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Summary

Welcome to the Black Belt Academy of Surgical Skills, where you'll find a special guest, Vice President of the Royal College of Surgeons of Edinburgh. Learn the nuances of surgery and understand the key principles of good assistance. We'll discuss the need to look and learn and how to handle reticent assistants. Plus, hear Clare McNaught discuss the importance of mutual respect and communication. Join us to experience the art of surgery first-hand, and ask questions to build up your expertise.

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Description

BBASS is joined by special guest Clare McNaught. Together we are going to explore the art of assisting and explain why good assisting helps the surgeon and helps the patient. BBASS will outline some basic principles and explain the art.

Learning objectives

Learning Objectives

  1. Understand fundamental principles of assisting in surgery, including learning to recognize steps of the operation and the importance of understanding anatomy.
  2. Develop knowledge on how to establish effective communication between surgeon and assistant.
  3. Learn strategies for handling reticent assistants – encouraging confidence and respect.
  4. Recognize the importance of posture when assisting in surgery.
  5. Engage in practical exercises, such as shoulder-to-shoulder collaboration, to understand the nuances of surgical relationships.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, good evening. Good day. Good morning. Good afternoon, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. If you're one of the 4230 people following and returning, I'm most grateful and of the 603 on Instagram again. Thank you. But if it's your first time for the Black Belt Academy, do we have something special for you tonight? I'm delighted to introduce a special guest, a friend and colleague, Clare mcnaught, who is the Vice President's of the Royal Colleges, Surgeons of Edinburgh. She lives and works down the road and that's where we're broadcasting from Blooding Park, Harrogate Yorkshire in the United Kingdom. Welcome and welcome to Clap. Yeah, a lot of you enjoy assisting. Some of you did not enjoy assisting at all and only a few of you have been instructed and how to assist for those of you have followed the Black about Academy. You recognize that my assistant this evening is not my son who's in Malaysia and that is why Claire is here, but Claire is an experienced surgeon and I asked her and I'll ask her now once from the system and hopefully we can porky food. Some of these okay. That assisting is not a passive job assisting is active. And the best question you can ask is why, why are you doing that? And you need to look and learn because a lot of what experts surgeons do, they do it because they've learned over years and has become tacit, a very few of them can deconstruct exactly what they're doing. That little twist, the little turn, etcetera. And unless you are paying attention to each of those steps, you'll miss the nuances of the art of surgery. And that's the important thing. I would also suggest before you go into theater and assist that you perhaps watch the surgeon do that operation beforehand. So you know the necessary steps, but also perhaps look up a little bit of anatomy. So your questions do become a bit more knowledgeable at the table. But I'm gonna leave this question. Declare now, what do you require of a good assistant? Clap. Well, David, thank you very much for the invitation to join the Black Belt Academy of Social Skills tonight or today. Wherever you are, it's my, my privilege. And in terms of being a good assistant, I think that when I was training to be a surgeon, you just wanted to get your hands on, you want to do your operation yourself. You thought that was the most important thing. But I promise you that when you become a consultant that you don't really appreciate the value of assistance until you, you actually have to start doing all these operations themselves. Because if you've got a good assistant who understands the steps of the operation, understand about what you're trying to achieve each point of that operation and who actually assist and helps you to achieve that. It makes your life so much easier. And there are a number of skills that you have to learn to be a good assistant. But I would probably say to you, the first one is that you have to understand the steps of the operation. So you must ask your surgical college colleague, what is it that you want from me? What do you want me to do if you haven't seen it before? Just ask that basic question. And there are a number of key principles that we're going to go through today. Like when you're actually exposing tissues, that's important that your assistant understands that if you pull one way or have traction, one way, they have to use the same counter traction another way to expose the planes, which makes your job as a surgeon so much easier because it keeps you in the right place. So a good assistant is someone who understands the operation, who knows all the steps, who is willing to speak up and ask you quit and question you and actually challenge you if they think you're not doing something quite correctly or you might be in the wrong place and try and assist you and try and get you back on, on