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My name is Glad I'm a plastic surgeon resident and I'd like to introduce to you Mr David Oregon, who is the Sensei of Black Belt Academy and um to whom I owe a lot and from whom I learned a lot. So David, you'll have the, you have the floor. Thank you very much. Indeed, glad for me to join you this afternoon. And it's a pleasure to be with you online from Yorkshire in the United Kingdom. My name is David Regan. I'm a cardiac surgeon, the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And I remember visiting professor at Imperial College, London. I started the Black Belt Academy because as you will see, I am wearing a black belt and I am third down in karate in second dance. And the idea it struck me that basic surgical training is missing a lot of elements in martial arts. You're taught techniques and forms that are brought together in the form of conscious and you progress from white up to back out of the cart is, and it is said only when you get a black belt, do you begin to learn and this is development of mastery because every time you go into the dojo, it is the beginning and never an end. And mastery is attending to the basic all the time every time. And in martial arts technique becomes before power and speed, it is vitally important that you are aware of your technique in the six stations will talk you through this afternoon's I referred to me um You too much Shashi, who's the undefeated samurai warrior of 16 43. And he's written about the art of growing the sword and battle plans. But there are nine points that I think are pertinent to surgery. Think of what is right and true practice and cultivate the science. Become acquainted with the arts. No, the principles of the crafts, understand the harm and benefit in everything. Learn to see everything accurately, become aware of what is not obvious, be careful even in small matters and do not do anything useless. And I think that applies very Actly to surgery, but there's an element of basic surgical skills and martial arts that is not taught that we hope to impart upon you today that there is rhythm in something and everything and in rhythms of martial arts in particular are difficult to masters without practice. Rhythm is manifested in the world in such things as dance music, pipes and strings. There all harmonious. And if you watch a good surgeon at work, they're not hurrying through an operation, there's purposeful, meaningful movement throughout. And if you think of the cardiac cycle between Sicily and dire silly, the Axion being Sicily, which is fixed, diastole shortens as the heart rate picks up. And it's that dire silly that I believe is often missed in teaching surgical skills. And this is all about set up and attending to set up. So let me talk about cetera. But growing on a metaphor of golf, I don't play golf very well. But I've used the power excellence of periodic course as a metaphor for teaching surgery. And with golf, it's grip address, stance, position, the grip is peculiar for a golf club and it feels very strange, but that enables your arm to move properly. Address is how your line, the golf club to the ball. And your note that on this picture, I've colored in red, a sweet spot. Now, if you attend to all of that as well as empty the mind, your golf will be very good. What's interesting with a sword? And this is my katana. The grip is much the same. But for 700 years, they've been teaching how to actually well the sword and understand it is not just a weapon, it's a mindset. And that mindset is we also teach with that in mind. That is why Vlad and myself call ourselves Sensei because we know better or worse than you were on the level. And Sensei in the Japanese term, literally means long in the tooth or gray hair or longer on the road. And that means we have more stories to tell more experiences to share. And that's what we want to share with you today in your development of your basic skills and glad. And I would welcome any interruption or questions from the floor. And if you call it out, I am very happy to be interrupted as we go through. So what we've done with the Black World Academy is taking the basic skills of use of the scalpel, the scissors, stitching skills, forceps skills and not tying skills as well as assisting skills as the key elements for any surgeon or in development. No matter what they stayed of their journey is we've taken all of these and they're available on the website be be a double s dot org as youtube videos, but we are live on metal platform on Monday evening and all the catch up is there too. Thanks to Medal. We can now interact life as we're doing. But we're also able to interview key people to talk about the mindset and strategies for surgery. Drawing on parallels from experts in other fields of sport and airline pilots and either educationists to help your development. And we wish that you can join the 3297 people who are following in the 590 on Instagram. So the first skill we're going to be talking about a knife skills, but like the sword and all the other instruments, all of this comes down to fundamental principles and the fundamental principle is posture. Here's a nine now automatically hands up those of you who iron, I can see the groom who irons at home. Can I see any hands you don't iron up there nor do we iron down there because we're not standing properly. And I think one thing that is missing in surgical teaching is the first course which in martial arts is called Tokyo co or great ultimate is all about posture. 