ok? So I would like you to now just with your scissors come through this thin fascia layer on the top, ok? See if you can actually, I hope you can see clearly there. You see there's a, a nice thin fascial layer on the top and I'm gonna hold it up and provide. Can you hold there, please? And I, you hold that bit of fat there and I'm gonna hold this bit of fat here. You can nibble to see if you can get into that little fascia there. There you see that little thin bit and see if you can get the tips of your scissors and dissect that through marvelous. OK. Good, good. All right. There you go. And this and this side, that little bit of fascia layer there as well. Ok? Now, the other thing that you can use the forceps and to do and I'm assisting Alistair by using my forceps to gently separate the tissues and you might want to try using the lady with your forceps and see if you can go round or get your scissors first and, and with the combination of the scissors and laying here, come around this vessel. All right, you see that fat there, we need to clear that fat off. So imagine that is a thin, little bit of fat next to the vessel. That's it gently small n small. That's great. Marvelous. Now, can you get your lay here underneath that? So I am I trying to just keeping it. Yeah, use it as a tool to it like I'm doing with my forceps to gently tease parallel to the two vessels, tease the two vessels open. Ok. That's it. Try and separate and see if you can now develop the plane around there and bring your lay underneath. Just develop the pain down here. That's it. There you go. And now see if you can bring it round underneath, gently, you just the side as well. You've got that vessel separated and underneath. Yeah. Ok. Come underneath. There you go. So in that position, we have now isolated the vein and next to it is the artery there on the other side. And what I'm doing is just providing each and every time to help an with his dissection, traction and counter traction to help him do open up and expose these vessels. Come down the side a bit further and dissect down the side. There you go, you can cut that closer to the vessel. There you go. Well done. We're gonna come underneath and there you go. We've actually dissected out the femoral vessels in the turkey thigh. And Alastair hasn't done any dissection before or very little and is almost learning on the job, but I'm seriously impressed with that. But what I've been doing is directing and pointing and at countertraction all the time. Now, as a new assistant, you won't do that as well as perhaps and intuitively as I'm doing it. But that's why you're assisting. It's a skill that you're learning. You're learning each and every moment and you're learning the bit and operating. Now, I understand there's a vessel there. You can see the vessel there. Do you want to see if you can open up that vessel? Now, open it up longitudinally along the vessel and I'm gonna provide through that hole there and keep it. Yeah. And, and come from this side perhaps and move your body around. Ok. Turn your scissors the other way, ok? Just for this bit. Ok? And see if you can come up parallel down the vessel. So I've moved my body, keep down the hurdle. All right. Very nice, very nice cutting. There you go. And if you hold that side and I'm holding this side, you'll see that we have actually opened that vessel and there's a clot in the middle, what I'm doing in each and every stage is holding the plane. So when Alice is holding, I'm holding the planes either side. Ok? I think you've dissected that rather well, actually, and there's another vessel around the back here. Do you wanna expose that one? And you hold that there just with the tips and I take this side and see if we can come down between the two vessels there. See that space, see that space, I'm holding it. So letting the forceps open is actually giving me an opportunity to gently separate tissues. Ok? And then come down this side and see if you can get that little bit of fat off. Uh You hold that, remember we got to provide traction, countertraction and I'm holding it. So hopefully you can see there the edge of the vessel and the fat involved just oh you on the vessel. That's it good. Very good. I like that. Ok? So now, no, don't cut that side. There you go. That's the, that's the vein. Ok. So we have opened the artery and the vein is there as well. Analysis without knowing it is picking up the avent tie of the vessels each time you've just cut through the vessels there. And that would have been a whoops. Ok. But uh you have just cut through the vessel and we say, oh dear, we'll cut through the vessel. Don't worry weird because that is a vein. I probably put a clip on the side and tie it off. But the exposure and separation of all these tissues is in fact, very good. And all the time, it's a dynamic movement of my forceps moving