track. So, assistance, it's so important and that's what we've been trying to focus on tonight. Hi, Claire. Sorry to interrupt. And we've got a question. How do you communicate with your assistant? I hope in an open and transparent manner and I was going to address that. Now, we've tried it already. Clan I a different height. Okay. And I thanks to fill, who's the manager of running park? He bought a step such clear stand on that. So we're at the same height. This is emblematic of two things. One as we have addressed before in the Black Belt Academy posture is important and you need to look after that. 27% of surgeons have musculoskeletal problems because they don't address the posture. And too often the operating surgeon ignores the training and we've talked about disparity of height. The platform I had this evening was too high, but that's the physical height. There's another important element that if your shoulder to shoulder, you are on the level and being on the level means that from clear sight, she's seeing the operation at 90 degrees from my side, neither which is correct. And the assistant needs to feel empowered to actually ask. Excuse me, sir. Oh, Miss, can you explain what's going on? And the best question you could ask is, can you explain what you're doing. And I remember operating with John Pepper from Brompton and we're doing a Stentless valve and he's putting it in and I thought to myself, this is a bit strange. So I did ask him at the time. Excuse me. Uh Could you explain the orientation of the valve? He said, yes. Yes. Yes. Yes. Yes. Yes. And continued. 20 minutes later, he said, I now understand why you asked the question because we had to take it out, re orientate it and put it back in. I hope that is changing in survey. It's the duty of trainers and surgeons to respect your assistant. Sorry to interrupt again. But we've got another question from Christopher. How do you handle uh reticent assistant? One who's differential and very polite. I, I think it's, you've got to try and engage them in the operation. And I think sometimes speaking about what you're doing, you know, perhaps asking them, um, do you know, you know, maybe pointing out some anatomy to them? Can you tell me whether I'm a colorectal surgeon, for example? So I might say, can you show me where the ureter might be in this part of the operation? Trying to engage them in the operation as they go along to try and get them, get their confidence and not to undermine them, not to ask them something so outrageous that they start panicking, they're just trying to engage them in conversation. Because if you, if you don't have someone who can help you, then the, the operation will take you longer in the long run. So you do want to you. So you have that mutual, mutual respect for each other and communication. And it is a dialogue. The best thing a says you can do with a new assistant is think allowed to talk through what you're doing, allowed, I'm now doing this, etcetera. Uh This looks a bit tricky and the surgeon needs to be honest with themselves. And the assistant saying I shouldn't have done that. Uh That's a whoopsie or I'm now in trouble. Okay. There's, there's, there's no bravado innit surgery is very much at leveling special cheeses. Uh Then you need to engage the training in doing that. We've got another question. How do you level the conversation as prime surgeon? How do you ensure that you do not belittle your assistant? Uh Well, I think, I think that those days are, you know, hierarchy in theater now, you know, with your, when you start off with your, with your team brief at the beginning is you set the scene for the rest of the day and how you conduct back, you know, introduced everything gets introduced at the beginning, make it quite clear to the whole operating team that often it's a training procedure as well. And that, that helps people understand that it might take a little longer to do this procedure, particularly if you're training, colleague is doing the operation, I think setting those um that conversation and that you're leveling that hierarchy before you even start the operation before you actually get into the operating theater itself is absolutely truly important. I also family believe first names are important. I'm always much preferred to be called David. Someone who refers to me as Mr Regan, I think I've done something wrong. But as Claire said, you set the turn at the briefing at the, during the day. And I've always invited the trainee to do the briefing before the case because it tells the team that know the patient. The other thing is an operation can be divided into its several parts. Uh A lot of anesthetists and scrub nurses will be touching their watches, going to touch, touch with running out of time. If the trainees doing the whole part, it's very simple. Focus on the part the trainee needs to do. So when I was training people with coronary artery bypass grafts, I would open and close. They would do the operation before they know how to open and close. But I would open and close and could make up on time. But time should not be an element of this. You plan your day properly with proper communication. Everybody can have fun. I agree. Absolutely right. So we've got to take you through a couple of exercises to demonstrate this traction, counter traction and simple, simple