27% of people. More than one in five of you in the room will have muscular skeletal problems throughout your career because of called posture. That means that you often see surgeons leaning over the hip and their chin extended out. And for every two centimeters from the midline, your chin is you gain 2 kg in weight. Such that at eight centimeters, your head is wearing 19 kg, more than it is said 29 kg on your neck, your shoulders, your back. And what happens is your shoulders were take forward, you hunch over and you get anterior pelvic tilt, shortening of the sternal clouded mastoids and degenerative changes in your back. And the first thing we need to do is understand how to stand properly at the table and also understand that you're not gonna iron up there or iron down there. You got to be operating at a height that is comfortable. And for those of you who work in the kitchen, why are countertops the height? They are, they are that height because that's the median height of the population to enable the functional working of the upper limb. And this is a vital importance and then being a vital importance, it is reducing the amount of stress on your neck and back. The thing is as soon as you move the elbows from the side, you're employing all the muscles of your upper lemon shoulder girdle leading to fatigue. But we know from studies reducing your ability to reach and fulfill actions and your hands and arms were causing significant problems with your spine and your neck. Uh That's right. It is the vibration from your side. Yeah, the vibrations might not, you're just uh I think so. So the way you stand is vital importance because the human arm and the hand is absolutely unique. Our ability to actually oppose our fingers, hold her hands in the mast, er and back prone eight and super Nate make the upper limb of the human unique. Without it, we will not be able to feed or find or toilet ourselves. Think about it. Your hands are very important and the most important element is your fingertip. There are more sensory input from the palps of your fingers to your brain than there is from the eye. And it's that fingertip appreciation that is absolutely necessary. To feel the instrument to get haptic feedback on what you're doing. Now, we don't often teach their conservatory. In fact, nobody's teaching that at all. But as Lloyd Barclay morning, Han says, rather than be a heure of flesh, you need to caress the tissues and respect the tissues because respect of the tissues reduces blood loss and also would mitigate the propensity for win infection and patient outcomes will be better. And that is why you need to be able to use this. So that is how we have deconstructed in the principles on which the Black Belt Academy are founded. I'd now like to take you through some basic skills which you're going to appreciate this afternoon at your various tables and don't expect to get it right. First time making mistakes in a learning environment is quite all right. We all been there. You're not expert yet. And as a third down in karate, I am still learning and every time I go into the dojo, I'm learning something as well because it's a journey and not an endpoint. Any questions so far from the floor vlad, you have any questions you please feel free to ask. So I'd like to make just a short recap first. And most important thing is the setup. So always take care of your posture, make sure you have the table at the right height, have the right instruments and have the right lighting conditions, okay. All right. I think you. So we're now going to go on to do the talk about the first of the skills which are knife skills. And I've often observed the training surgeons are very hesitant using the knife. And when cutting through the skin go through each of the seven layers, one by one, we'll, if you do that later is going to ask you the layers of the skin in Latin and their function. That will be your homework for tonight and we'll be setting homework as we go through. But sharp dissection is clean dissection. Very simply. If I take a sponge and I've colored the edges. If my blade does not move cleanly through the tissue, you can see that I've bacon sliced the skin there and the blue is showing. Whereas if I made a clean incision, it's a straighter line and there's less trauma to the tissue. So the whole secret about using the knife is being able to feel it, but also to make sure the knife is perpendicular to the skin throughout. But as with everything sharp and in your room today, safety is important. Please don't not wave it around and dispose of your knife safely. I'm going to take you over to the my work top and go through some basics. Now, the surgical blades and this is from Swan and Morton have a bevel and a groove on the side that you could probably see there where my finger runs, nail runs in that groove and the blade has got to sit in that groove and hence the unusual shape of this. And what we got to do is pick up the blade on the blood side and then with your hands resting on the table, insinuate the blade groove into that groove. You see there and slide it on, uh, wrong size. I've got the wrong size blade handle there. Let me get the larger blade handle just with a smaller one. So there you go exercise 10 blade, make sure you've got a good grip of the blade and you slide it into that groove like that to take it off, you lift off the edge, get a firm grip again and you slide it away. Only one is moving and therefore we are not pudding it with both hands and the risk of it flying off is reduced. So blade safety is very important. The other thing is is that the blade should be passed in a kidney dish every time it should not be passed inverted, commas naked. If you're doing that, what you need to do is ensure that the blade has passed blade down handle towards the person. And if they take it out the blaze not going to cut your hand. So safety is important. So how do we actually hold the blade and with everything this afternoon, what we get to focus on as for the golf club and as with the katana is how to hold the blade note that I'm holding the blade like a regular knife. The blade itself is sitting in the palm, my thumb and