around, anticipating where it's going. Just take your forceps out and use your scissors and dissect out a little bit more. OK. Come further down. OK? And I'm just, and come further down this way and a combination of scissors and maybe the knife to cut through that bit. So come back to the knife and cut straight down through that bit to expose that. No, no, you don't swap, you don't swap the knife. The knife is always in the dominant hand. All right. So come down that bit like in parallel in line with the rest of the incision left to right or right to left from there to there. OK? Do it. Yeah, provide your s you put your fingers on the side like that to maintain the tension and just feel the knife through. Perfect. That's a nice cut and that's all the way through there. Very good. So would you like to get the scissors? Now, you see there's a fascial layer and I the fascial layer there, you can get use to expose. OK. Just do uh to see. There you go. There's a facial layer you can cut through that. So my forceps are actually helping Alistair identify fascial layers and pointing out what he can cut. I see. OK. Thank you very much Aly good and retract that and come down on this bit here. So the whole process is dynamic and we're down to bone there. And I'm just saying, following the bundle, the bundle continues that way, doesn't it just see if you can get some of the fascial, let, let you go. Don't cut across it when you're using your scissors, keep your scissors parallel to the vessels that you're looking at. Don't cut across it if you're going to cut, make sure the cutting action is that way and not that way. Yeah, it says next to it. But I think you've done a very good job there. So, what we're going to do now is we're gonna put some stitches in and we're going to stitch a couple of the layers together. So if you'd like to mount a suture and you can have a go at stitching that the point is this side. Correct? Yes. So you put it in. So the, the point with the suture is in a packet, always come in at an angle and then pick it up like that. OK? Off you go because Alice has helped me with the stitching things before. Look at that, hold that up, Alistair keep put that in the field, look it out for a needle position angled out just beyond halfway and there's no space, I'll take it slightly closer, but that is a very good pick up of needle. There you go. So let's stitch the tissues together. So when someone is stitching, you need your forceps. When somebody's stitching as an assistant, you can expose the layers that they want to stitch. So we're gonna stitch this layer there. OK. Not like there. Yeah. And we're gonna stitch that. Well, let's stitch. Yeah. Don't lay there to that layer there. All right. And I can hold the two layers together. So 90 degrees across what you want to stitch. That's it. Very good. And an was just practicing palming his needle to order it today. And I think has got the technique of palming his needle holder very well and out. Yeah. Take it to halfway, remount the needle just beyond halfway there and pick it up and you're ready to go. Now, do you wanna try putting a stitch? Throw a stitch, a knot in it with your left hand. Keep hold of that. OK? There you go. Take it through to the short uh short end finger and thumb, short and finger and thumb. Hold the very end of it, the very end. That's it. OK? I'll turn it towards you said, you know. There you go. OK. All right. Yeah, that's all right. That's good. It is. Now you can flick, flick through. Very good and towards me and I see that took it through the loop and his fingers on the knot do that again. Other way. That's it. Perfect. You gonna flick it through and you're gonna take it towards you, ladies and gentlemen, for somebody who's only just learnt to tie a hand. Not today, I think you should be giving Alice a round of applause. Now he's going, he's gonna hold that up. And as an assistant, I know he's going to be stitching, but he's holding that end up to cut. So I come in with my scissors. I open up no more than necessary to do the job cut and take out. I now follow finger and thumb and follow the suture, finger and thumb towards and Alistair is gonna continue stitching towards his right hand and I am going to follow. So you go over and over and take that layer to that layer. No, it doesn't. You just turn, you turn the needle, hold it the other way. There you go. Let's just point that OK off you go and now you can stitch that layer to that lay. And as an assistant, I am holding this 2/5 3/5. So ans got space to actually rotate the needle do one side at a time and one centimeter apart. OK? One centimeter apart there. Yeah. Very good. And let it go over it as you go through. OK? And pick it up. Take it a little bit to just be on halfway and then pick it up properly. Oh That's all right. Take it through and reposition it with your fingers and pull it up