Mary's. Now, Claire said she's never adjusted the table for a training, his height. I think if you've got a very tall training out of respect for them, you stand on the platform. So you both have a comfortable height in that relaxed posture. So you functional anatomy of the arms, correct? So, put this around your waist, the other side, take your end to preserve yourself around your waist. Now, and we're going to put this on, this is a band and we're going to be wearing this as an exercise today and it's a bit like dancing. Okay, Claire, I know college functions is the first on the dance floor and probably the last on the dance floor. Claire likes to dance. There's a dance pervade when the system. So choose where you want to move, you're gonna move around as if you're operating. Okay. So if you move that side, so if I'm going to go to my left, then you'd have to go to your right. Yeah. There you go. I go to my left as well. And the reason for doing that is that our shoulders remain parallel throughout and this is important because the midline between us is like the yellow line on the road. We do not cross the midline. Okay. And if you move around the other way, there you go. And by keeping your arms parallel and shoulders hurt every time I'm following. So I'm going to follow Claire this evening and in essence, wherever clear goes, I'll go to actually keep this. And in doing that, we are maximizing the space between us to allow our hands to rack. The other important thing is and Steven Spielberg Westby, who made some of the best movies for Aorta Group Replacements. I had the camera from above. And what it taught me is if I put my hand in the middle, not any would I get rapped on the knuckles with the tubing club, But it taught me the operating space for the surgeon is in the middle. I assist on outside, declare will be assisting from insight. You'll be operating on the inside and I'm assisting on the outside, we're moving together and when we're moving around again, our hands are moving together and we're moving around this way, our hands are moving together. My hands are not getting in the way of the surgeon. I'm never reaching across and never reaching in and never grab it unless invited. Now, there's one other place depending on where the scrub nurses and Kale, where's your scrub nurse for you? Usually in laproscopic coetzer, they're usually at the patient's. So they're across from me and diagonally across from across and diagonal. Uh When I'm operating in Codec city, the scrub nurse was to my right hand side so I could put out the hand, an instrument we put in that and I can use instrument. What I'm saying is there is a space between the surgeon and the scrub nurse where the traffic of instruments, sharp knives, sutures is passing on a regular basis. That's not the quadrant that you want your hand in. You could be stabbed and you could get him injury. So there you go. Very simply moving around. Okay. So the assistant is providing traction and counter traction all the time. So I'm gonna put a simple model on the table here and uh to push me, pull your model, I've got a forceps. The important thing all says assistant as with the surgeon, you never cross your hands. So you have your own several midline and you don't cross your hands. That means if you get into that side, you put the instrument in the other hand, okay? You never cross your hands and you never, never doing that. That's kind of silly. So players going to take a forceps and there you go and I'm going to, and to try and anticipate what Claire is doing and you're gonna take one of those and I'll pick up equal and opposite wherever you are okay and maintaining traction. Taking on one class, you can take two of these. You can make this a knockout game and see if you can actually give okay. I'm using a different hand and different forces. I'm trying to anticipate Claire's move. All right. At each stage, I can see her moving and I'm picking, picking up equal and opposite. And the idea behind this game, you can go faster and faster is not to pull the pin out of the banana. All right. Or it could be a pin out of a hanging edge that is a banana, not hanging me, but there you get and keeping up with your care at the moment. Okay. Keep going. And I'm trying to anticipate Claire's move. I can see where she's moving because that's the nature of the forceps in the direction we're going. This is simply watching the intent of the surgeon and I am actually now saying okay, we're making kind of fun now trying to catch me, try and catch me up. All right. So I'm actually as an assistant trying to maintain the same equal and opposite each and every time. And that is important and, and critical in traction and counter traction. But this is the sort of anticipation game as well, but I'm not going in there and starving with my forceps. I'm watching the operation and watching the direction of intent. Okay. So we haven't, we haven't built the print out yet. I, in fact, I nailed it into the plate. That's neither here nor there, but there you go. So it, and an interesting exercise to do, but it's teaching your assistant to actually think how am I going to provide traction and counter traction. Now, we have done that simply with a pin shoelaces and a couple of forceps. I'm some interesting exercise to you practice at home in pairs with somebody to do the same, to