middle finger of maintaining a perpendicular and we're coming back to this perpendicular all the time that 90 degrees, my index finger is extended down the blade and then extending it down the blade. I'm feeling with my fingertips and getting pro perception and haptic feedback from the blade. So there you go overhead and it's 90 degrees. Now, the great thing about 90 degrees that will come to it as you look around the room at the doors and the windows in the corners, you can see 90 degrees. We are surrounded by 90 degrees everywhere and therefore hardwired to appreciate what 90 degrees looks like. I've done a study which demonstrated that students pick out with reliability, 97% and 90 degree angle without hesitation. So how do we practice? And how do we feel? What? Well at the Black Belt Academy we have got and extol the virtues of low fidelity models. This is an orange and with an orange, what you've got to be able to do or any fruit you like is take the blade directly down through the orange without cutting the flesh underneath and feeling it through the skin all the way such that you do not cut the flesh. And if I squeeze this orange, there's no juice coming out because I can feel it going through the skin. If I take the knife through the skin, as with the pork belly, you can see what a bacon slices there. That's the bacon slice is what you'd see cutting through without going at 90 degrees. And I'm just going to try and build this orange. Now for where I can't see my cut. Actually, it's so clean. I'm gonna peel this orange now and demonstrate to you the edge. Uh Now if you look at this orange and look at the edge and this would be true for the skin as well. You can see that I've cut through 90 degrees to the skin. Yeah. And I have not cut through the tissue underneath. As you can see that you can try this on all vegetables and all fruit and just feel your way and feel the death. The difficulty comes for many of you, you'll end up doing an excision of a lesion and let's put um argument there and you'll be given a smaller blade like a 15 blade. Now, the thing is with a 15 blade, it's very easy going around curves to twist the knife and bacon slice the skin. And therefore what plastic surgeons use is what's called a barren blade. And in this circumstance, you can see it's like a pencil or pen and you literally using it like a pen or pencil. So as we do this excision of a lesion, we've got to be perpendicular all the way around on the curve. There you go because the two edges come together and remember your wound healing starts from accurate excision or incision of the tissue and making sure it's 90 degrees throughout without actually baking, slicing the skin. I'm going to bake and slice that bit. So you can see the difficulty with the problems here at this edge. I have got 90 degrees to the skinning there, but on this, I've got a curve on it and I sliced it at an angle and people often do that on the skin, but that will be difficult as far as closing is concerned. The bigger blades, the 22 blades or just like the 15 blades, and there's no need to be nervous about them. The cutting edge of the blade as in my katana is the curve there on the Qatar know it's called the Roshi and that's where the cutting happens. So that is your knife skills this afternoon. The other thing to say is when making an incision, you support the tissue or the pigskin all the way down. And the first incision you're going to do is five centimeters. And it's a two handed process that you're spreading the tissue out between your thumb and index finger all the way or gently pressing down with a knife and cutting at 90 degrees. You'll find as decisions get longer. People end up doing a curve and the curve becomes problematic. You can see they're a curve. So as you come further down, I am abducting my shoulder to try and keep it straight and you can do this yourself without a blade on any surface. Can you go 20 centimeters straight down? The middle surgeons jerk a cardiac surgeons because they say we only do one operation. Well, I say to them yes, but you try and get 22 centimeters perfectly down the middle. So that's the first skill for this afternoon. The next skill we got to take you on too is this sister skills? No. My most favorite instrument is called the mcindoe scissors. This is the thin version, the mcindoe scissors. And you see there's a curve and the scissor and this is the medicine bomb, which is slightly more chunky. Again, the scissors need to be held properly and I'm holding it between my ring finger, my thumb, my middle finger is sitting across the top of the loops and my index finger is extended down a bit like holding the scalpel. So in this plane again, you see the index finger is extended down. But the important thing is is that the belly is curved down as well, such that I can see the curve and I can see the tips. Now, when you put your scissors in to do something, you're opening it up and then you're closing, opening it up and closing, but you open up and you never close. If you cannot see the tips and you always close within view, you always close your scissors within view. Now, the ancient art of in China was paper cutting. And I'd like you to marvel at this that is hand cut with scissors. And we used to joke at school. You're asked to cut things out with scissors. The most common problem I see is that the distal interphalangeal joint is actually insinuated through the rings, you lose control, even if you've got small hands is important to have. That helps of your fingers. Remember I said that's where all your field comes from obliquely through the scissors. That is quite remarkable. And a simple thing you can do to practice your scissors skills and accuracy is print off some black circles, oh some straight lines on paper. And as well see now we are going to practice cutting things out. So again, with