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Hello. Good evening. Good afternoon. Good day. Good morning. Wherever you are in the world, I know many of you are turning in from all over the globe, and I thank you very much indeed. Especially to the 3286 followers that we have on Facebook and the 516 on Instagram. If this is your first time, welcome. And if you're returning Thank you very, very much indeed. My name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. I'd like to thank Medal for all the help with this program. And Gabriel, who is behind the scenes during the production. Gabriel, if you see the camera go out of focus at any stage, please remind us. And you, the audience are very welcome to put questions in the chat that Gabrielle will read out. And I'm very happy to be interrupted to answer your questions. We're running another competition at the present moment to find the most innovative home exercise in any of the skills that the Black Belt Academy is talking about. An armoured has put on Twitter a fantastic example of tying a knot with the human hair. I'd like to see more, and the closing date will be the middle of December. The winner will get their own set of instruments, Mark has replied. He got his instruments following the last competition, and I'm waiting to hear from Gabrielle a mall and jury. Gabrielle says she hasn't received them yet, but they were posted registered to you. Another person I'd like to thank is Sue, who on Twitter pointed out that a teddy had become mauled and there was a scattering of stuffing all over the floor. And she said, Thanks to the Black Belt Academy skills, she is now going to go about repairing her teddy. I sincerely hope that the teddy recovers. We would like to see the picture of the teddy and sue. We'd like to see an example of your stitching. Thank you. I'm looking forward to joining the foundation Training Surgical Society in Merseyside at Aintree Hospital on the 26th of November. I will be joined by my fellow sensei, John Taylor who's fifth down in martial arts, and he will be hearing from him in due course. As we draw on the parallels in an interview tonight, I'm talking about Can you feel it? And I'm reminded of what I said last week. Talking about holding a rifle and the National Rifle Association, I said, Can you feel the weight of responsibility holding the rifle? I put it to you. I think we should reflect on the weight of responsibility of holding the scalpel. We need to remember that decisions come before incisions and once you've made that incision, you cannot go back up. Until that point, you, the responsible surgeon, can stop the procedure and think again. Remember that incision and how well you do it will result in the quality of the scar. And the scar is the indelible signature that you make on your patient for the rest of their lives. You might not remember the name of the patient and if it was a routine operation, surgeons seldom remember the operation. We have a tendency to remember things that have gone wrong, that that patient will look at that scar and remember you for the rest of their lives, so we need to make it good this evening. We're going to talk about how you feel the scalpel, and I'm always dismayed that people look at the scalpel, pick it up tentatively and then scratch through each of the seven layers of the skin. If you're going to do that, I would ask you to name in Latin the lives of skin and their function. But I'm reminded of when I was operating as a Reg trial Saint Mary's and I was doing an emergency operation on a gentleman who had hepatitis C. Everybody took appropriate precautions, but with patience. With hepatitis C, I do not double glove because double gloving I lose the field. The registrar who offered to take the radial artery started to put on double gloves, and we don't usually wear double gloves, and I recommended that he did not because he would lose the field. Yeah, good, I said, Never mind. Okay? And I proceeded with this tenotomy. And then they came at plaintiff whale from the opposite side of the table from the registrar who is making an incision to expose the radio laundry. What he had done is sliced directly into the radial artery, and we had infected hepatitis C, blood spraying all over theater. Now the gloves need to sit at your fingertips, not baggy. Just comfortable. Your fingers should not go numb. So do make sure, when wearing gloves that they fit comfortably, that there's no air at the top and they sit comfortably of the fingers and do not cause numbness at the tips. I do not wear gloves for these operations because I'm dealing with low fidelity systems and food stuff that you would find in the kitchen. On top of that, I don't want to be using lots and lots of gloves because it is expensive. The first and most important element where the scalpel is to reckon. Recognize that it is sharp, no matter what level you are. White belt or black belt in the Black Belt academy. If you can't mount a scalpel properly and pass it safely, you will be failed. Now that sort of criteria is also applied in the division with