anticipate, to see equal and opposite traction. Sometimes. I think David, you're quite right about when you're, when you're assisted, you have to pay attention. And I know it's very difficult in a long operation that your attention can often drift. But really, um, as you said, at the very beginning, assisting is an active process. You have to be watching the surgeon and uh they anticipate facing what we're going to do next so that you can make just make sure that you're in the right place to help them. And so it's to be a good assistant is actually quite a difficult thing. It does take practice and you can learn to be a good assistant, which is why we're here this evening. Well, it is sad that good assistance, make good surgeons and good surgeons, make good assistance the to do go hand in hand. So we're gonna take this model a little bit further. Claire's gonna do some stitching. Okay. I'm going to assist the stitching. I'm going to hold up a couple of other things, your note on this model and you can perhaps zoom in. So you can see the triangle. Please understand. I've got a triangle on a simple bit of cloth here and the triangle is there to emphasize the point of triangulating the forces to ensure that what you're stitching on is in a straight line and triangulated. So I'm not sure which line Claire is going to go down, she's going to pick it up somewhere. Uh, yeah. Right. And Claire's going to stitch the blue line. Yeah. Whichever which way now just pause there one moment as well. These cramps, uh, the art of assisting is to hold the suture out in the direction it is taken as a lateral hold and not a pool. And this is very important when you're stitching, bowel and stitching nasty dissected vessels Because this polling can a bit like a cheese wire. And as a cheese wire, if you pull too tight, it will pull out. The other important thing is you note, my finger and thumb are directed towards where the sutures come out. Such that if I was not paying attention and Claire happen to pull the suture through, it will slip out between my finger and thumb, I would not be caught or tear out at all. So it's important that direction and hold is important. The other thing is two thirds. Well, 2 53 5th, Claire needs enough space on the future to make rotation's but does not need to be tripping over the suture at all. So the length and direction you're holding this now becomes critical such as you connection Stitcher. And I am following the other hand and note that I'm triangulating the forces. I'm not gonna let go until I'm asked to, I wait for Claire to take up the attention and you hand it back to me and note the triangle that we have on this cloth needs to be maintained under tension to allow you just ditch a very nice job. Mhm. And it's simply understanding the need to triangulate and the triangulation is coming from the future that I'm holding with my left hand. And the four steps I'm holding in my right hand and the Forceps Claire is holding in her left hand. So part of the tension is also the suture. Absolutely. And following the following the suture with correct tension is of vital importance, not only the tension but the direction in which the sutures taken out. I can assure you my first time being cardiac surgery was eight o'clock in the morning at the training beat hospital and I got up without breakfast and at the end of the day that 70, Prolene became rather small and I felt pubis surgery is a demanding specialty even for the assistant. Make sure you're properly hydrated and nutrition on board before you go in because it does require concentration. So do you want to come down another direction, Claire? Yeah. Okay. So I would, I would know that this stitch if I was going to sit across this direction, I would actually move my body to make it easier for me. And so I would expect my assistant to move as well. And that's exactly what I've done. So you see the rectangle between us is maintained. So without asking, anticipating, clear was going to move. I moved to such of our shoulders. The power should never be and should never be afraid to move. Because it often if you, if you move, you put yourself in a better position, it makes it a lot easier for you to shoot your, but you see your assistant has to move to. And the one thing we don't teach about assisting are these simple principles and how to move to make it easier. It's like it's like having a good dance partner. You're dancing is gonna be no good if your partner can't follow. Sadly, David's one of David's skills isn't dancing various nights out. Um But he's a very good surgeon. No, I like Claire do the uh at the college functions, I could get it. She brings enough energy for the whole of the college. So any questions from anybody, Claire's just slightly adjusted their position and I'm coming around as well to adjust the position as well as a baby sitter. They're, they're, yeah, build it back. I'm not grabbing the suture. I'm taking it out in the direction it's given to me as a lateral hold and not a pool. That's right. So I saw my sister was holding it here, which what wasn't really allowing me to do? I want to do. So it's never be afraid to say to your system. I'm just going to move you slightly. If you can just hold over here, it will just allow me to see that corner, which is where I want to put my stitch. I started to move