the scissors carefully, we're going to cut some circles out and the holding with forceps, holding the piece of paper with forceps, I made that out the way we're going to literally deliberately cut through. So when you get to the circle, I don't want to see any dog ears and we gained, you cut the circle out very carefully using the tips of your scissors. And what we want to do is be able to do it without seeing any black as you see there on the cutting edge. And without saying any white on the black edge. So literally, this is a black and white scissor test to test your skills in cutting and dissection is all about controlling the tip of your scissors. The other thing we do is separate tissues. Again, we're using low fidelity models and we're just gonna peel the skin. What I want to do is try and take out of this tangerine a segment. We're gently separating the tissues like this with the discipline that I'm not closing my scissors within the tissue and I'm just sitting out a little bit of segment and gently lifting the segment down as you see there. And you're gonna be able to do it without crushing that segment. It's skin is intact. So this is a lovely model for practicing separating of tissues. You can move on to an orange, which is a little bit more difficult, you move on to a great fruit. But that is a lovely model for separating. So the two functions with the scissors, one is to snip carefully and you never open your scissors any further than necessary to do the job. Take them against a white background. So whether you're cutting sutures, whatever no more, you never hold it like that. And if you're cutting suges, you don't sweep in and cut like that, you place them in position, open cut, remove, it's a deliberate process. Any questions on the scissor skills? Uh No questions on the scissor skills. So everyone is all right. So the idea is to hold it with the lightness of touch and have a great keep control, open it as much as it is necessary to cut and cut only what you deliberately want to. And when you cut with your chair, as David said, don't be like fourth quarter pilots, okay, just make a deliberate mouth control, go rotate and cut or a limited. Now, one thing that I'd like to add, David is um as, as junior doctors, but it's important to know which scissors are good for cutting sutures and which Caesar's are not. So the max dose for the medicine ball, please don't have the searchers with them there for my segment features with this type of scissors, them, it is their tip. So they become unusable for clean bisection. And so when you approach the tissue, want to cut your approach with the scissors closed or yep, do you reopen know? Okay, you put it closed and then you open it as long as it as much as necessary and then you're gonna estimate on, on the tissue already. Yeah. Oh And also if you, if you need an extra bit of stability, always try to lean on your hands. So for example, let's say you got a very difficult to do, you could rest the scissors on your finger. Yeah. And then see very, very few versus this where you can see a bit of traveling. Thank you. No worries. Any other pressures? Okay. I think we can move further. And the next one is structure. And our stitching is something that needs to be practiced over time and we use needle holders. So the first thing to say is, and I'll bring you to an overhead camp to deliberate to show you something important, all meals, no matter what their size are made on a curve. Okay. And the idea is on the curve, it fits on a circumference of a circle. So your job when stitching is to be able to take the needle through the tissue, such that the whole created by the needle go through, the tissue is then filled in blue by the future. If you drag your needle in or out, you're going to have a gap, they're Children green and that green there is a micro up sis in bowel surgery. It's vascular anastomotic leak in vascular surgery or cardiac surgery. So the principle behind stitching is very simple. You need to be able to take the needle I/O to the tissue cleanly all the time without disturbing that circumference of curve. Now, as I explained in the beginning, the forearm does do that for you very well. And the perfect rotation is between the index finger and the middle finger and the common flexor origin. That's when the radius folds over the owner and you get pro nation and super nation. I want to show you an important element. We recommend that you hold the needle holder between the index finger and the middle finger, place it in your palm and then fold the 4th and 5th finger over the rings. We do not advocate putting fingers through the rings because that limits the movement and limits the rotation. So we've placed it in the flat of a hand between the index finger and middle finger closed the 4th and 5th finger over it. And now we simply take it on and off by using the opponents policies like that. This takes practice to get yourself a certain needle holders, pop it in your pocket and walk around simply putting the ratchet on and ratchet off. That's the ratchet on. I've abducted my thumb and that's the ratchet off. Now, why that is important is very simply this bladd. Uh I wanted to, to, to tell them a little story. So when I was in my first year as a resident, when the there was the work visit, I would sit after each patient and I have my menu little holder of my back and just do the wretched on and off. And it took me about two weeks to actually get a really smooth movement. Okay. So, so it's something difficult and you shouldn't be scared if you're not able to do it uh quite easily and worthless. So why we suggest that is if you look at this by way of example. All right, there you go pronated. I'm around at 90 degrees. I'm gonna super Nate and I almost get up to 270 degrees. You agree? And if you look at the tip of my needle holder, it has not really