towards me or do you take up the tension and once the surgeons taken up the tension, the surgeon holds the tension only then do you reach in to follow again, maintain that tension. And my forceps are now going to continue to show the area that Alistair is going to be stitching, stitching that fascial air to that fascia air carry on. Very good. And I think for somebody who has not done any surgical skills before you need your forceps, you're gonna pick up that and that. All right, remember place a needle 90 degrees across what you want to stitch this side, this side here because you're stitching towards you from there to there. Yeah. Yes. That's it. Rotate it through. Use the rotation of your wrist di two preferably OK. That's it. And we're unlocking the needle, I'll take that out the way, making sure you don't trip over it. Pick up the tip, tip of the needle. OK? Just bring it through iterative and, and, and now pick it up because it's in the right position and you're ready to go again. Take it through, hold it out towards me and I hold the tension between my finger and thumb and do that again. Keep going. You're doing a fabulous job. One centimeter, one centimeter. Do do it in two. Which side of the suture need to be. You coming there. Yeah, and you're coming the suture, you're always stitching towards yourself. All right. So I'm keeping the loop out two and two. Don't try and do it in one, do this side and then do the other side, you'll find it easier, but I'm seriously impressed that you're able to palm the instrument and you've picked it up perfectly ready to do again. You take it, you take it through or I hold, take it up and I use my forceps to make sure it's placed down and I can keep the tension. So not only am I directing the two layers to be pulled together, I do it in two, do that side and then do it again to that side. So when I say do it in two, come out there in between. That's it. OK? And two. Yes. OK. You're doing very well. Let the needle do the work for you. Any questions from the Orance or any observations, Gabriel, we have cops for Alata a lot, lots of clubs for Alastair. Very good. Thank you. Yeah, that you do. No, no. Pick the needle up properly, first of all. And you were, you're doing very well there just rotate it down when you rotate it, the, the needle comes out up towards you and then coming up towards you. It enables you to actually pick it up. OK? And keep rotating it like that bit by bit just from the suture end. That's it. Now you can pick it up and take it out, take it halfway just beyond halfway and you can pick it up. Yeah, perfect. And you're ready to go take it through and I am with a new surgeon, they might not be aware of the need to place the suture down. So I'm gonna make sure to place it down and I'm gonna hold the tension. So do it again. You do it. You're doing very well, do it and do there. OK? We're gonna do a couple more cause I think you're doing fabulously well, one centimeter come out into the middle and then take the other side. OK? And you see, I am actually very good and rotate it out. And when you rotate it out, the needle comes out ready for you to pick it up again. All righty. And you're probably going to have to place, take it through. No, that's fine. Continue through and I take the tension up on the suture, but you'll probably have to readjust the position of your needle before you start again. Day care, perfectly mounted. Perfect position and off you go the other side. OK? And you have, don't take it all the way out, take it to half, just be on halfway and then the tissue holds the needle for you and you'll be able to pick it up without the extra movement. I'm gonna place that down and I'm going to hold. So my traction as an assistant is my forceps, I'm not grabbing anything with my forceps here. I'm literally using it almost like a fob. The fob is that piece of wood that sign writers uses to support the brush as they're steadying their hands, painting a sign. So I'm using that to hold it away. I haven't grabbed anything so I can hold or can actually use the flat of this to push it away. Do two. OK. Very good. Take it just, just a little bit. Don't take it all the way out. Stop that. Now, pick it up again, just be on the halfway and continue the rotation out and just take, just reapply the reapply it. Very good. So if you take it part the way through, that's it at the tip, reapply it and then you can do it. I think you're doing extremely well. One more stitch. OK? And I can hold that out the way you can see that through and one rotation very good. Take it just be so you can see just halfway it, stop there and now pick it up. OK? And you're ready to go again. So the surgical process and I place the suture down and I take the, the stitch. So as the assistant with a new surgeon, a complete novice with understanding and anticipating the various elements to