because I could see yours in the way. Exactly. Ok. Lovely. Thank you. Thank you very much. Super. Okay. So we're going to go on to our next exercise. Okay. And you will recognize this as the Black Belt Academy skill, but this time with an assistant, so Claire's job is to put 12 perfectly radio switches around this and use the forceps appropriately on each of the staples going around. I am going to hold suture going round as a lateral hold and I am going to hold the staple opposite. Now, the thing about the staple in the banana they easily taken out says literally a gentle hold with this. And as we go round, Claire will automatically and unconsciously move potential we're going around. I need to follow Claire all the way around. Hello again. So I'm not quite, it's not quite clearly wanting to do the inside out, from inside out, avoided the edge from inside out in the continuous suture. Um It's not like before. Okay, good. Yeah, okay. I do have the shop spin. So you mean one if you want, we can put a clip on the end so you don't have to tie it. I'm going to show you another little fabulous trick that will make your surgeon very happy if you know how to pass the future later. So remind me of that Jingjing and I'll demonstrate that. So wherever you want to start 12 perfectly radio stitches, you note that polling has got memory in it. Okay. And it's my duty to assist Claire. Such that Proline does not get in her way. Yes. No, that's fine. I just put those in because I be applying counter traction somewhere just wanting to let you know that there's a running commentary in the chat by Christopher um talking about different attributes. And we also have another question in the chat, um, from Keenan, sometimes the assistant notice is that the surgeon is not keen on teaching. What's the best course of action in that case, if the surgeons are keen on teaching. Yes. Well, my simple answer to that and, um, my director of the Faculty of Surgical trainees is I don't believe and we had a debate it and I percept meeting that all surgeons should be teaching. Um, and therefore they should be disqualified, they should not get trainers. It's a privilege to actually train. It's a privilege to have the future surgeons working with you. And I'm quite adamant and open about that as well. But if the surgeon's not wanting to teach you okay, I'm just going to move it, my hand around, the surgeon's not wanting to teach you, you can learn something from everybody. And the important thing is to pay attention to how they hold any instruments, how they're holding, using the tissues and look for any tips and tricks. Many surgeons over the years have actually learned tips and tricks. Lloyd Barclay morning and said surgical experience is a posey of other men's flowers. So even with somebody who's not talking, you will be able to learn something. By the way, they're holding instruments, uh holding a tissue, uh tashi, oh no, of Toronto. And his management uh series used to take on new managers, put them in a prescribed circle on the floor and says, look and they were left there all day on the production line to observe what was going on. And at the end of the day, he came back and said, what did you see? The interesting thing is that Gary Kaplan of Virginia Raisin Medical Center takes his medical team across to Japan. Should do exactly that. So even though you will not get instruction, you can look and learn, but you need to know what you are seeing. I'm slowing down the switcher and then I'm going to hand it back to my assistant and you know this banana mulder look, you told the title cause Problems note that I haven't actually reached in or grabbed Claire's moving slightly now and I'm moving with her as we go round, I am not reaching in and my signal is to take it from Clare and holding it out in the direction in which the stitch has been given to me and psa lateral hold and not approved one of the first cardiac surgeons are actually assisted with Jim Monroe. It's called gentleman Jim and leaked it. It's a lateral hold and not report because this protein even at a 70 level, any sudden movement can result in a terry out of the gods met in Corey vessel. Your cardiac surgeon would not be too pleased if he exhibited that sort of huge approach and without care knowing, do note that the triangle in which we're working and it's staying parallel. Um David um Christopher asking if you would like to point out how Claire has changed your weight distribution. Yes. Um Claire has actually moved her weight. I'm waiting for her to move to about to change the backhand, I imagine because Clare is now definitely on her left foot. I will actually move and I'll continue to stitch forehand because it's much easier for me to, since I don't know. Uh So the direction Claire is moved is almost opposite. And I have actually moved around a note. Now I'm gonna move my forceps to my right hand and I'm going to follow now with my left hand because I do not want my right hand and my left hand to cross and these simple principles will stand you in good stead when it comes to operating. Yeah, I understand you're mastering the camera. Would you like to make comic uh careful? Actually, your alternative for a really expert surgeon would of course be to switch you with your left hand, but not many of ambidextrous. But that takes the skill of an orthopedic surgeon