moved. Yeah. There you go. Whereas if I put my fingers through now, immediately you see, my pro nation is limited and that's as far as I go with Super Nation, that is one, just over 100 and 80 as opposed to 270. But you know that because the pro nation and super nation is part of how you use the screwed rainbow, your shoulder and elbow can get your forearm into any position. You like to be able to affect pronation. Super Asian. Not that I'm advocating you stitching with your hand behind your back. But that is why we are quite clear on how to hold the needle holder and that is where that difficulty is going to come from. So now let's take you again over to the top to explain. Another important principle is the anatomy of the needle. Then the anatomy of the needle enables you to do many things. So you got a sharp point and you've got this wage and the working angle of the needle is the middle bit there. You need to be able to pick up your needle properly just beyond halfway and we need to angle it out and there should be no space between the tip of the needle and the top. That angle. There is the I go between the horizontal and your forearm because your wrist is lower than your album. And I know before any trainee takes a needle into the tissue, that that angle is important and is absolutely necessary for stitching. And I'll show you why take, for example, past the needle holder like that and I take it down into the chest, listen carefully. But if I angle it out the belly hits the surface, now, if I was sitting down my wrist and elbow at the same level, I'll be able to rotate that needle cleanly with my wrist uh and are with the same level through 90 degrees with per nation, super nation. But look what happens to that claim that plane there, which is a 90 degrees to the plate. Yeah, look what happens when I stand up. That surgical play now is twisted as my needle hold it is touching the plate and that's why I have to angle it out. So one of the simple ways of practicing this is taking a baked potato, microwaved. Remember microwave, potatoes are hot and good alignment of the needle is 90 degrees. And again, this night degrees is important. Why? Because 90 degrees is fourth part of the circle and the perfect angle. So every single stitch you take from now on is going to be 90 degrees. Now, for those of you who stitch buttons on your shirt, you can see the weapon and left of this material. Yeah, you can see there are spaces and my needle goes through quite nicely if it's 90 degrees to the tissue. Whereas if I come through at an angle, it catches see that and you know that stitching a button, my shirt, whereas the needle drops through the tissue at 90 degrees, easily stitching a button. It doesn't. And that's a simple reminder that a daily activity that you've taken for granted. Key is the principle of how we stage. So you pick up your needle properly. 123, just beyond the halfway angled out in no space, your alignment, every single time is 90 degrees across what you want to stitch. Once your alignment is correct at 90 degrees, what you want to stitch, you simply prune eight, take it into the tissue at 90 degrees, continue rotating it out and you should come out 90 degrees opposite. Now note that the needle is actually held by the tissue and therefore I can deliver it it tentatively through that just beyond the halfway, continue the rotation, pick it up and take it out and I'm ready to do that again. Why we use the potato for this model is it is totally unforgiving because if I'm rough, you can see I've torn the potato there and it gives you an indication that your rotation of the needle is poor. Yeah, you can see this what I call a splash divers at the Olympic Games, diving into a pool get full marks if they enter the pool without a splash. And therefore at 90 degrees, the great thing about the potato, it enables you to practice stitching away from you towards you um this side and what you need to then work out is what is your body position to be able to do that? What you position relative to elbow in this position? My elbows up in the air. Yeah. And my wrists in Albert at the same level. And therefore I can close that angle to 90 degrees because there's no angle between my wrist and elbow and rotated round. Now, the hemisphere of the potato enables you to do that without difficulty. So we have a number of different models to actually test this. And the first thing to say is you can use a banana and you've got bananas this afternoon and simple uh stitching is 90 degrees of cross what you want to stitch and into what you want to stitch. So this mimics a continuous suture. I've put a line on the banana 90 degrees to that. So I'm going to take it into the banana and take it out on the same line. I'll come in close as you can see. And you know, I'm not cheating. This is live and this is simple exercise for taking it I/O of the banana. And what I find is that with continuous sutures that I go in the position of the needle is actually lost. But if you actually, it's a relatively deliver the needle from the tissue, you're ready to pick it up again. So there you go. And I'm slightly off that. No, I'm on the line as in tennis, uh, tissues holding it and I can pick it up again, continuing the rotation at all times and it's not meant to be easy. These exercises are meant to be very, very difficult. Now, I'm not stitching rapidly automatically, but I'm focusing every time on the set up every single time and focusing on the alignment of my needle. So once you run out of lines, simply put some dots equal and opposite. And I'm saying to myself, each time, 123, have I picked my needle up properly and then place point, rotate, place 90 degrees across what I want to stitch. I rotated back. I pointed 90 degrees into what I want to stitch. I've unlocked the needle holder in doing that and I'm simply rotating it