another one, the various elements I call this robotic surgery and your laugh because to be honest, the robot doing it at the moment is far more intelligent than any artificial intelligence. You can make his following direction and understanding, understanding it. And this is better than robotic surgery just ok. Stop that. Now apply the needle. Yeah. And with your hand the other way, that's it. And now apply the needle, that's it. Pick it up, continue the rotation and take it out. Excellent and do do the other side as well. And note that as the string got shorter, I'm maintaining this 2/5 3 5th all the time because the last thing a surgeon wants is to be tripping over the suture. So as you'll see, Alice is stitching towards himself, towards his suturing arm. And therefore you have a question, David. Yes, of course. Sorry to interrupt. Um It, it is slightly related to that. So what is the ideal length ratio to hold the tension? Sir? We'll just hold it out and it's basically, I'm holding 2/5 the bit between the tissue and where I'm holding is 2/5 of the length. So five fifths being the whole length to the needle. So I'm holding 2/5 leaving 3/5 for the surgeon, but basically take a stitch again. The the thing is it's not fixed the important principle as you can see there as Alice is holding there, I'm holding the suture out such that he's got movement of the suture. But with enough slack to affect the rotation, but are not enough, not enough to trip over into that bit there, not enough to actually trip over or lock. And if necessary, I can hold the suture out the way but if it's 2/5 3 5th, then you're not going to lose it. The point is that when you're assisting, you are actively engaged in it. This is not a passive process. I am thinking all the time about that again, I'm thinking all the time and anticipating the next step. Uh as a, a senior surgeon training and a trainee, I can anticipate the next steps. There you go and hold and expose everything all the time. Very good. So I think beautiful pickup, continue the rotation like that. The twist of the wrist in rotation, you can take it out, hold it towards me and put it down. I think you've done very, very well indeed. So let's go back to the dissection and very good before you do that. There's one more question. Um Is there any role in guarding the needle when coming out of the tissue? I guess that's referring to the assistant? No. Well, the assistant hand should never be in the operative field. My hands are effectively outside the operative field on the periphery of this plate. I'm never reaching in at no stage you reach in. So Alistair to do another stitch, Ali's hands and movement is actually within this area. Here, I am keeping my hands out on the periphery. So I'm not in his way. Do you know the stitch out? And again, making sure that I haven't got excess length and taking it up, use your forceps and I'm holding the tissue back. You need to pick up that uh uh good. So I can hold the les and direct an operation by pointing with my forceps exactly where I want it. Now. That's perfect. Perfect. Pick up a rotation, lovely and do that again into that side all the time. My hands are on the periphery. I'm not getting involved. Now, when I worked with Steven Westby is famous for aortic surgery and Marfan surgery, a very gifted surgeon. He made lots and lots of videos and the first videos he did of aortic conduits, the light was from a top and I was assisting and had my hands on around the side. If my hands came in the middle, I would ruin the film and I'd get a wrap on the knuckles for it. But the interesting thing is it really did reinforce to me the concept of my hands as an assistance. Stay on the outside. I nicknamed him Steven Spielberg Wesley because the films were that good and the direction was good. So just to before we finish off, I want to show and Alys will demonstrate how to use a knife and how to take off this bit of skin. Now, when you're operating across a plane, the important thing is I've got to hold the plane up. So Alistair is gonna hold down here. I'm, and you can see as I demonstrated last week, the triangulation here holding this tissue plane and now you're gonna brush your knife as you've seen me brush a knife against the tissues and sweep it along and keep it the blade more parallel to that edge. All right. So you're brushing along that edge with your blade, kissing the joint. All right. Not that way, this side. OK. That's it. Brush it and come all the way along the surface and I'm maintaining marvelous. Just keep your blade a little bit more parallel to, to that beautiful. There you go. You see how easy this is when you've got an assistant holding out the tension and holding out there. So where are you gonna go? Continue down there? Good. And I'm anticipating the, the direction. Just keep the blade at all times just onto the surface like