to uh, well, fabulous. Alice said I did that one time on a colony vessel uh deep down in the chest and I found myself having difficulty going to background. So I stopped the needle holder to my left hand. I completed the an osmosis and turned to my assistant and said, did you notice anything during that? And as nurses? And he said, no, I said, well, halfway through the anastomosis, I put my needle holder in the opposite term and a half the anastomosis, my left hand, he had not, he was clearly not paying attention. And I was thinking of the party on Friday night rather than the operation in front of me. The other thing is surgeons are very particular about the field. Do not go in there and start poking around the forceps themselves are very sharp. And if I went in there, albeit with good intent to help that suit you go down. If I'm not careful, I would stab something and you would not be the most favorite person in theater. Yeah. One thing that is quite interesting is how the assistant actually holds the Fred. And I was always taught to hold it in such a way that the Fred would be released very easily. And I always held it between my thumb and my forefinger at 90 degrees to the way you're holding it. So it actually slipped out just that little bit more simply the reason why I did this way. It literally pulls out if you do it this way. Yeah, it's got to slip out your fingers. It must so part of the fingers very easily because if it jags uh as you have it now, then it's very difficult for the unsold things down. So I'm not going to change because actually I can, by changing my position, it's always much easier to stitch forehand. So if I move and David moves away, I can then go back to stitching for. Uh and I've changed position too and note this rectangle between us. Our shoulders are parallel, my hands are not getting in the way and I'm being patient and waiting for Claire to hold the suture up for me. I didn't think you couldn't expect to be stitching this. Uh Of course, as cold proctologist don't really switch. You were just done these days, but I'm teasing, we do a lot of anastomosis. Uh um One of the colorectal anastomosis where you have to be a very good assistant is when you're doing an anastomosis and you do a canal suture because that actually takes the assistant swapping hands on every suture to make sure you're inverting. Yeah. So each, each, each cycle of the canal suture, your assistant actually has to use both hands. You have two hands. And actually that's, that actually is quite a difficult thing to learn as an assistant. And, and it's very important when you're describing that to assist at the first time, it's really important. You help them understand because they have to essentially change hands each suture or else they'll get in your way. Super. So I hope you understood that we moved around. We've changed the body positions. I followed the surgeon by doing, mimicking the position, the body position. So Claire the last exercises for this evening to, to complete your singing for your supper. Um We didn't barbecue this chicken. We had rib eye steaks in the Barbie. And I would like you to start dissecting this home. Which one you want? You got a choice of knives and scissors and things and take the skin off. One of these. So dissection for a surgeon by themselves is actually rather awkward. You do need forehands, but you need four intelligent hands to hopefully belonging to the surgeon and the other two belonging to your system. So when I see, when I, when I see the skin, I also think of the human skin as well. And actually when you, you're even about to make your skin incision, it's getting your, your assistant in yourself to give counter traction on the skin. If you're going to make an incision, you would want each of you to pull one way or the other. So that when you make your decision, it's nice and straight because especially people as you get older I get. Uh So, so David, we're going to take this, this off here. So if I can ask you to hold away from me, you're going to, I like to have you get traction this way and I can hold this up as well. Okay. Uh The important thing is is that in assisting the dissection and moving across the plain, I've got to move my forceps with Clair's Scissors in life. So I'm maintaining traction all the time to enable that to happen. You can see here this is like an adhesion where you're doing abdominal wall dissection. You can see here that if David picks up this side here, suddenly I can see where the edge of this was Bill, I can see where the tissues are and actually be able to dissect under tension which makes it much more, is much safer, much more effectively have I'm doing it. And certainly when I'm, I'm taking a trainee to a new operation, I can use my forceps as a direction and help them with the dark process as well. What I'm trying to do is anticipate players move and help her traction and contraction and counter traction all the way through this. So whether you're actually doing it with forceps, whether you're doing it with suture or whether you're doing it in dissection, this traction and counter traction is a continual process throughout the operation. And it means that you have to stay focused on what's being done at each stage and anticipating the anatomy and known the surgeon, this becomes a lot easier with time and becomes