out. And you notice every time with my proper placement that I'm hitting the mark in hitting on target. Of course, when you got a curved incision, united degrees changes across that. And you'll see that these are angled in, but that doesn't mean to say that you should not attend to the 90 degrees on a curved incision as well. And that curve is all the way through. So simple practice at home is high. Whoops. You can see they're a window flying practice out. So what about going round and round in circles, going around, around in circles is actually tricky. It is very tricky and I'll come to this plate to demonstrate what I mean. Now, we often talk about, just wanted to orientate it, right. So I can see we often talk about stitching according to o'clock. Now, 90 degrees, if you remember your circle theorems and drawn your nuts, is that the tangent each and every time and the radius of the cycle. So with a plate here showing me 12 o'clock, six o'clock, three o'clock, nine o'clock simply mark those on the plate and look to yourself where your alignment is going. So I'm starting over here at nine o'clock and you can see I'm moving this round, but as I'm moving this round, my weight is changing on my foot and I continue to move around. And then if I'm right handed, I'm in this position at five or half past four. And I'll put that mark line down there 5.5 past four. That is a position stitching into her shoulder. And that is the most difficult stitch you can possibly do in surgery. And it's in that position that you need to swap to back out, change your stance to your left foot and continue now going around 90 degrees all the way around. And you'll see at this point directly opposite I have to now switch back to four hand and there you go, I'm back to four hand and to continue around. So when you're going around a circle, you're going for four hand to backhand on that circle as you go round. And one of the Black Belt Academy models that we have to test your skills in doing this is simply take a banana and apple cora make a hole in the banana and your exercise is too initially, take a needle round that banana and stitch the edges. I'm just looking for my needle, a whole needle at the moment. Here we go. Uh Say again, I have drawn the marks in banana. And what I need to do is take my needle I/O on the hour. Every hour, place point it in and rotate and it's, the needle itself should be pointing into the lumen each and every time and that my needle holder is not mushing the banana on the inside. Okay. Now you can do this yourself at home. I'm not rushing. Please take back. Uh huh. Take it out note that I'm not using my forceps. I'm going to show you a little trick because I'm holding my needle out at an angle. I can then point that needle in and prevent it over the top. And I've now got a backhand point my needle into the surface put over the top and I have a forehand and simply getting the needle to work for me like this enables me to move my needle around the tissues and I don't have to use my forceps. So when I get to this position, I leave the needle in the tissue, take it through. I'm swapping my weight to my left foot. I'm not gonna pick it up at 90 degrees and I'm going to rotate it through the tissue again and I can continue the exercise all the way around. Very simple, very straightforward exercise to do it. And the black belt skill is to deliver 12 perfectly radial sutures without pushing the banana without leaving skid marks in the banana as well. Because you'll find at the time the exit wound of their banana will develop. And I'll come down here, we'll come back to it later. You see the clean punked um there clean whole clean hole. If I don't take the needle out properly, it will macerate the banana in the tissue. So another very, very simple exercise to do to reinforce your needle holding in tissue handling as well. I'm not using forceps and 12 perfectly regular stitches and I've picked it up and now, whoopsie, I've gone out focus, sorry, gonna feel I now can come back, prove it when you leave the top and continue my exercise. Forehand what you actually adapted doing this. You can look at the marks, you can see they develop rather quickly. There you go. You see the exit winds the banana. I hope you appreciate that. God there is a clean exit wound on the banana. You do that for 12 perfectly radio sutures. Then you're on a winning wicket in your stitching. It is slow, it's deliberate, it is purposeful and it works. So, there you go. That is your stitching skills. Any questions from your side? Does that make sense to everybody? So, everyone, all right, with the idea. So, just to recap palming and 90 degrees, you may have noticed until now that uh we always talk about the 90 degrees and the most important angle, the most frequent one in surgery. And it's the one that makes the instruments work for you. So you'll see when you do, you feel when you get that nice feeling you will, you'll feel like the instrument is doing the work for you. You feel like the instrument is actually operating in front of you is the ease of touch. Okay. Right. So forceps skills. Now, I just want to show you this because I think this is important. This is a banana and I have grabbed the edge with my forceps and at the bottom bit in the picture that's with the tooth forceps. These are two rats teeth at the end, you can see the rats teeth of the Addison's forceps, the into digitate and they grab and they bite. Adson was a neurosurgeon. The other forceps on the top edge I've used are DeBakey forceps and these are described as noncrushing forceps, but just take a look at that. If we take the pinch pressure, you pinch your neighbor, go and pinch your neighbor. I want to see you pinch your neighbor. Please give him a pinch. They'll go ouch. Give the pitch pressure for the average person's about 25 newtons for men. It's about 30 