that. Yeah, and brush it against it. And w what I do is actually take it out of my hand a little bit further and you literally brush it like that. So I'm holding it at the tips of my fingers. Yeah. OK. Not in the palm of your hands. It's like a brush. OK? And you just brush it along the, use the flap of the bra along the, that's it. So that there you go. That's it. And I'm holding this tied and you see what I'm doing. I am trying to maintain the tissue in tension and that's what in the system. Just pause there for a moment and we do forceps. You'll see the three forceps are triangulating the tension across the tissues all the time and holding that. And is that maintaining that triangle? If you're watching the World Cup football, the Spanish were very good in standing in triangles and doing one touch football between the triangles. I've got a triangle here and you are stroking along those edges. OK. OK. Satisfying, isn't it this side? And same again. That's it. Lovely. Keep going. Now, for those of you who are thinking that we are going to waste this turkey leg. And actually at Morrison's, it was five lbs 25 which I think is a fabulous price to pay for something that gives you a femoral canal and all of these bits of tissue. But we're gonna put this in a slow cooker and make up a lovely stew for our dogs. But the other pizza we've also got will probably the leg will probably put on the barbecue. So that is what I call sustainable surgery. You don't need plastic. You don't need other models. You have got all of this to help you. We would be delighted to answer questions and I think Alistair would be very happy to answer questions as well if you wish Alistair, that's you. Yes, an answer questions, answer questions. So any questions from anybody? Not really a question. Uh Just we have a clarification from wrinkle. So is that the surgeon's job to guard the needle in order to avoid needle sticks? It's the surgeon's job, holding the knife and holding the needle to be mindful of their movement. But the assistant likewise needs to be mindful of where they are putting their hands and keeping your hands out. Now, the other area that is important is depending on where the scrub nurse is in cardiac surgery. I had my, the scrub nurse to my right hand side and as I asked for an instrument, I put my hand out to the right and the instrument would come to the right if Alastair was assisting me, if he put any hand into that quadrant to my right, that is the flight path, so to speak, for the knife and instruments, the knife should always be passed in a kidney dish. The needle holder sometimes gets passed out but the movement is never to grab, never reach across. And I'd say when operating from a, a cardiac surgery with a scrub nurse to my right, this quadrant is the flight path and you don't put your hands in the flight path like you don't as an assistant, don't put your hands in the operative field. It's on the periphery. It's a lateral hold all the time and it's a hold using your lumbrical feeling, the tissues triangulating, holding and retracting. As Jim Monroe said, when I first started cardiac surgery, when I was following the seno Prodrin, it's a lateral hole and not a pull. There's very little in the way of tension that's required other than the simple weight of the arm and forearm, there's no pulling, there's no grabbing and no force. And I put it to you that applies to orthopedic surgery as well because as we know in martial arts, its technique before power and speed and I was holding the kick pad in the lesson the other day for a and he is doing a fun kick and I was braced with my back foot and it didn't look like you put any effort in it whatsoever. But bowled me over backwards. He had a wry smile on his face as he did it. But it was technique before power and speed and it's the same with the system. So I hope we've answered some of these questions. The best thing to do as we said, if you think there's something wrong, excuse me, could you explain the anatomy or explain what you're doing or I'm not sure what the step is and repeat the question I was assisting Professor Pepper doing a Stentless valve when I first started the Brompton Hospital and he was doing a home and I was looking at the orientation of this and felt that the pillar was actually over the Coronary Ostium and it didn't look right. So I asked him, excuse me, professor, please, could you tell me how you orientate the homograft? And he said, yes, yes, yes, yes, yes, yes, because he is continuing operating. 