a pleasure. All right. And I should be able to assist without care, telling me, hold this, do that move there, whatever. Uh So it ends up as a natural process, but it doesn't become a natural process overnight. It only happens with understanding the principles. So would you like to take out? Is it, can we take out a little bit of that? Uh The dogs were going to get this book later. So don't worry about uh we go for Sustainable Eco Friendly Seven. Let's see if we can get it naturally. I've taken some of this um this next layer off here. Let's take this hair off. Okay, let's do that. Mhm And this is very like a TZ license. That's it. Tt's when you go into some line moving to where it's something where the tension is greatest across the tissues because we put good traction, counter traction. And that makes it so much easier than to dissect off if you got it right. David Chechyna. So do we have any other questions from the audience, please? Not currently. No, not even Mr Caddies passing College, which um he says traction and counter traction, beautifully demonstrated by Claire and David. Thank you very much, Mr Cuddy has to see that because we paid him. It was one of the senses. The same principle, of course, applies. If you were to use a knife problem. This isn't absolutely you can, you would want to pick up. Absolutely. In fact, in fact, very difficult. It's usual ISIS. That's exactly right. It's actually sometimes safer to use a knife because actually when the planes are, is easy, easily seen. Again, the key ist again, traction and counter traction. Once again, I see that beautiful plane coming in there now. So Claire's not given me instructional where to move. But I'm trying to think to myself, if I was doing this myself, where would I want to be focusing my attention? But not just that. How can I make it easier? And that's what? So it's a very dynamic processes. I didn't really realize that you could dissect a chicken so carefully actually. Okay. I get immersed. I get immersed in doing a regular basis. I'm actually having a lot of fun. The thing about these models is with practice, you find yourself getting totally matched these and we're coming from a caravan park in Yorkshire. This is not a hybrid, get come back up. This is not high fidelity, bespoke wet, like not at all the outside with the Yorkshire sunshine, the sun is going down. You can hear the birds tweeting, but we can practice and we can actually have fun. And that's the whole thing about the Black Belt Academy is to point out to you. Yeah, a little bit of imagination. Low fidelity models and organic models are better. It's interesting. Uh a student actually tweeted the other day. These future parents are absolutely rubbish. I don't understand. And I got to thank Angus Watson for actually saying, have you looked at the Black Belt Academy? Organic material? Beats anything and everything that I've come across in the past 35 years, etcetera, your banana, chicken, anything. And it's up to you wherever you are in the world to actually send me examples of your practice. And the most negative one will get uh instruments, I'll post it to you. I did send some instruments to Abby Dobby. Unfortunately, on two occasions, they were sent back because they weren't collected. Um, apologies to the viewer. I tried and tried repeatedly. So the last little think I was going to show you, OK, is, could you pass suture to me? And if you pass suture to somebody like this, you got a wiggly and you're passing it down somewhere and somebody is desperately trying to pick it up, uh does not work okay. So if you really want to learn something very sneaky right hand and left hand, if you want to pass somebody something, use the leahy or Roberts and your bow string suture over leahy or Roberts and they can pass underneath anybody and let go and take it away. That is the most accurate way of decisive way of doing it. Now, if you can practice doing this right hand and left hand. Whoa, you have actually now become see, I can take it down to a one. Claire gets it and release. That is the best way to pass suture. So next time if your assistant and the surgeon says, could you pass me that suture? Just tend to describe nurse and say, do you have a Roberts Lady and do that? I think the surgeon will be most impressive. Thank you very much for your attention. And I want to say particular thanks to Claire for this evening and joining me, I've had fun. Oh, it's been good fun, David. Absolutely. Did it make sense? Yeah. Fantastic. Yeah. Do you think the model, the work models works for you works really worked really well. It's um actually it really does challenge your basic, basic skills, but it's important if you can to do it with a colleague um to get the assistance um and the traction there, you know, it's good to practice this and it's so pair up. It makes it much more fun. Thank you. Thank you, Alister. Thank you very much for joining us wherever you are. Thank you Jingjing and Sue in the background for the production, Mr Carty Sensei uh for your valuable contributions. Wish you well and look forward to seeing you next week as we're going to explore the use of the blade. One of these things okay training seem to get very nervous when it comes to this sort of thing, but hopefully we'll teach you otherwise. Thank you. Goodnight and be well and thank you Claire.