Newton's. Then if you actually then consider that the end of these forceps has a surface area of five millimeters squared. And you remember from your physics, that pressure equals force over area, you've got to force the 25 newtons over an area of five times 10 to the minus 6 m squared. That gives you a pressure of five million 5 million m newtons per meter squared. That is 1785 P S I. And when your car pressure is 35 P S I for your car tires, you therefore have got a significant pressure problem. And we've seen this in particular surgery and we've seen this in bowel surgery that the four steps will crush. So which muscle does this? Anybody? Which muscle does this? See? My distal interphalangeal joint is extended? Which muscle does that? Shout out. Let's check. So, uh yes, excellent. And why the number to call so special? Yeah, why is the lab recall so special? There's no way the Lab Ricos is a really special muscle. Well, because they allow us to do this. We'll think, think of being insertions. We're on the insertion and they're under process. Yes. But usually, uh, muscles in their chronic, oh, so they insert on, on other tenders. Exactly. Correct. Correct. So, they're only muscles in the body. They don't have a bony origin or bony insertion. All right. And they've extended your D I P joint and with the opposition of your flex of policies, Brevis that brings the fingertips together. And as I said to you, the fingertips give you more century input than your eyes. Think about it. That pinch pressure. There is what climbers hang onto that. Flexor pollicis longest flex, the digital Profundus. And that's what people hang onto cliffs with. Those are the Popeye muscles of your forearm in the third compartment, the biggest muscles of your forearm, those are not what's required in surgery. You need the intrinsic muscles on the hand. So what exercises have we got for you today? So this is another exercise very simply being able to pick up grades of rice and then the first instance, pop them in the ends of straws. Now bendy straws are here and your note will come down closer that the rice has got a width that's greater than the diamond of the straw. So you have to now orientate. Yes. Pick it up and drop it in, pick it up, drop it in. And we have a number of exercises that will enable you to do that and its lightness of touch. And you got to be able to do this with your right hand and your left hand. Another nice way of doing this is actually, I've got it in here. A number of seeds and the seeds in here are pepper, fennel, coriander and mustard seeds. And I'm going to put those around my little dish. You can use any seeds you like. But you can see that if you pick it up too hard in these mustard seeds are small and very awkward. This get away the femoral seeds a little bit easier. The pepper are irregular but also hard and then the coriander seeds around. But you can go through an easy practice at home of how to refine left hand and right hand. How you pick up? See that was a coriander. That's a pepper and these little mustards ones are awfully awkward. You can have competitions with yourself and we had a competition at the Association of Citizens in training is how quickly can you get eight bits of rise into four bendy straws? Somebody got down to 15.73 seconds, you drop it, you're out. So there's another simple exercise for you to use at home to improve your skills. Any questions? So are there any questions about how to use the forceps? So just for a short rehab, as David says, have this number, does muscles have this gentle muscles? Okay and we always rest defense the forceps of our return. Uh and then with the extent that distal interphalangeal joints. So proximal and distal, this one's extending and with this extended, you have isolated the force you no longer can apply a lot of force for what? So 11 thing that I'd like to add is look at my finger nail, okay. And when I press with the forceps, my, my fingernail is still reddish in color. But if I press too hot, you're gonna see it turns white. That's the moment when you know, you put too much pressure. All right, good. Well, I've sent, we need to get you practicing some skills. So I'm going to go through the next bit very quickly. But there's a video to explain not time skills, but what not do you regularly do every day? That has an important function in your life. Anybody hands up blood, any hands up any, any suggestions from the floor. Let me, let me repeat the question. So what's not? Are you tying in your everyday life square? Well, yes. But where in what circumstances? The shoelaces? There you go. Well done. So, I'm hoping the right shoe and a left shoe, which not is the correct not. And why? One second? Let me just show them. So which note which one is tied correctly? Any ideas? Yeah, they have an answer. So the one on your right side, correct. The one on the right side has the loop going across that has the loop going across the shoe. One on the left side has a loop going up and down. And let me just show you exactly why that is important by coming over to the table. Again, the two types of not there is called a cross, not an uncross not or flat not or reef not. And they're very simply summarized like this. This is a flat not and that's across not. And you can see the flat not is sitting flat on the table where that is colloquially called what we call it a granny not, it doesn't sit flat on the table. If I work this with my fingers over time as we're walking with your shoes, that is why your shoe laces come undone. This one is a square not and this tight knit it does not come undone, it tightens itself. And that is why we have what's called square reef knots. So you don't need a fancy table. You don't need a fancy table at all. I'll turn this race. Sorry. All you need is a block of wood, an elastic band pops in thread under and this is my what