20 minutes later, he stopped, he said, I now understand why you asked that question because indeed we had it rotated and we had to take it out and put it in again. Remember as an assistant, you are a valuable person in theater and any surgeon who thinks otherwise needs to actually have somebody to have a little word with them. And I'd be delighted to offer that little word. But remember the simple perspective, you would say that's nine, But from the other side, it's six, but it doesn't show up there. Oh, that's a square, a cube, a cube. In fact, it's a cylinder. It depends. I have one more question if we have the time, of course. Um So it was said that the assistant and surgeon move dependently on each other, mirroring each other. Um But Milda is asking, are there any surgeries that require two assistants and how then they would move and perform their duties? That's a very good question. And there are many operations that require two assistance and in cardiac surgery, in particular, when putting valves in require two assistance and they have different roles. The assistant, as you shared seen here is following an assistant, the second assistant is assisting the assistant or holding a retractor. Now, the holding a retractor bit is often being boring. But what I used to do with rehearsing for an aortic valve replacement because of the needle angle of being angled out in 45 degrees. I would actually have the team rehearsed with the 19 sutures, mattress sutures that go around the annulus in the different roles. So as I was stitching, I put my hand out and say four is 45 degrees, four is 45 degrees. The valve needed to come to this my right side so I can continue the sutures on the backside of the valve. So the second assistant became the first assistant, the first assistant became the second assistant, but the whole team was organized such that there was no hesitation, deviation, interruption or repetition. And I could get in an aortic valve and a cross climb time at 24 minutes. Not because I was hurrying because I removed all unnecessary movement and everybody was rehearsed and coordinated. So from the pick up of the needle, 45 degrees, hold this back hand, 45 degrees. I literally kept my hands moving all the time, not fast, but they kept moving because each person had practiced the role and that is part and parcel of your briefing and understanding the operation. So if you've got a complicated operation is to explain the role to the person, this is what is expected and this is how you can help and how you can be involved. And I think that's very powerful to get the team together. The other important thing is we on first names, we're on a level. So as I said, in the Black Belt Academy, I must sense a that doesn't mean to say I'm any better or worse than you. It just means that I've been on the road longer and I've got more stories to tell simply as that and nothing more. And is that dynamic and relationship in theater, that is the essence of human factors and their non operative, technical skills. The other thing is when you've got a good assistant following you, as you can see there, even for somebody who's very new at operating and Alice has done extremely well. Today, when you've got a good assistant, your operation becomes even better. And when you got a complicated operation and you've got a good assistant, it is an absolute pleasure because your tension is focused on the movement. But also your situational awareness of what's going on in theater is not diluted because it becomes relatively automatic in front of you. So with the goodest system and cardiac theaters, the team always knew that I knew within 30 seconds to a minute, the cross-clamp time and bypass time of an operation and everybody operates furiously. You even in cardiac surgery, you don't have to be quick. You got to understand the rhythm and in every operation, there is a natural pause and you use the pauses to do something else. There's one surgeon I operated with who is frenetic, who is going all the time. And it, it really didn't set the relaxed tone in theater. And in martial arts, we talk about the term doing that. What is that? You forgot that? Yeah, I'm asking you, uh, when you pause and you're holding that is mind like water. And it was interesting part of the Bruce Lee philosophy. He talks about be like water and it be still, be calm. And that's why I like the comparison of the study of martial arts. The study of surgery is not just technical, there's a mindset and purpose in it as well. I would like a big round of applause to answer. He goes back to school in Malaysia on Saturday. So the next time he'll be assisting will probably be in December. Thank you very much indeed for joining the Black Belt Academy of Surgical Skills. Next week, we're going to talk about the scissors. We have had an excellent demonstration of use of scissors. We will expand on that further. And in on the 25th, we are going to have another special with two of Chris Caddy and Tim Terry who are gonna talk about Kar reflection, quietness of mind, the need for a mentor and the need for a coach. Thank you very much indeed for joining the Black Ma Academy. I hope this has made sense. Do spread the word and wish you well.