times patient. We're going to go through a simple knot and that's on the video for you to watch. You have a short end in a long and you hold it with a finger and thumb. Super Nate extend out. And the idea is that shortage is gonna reflect through the whole, you catch it and you take it away from here. You're now holding it between the middle finger and thumb, gonna sweep out with my index finger. I hold it out again and I figure four and I'm gonna flick the short end through, catch it and bring it towards me. And there I have a flat not, we'll play, play the video this afternoon for you to watch that and this video is setting not trying to, music will make available to you for you to practice your platinum. What's the important thing is, is that you start with a bit of string, start with a bit of string. You can do it on any surface you like. Now, once you're done then in time flat knots, basically, your hands are moving like that. They're never crossing, they're moving like that as throw one way through the other way, throw one way through the other way your hands are moving. But to get the not to bed down, we often throw, to throws the same direction as you see here with two half hitches and that enables you to tie down. Now, the important bit about tying knots is that your finger needs to go on the not. So you're tying it down. So I'm going to throw one throat and you see there, I've extended my finger and I'm holding it down. I'm going to throw the same again and I've got two half hitches. Now my finger is on the not and I can hold that down on a coat hanger such that the coat hanger is not coming off the table and then I can complete by frame a series of flat knots. The important thing to do is to show that you haven't got any movement of that thread across that bit of plastic and that you are able to throw that not perfectly. You can simulate it with a bit of garden hose because this is a bit like a drain. And if you don't tie your drains in properly, it will break. So what can you use after string while string is a braided filament abraded material. But so is cotton and I love cotton as not practice, but don't go on to this until you mastered the string. But remembering that much of our searches are pralines and here's a bit of Prolene I've got here. You can see it is a stretch bit of plastic, but fishing line does the same. So once you've mastered, you're not tying with string, cotton and fishing line, you can then move on to practicing on other material. But the important thing is, as we said in the black part Academy, you don't start doing anything complicated without attending to the basics first because the whole thing about practice is you got to do it properly, purposefully deliberately and we practice until we can't get it wrong. So the last thing on the skills can we ask question, take questions on the not tying skills. So, are there, are there any questions about not trying? Have you understood the difference between a reef not and the square? Not okay? Well, we'll see, we'll see very good. So the last thing to say is that as training surgeons, we often called to assist. And there's a simple principle is that never cross your hands and never cross the midline, reach across to the surgeon side. And therefore you need to be guess what, 90 degrees to the surgeon each time. So if the surgeon states that direction, your shoulders are parallel to theirs, United Greece become this direction, your shoulders, a soap parallel to there's a new ignited Greece and this means that there's almost an invisible line between you and the surgeon that you don't reach across, you never reach in and your fingers on the outside of the word outside of the retractor holding with a lightness of touch, guess what? Between your finger and the thumb again with a string in the direction in which is taken up and held. And when they take up and hold it, that is the centers for, for you to lightly hold it until they're ready to stitch again. If they don't tell you to let go and it pulls out your fingers not going to pull out to the tissues because you haven't hooked your finger around. It's a simply faint lightness of touch, fingers and thumb in the direction in this health. And it's a lateral hold and not to pull, to hold the tension and you can practice this yourself assisting when stitching the banana. And you will see that if the assistant does not let go or gets the finger caught, it will tear out the banana. Some surgeons would get very upset about that. I worked with Stephen Westby and I called him Steven Spielberg Westby. He's a very famous cardiac surgeon. He did a number of films on aortic root replacement. And because the camera was above the table and he was very keen and getting good production videos. If my hands came into view, I'd be rapped on the knuckles with a needle holder or tubing clamp because my hands had got within the operative field, it certainly taught me to keep my hands on the outside. So remember assisting is a bit like being a dance partner. You're following the surgeon as they move around and your hands on the outside. And it's a lightness of touch and you pick up on the rhythm and the flow of the operating accordingly. And that is in essence a summary of the basic skills that we teach the Black Belt Academy. All of this is iterative going from white belt to black belt, but all takes practice, practice, practice. And as you go around the stations this afternoon, I want you to appreciate these basics. But each time we go to a station, adjust the height of the table because that is a position that we need to stand in the hands of palmer flex. The elbows are slightly extended and that is isolating intrinsic muscles of the hand because that's the most important thing you can do as a surgeon is bring the pumps of your fingers together. Thank you very much indeed. Thank you, David.