a sword, and it is an absolute non negotiable and ensure safety. So the first instance I'm going to take you over to the camp and ask you to look at how we mount a blade. The blades often come in packets like this. Take it off the packet. You need to pick up the blade on the blunt edge with the human start the large surface area holding the blade. You'll see that the scalpel blade has a very nice groove in it will come focus down onto that groove. You see that groove there so it fits the end of fingernail, and it's in that groove that the blade is going to sit is going to sit as well with a corresponding bevel. So you line your blade up with the bevel and you keep it pointed into a surface, and both your hands are on the surface, not on the patient going on the table, away from the table on the scrub up trolley, um, instrumentally. You insinuate the blade, the narrow bit here, into the groove, and you slide it over the top and you pull it on and it clicks in place to take it off. You reverse the process, but lifting the blade off bottom over the bevel, securing a glip with a hemostat and sliding it off. And it's a one hand Axion your hands on the surface of the table, and there's no pointing into the table, and there's no risk of the blade flying off and causing a problem. The other point important thing is it's a pasta blade in a kidney dish. Then nobody is going to be cut or hurt. But if you're passing the blade by hand, make sure the blade is down. You pass the blade first, and you pass it directly and under control in direct vision. So if somebody takes it out your hand, it's not going to cut your palm blade. Safety is an absolute paramount importance now my favorite blades for operating on the 20 to 15 10 and those are three different sizes. And then there's the 11 blade, and they all come on handles and mounted appropriately. What you should recognize, and those of you who shave will know how uncomfortable it is to shave with a blood blade. You can feel it against your skin and the sharp of the blade, the smoother no shave, and it's the same with dissection, so don't hesitate to swap your blade over if it feels blunt because it's that sharpness that is going to give you the feel. I'm extremely grateful to swan and mortem for giving me these blades and these handles and Swan, Morton and Fairweather were in the razor blade business back in the 1930 two's. And when the Peyton Grant ran out on the scalpel in 1935 they entered the scalpel business. Swan and Morton are based in Sheffield. Their handle and this academic design is patented by them. And on the other side of the handle, we have a very useful rule. They make 1.5 million scalpel blades a day of 70 different varieties and export to 100 companies. What's interesting about this company is there were the first in the world to approach the UK Atomic Energy Agency and established cobalt gamma radiation sterilization of their blades. And they do so today. One of the biggest arms is that sterilization and control of infection. What I love in this history of this company is, they feel for their employees. Then values are in four simple statements. The company is built on labor delivered by human beings. The company cannot pay for that labor. A new policy is required, and if the management cannot deliver their policy, new management is required, and an individual employees can demand. All these objectives have met at any one time, and the profits of the company go into a trust and shared with the employees. I would love to work for a company like that because this company has a feel, a human factor, a heart to it. So as we proceed on, I now like to talk not only how we handle or should handle employees in an organization, but how we hold the blade to obtain the field. It should be held like a knife and not like a pen that is a pen. The blade should sit in the palm in the hand, and it's important that the thumb is pressing the blade against the middle finger, and thus the sagittal plane is maintained. And see, my thumb isn't either side of this patented handle. There you go, and it maintains the sagittal plane. My index finger is extended down the plate and by extending it down the blade, this gives me feel of the pressure that I'm exerting as I cut through the tissues, and it's important that you practice this field at home, and the reason for this lesson this evening is to take you through some simple models, and I have a new, exciting model for you to practice that feel. I like the 20 to blame myself, and I remember my consultant trainer when I was a message of Mr William Walter Frederick Southward. He was a Dhiman with a blade and could do a gastrectomy in 20 minutes and open up a redo operation, cutting through all the adhesions because sharp dissection is clean dissection and adhesions would tear the bow, the lung etcetera if ripped or torn apart. The first thing we do as surgeons is the incision, and I have here a piece of pork belly. And in the Black Belt Academy, we do practice Incision's five centimeters, 10 centimeters and 20 centimeters. The 20 centimeter incision is akin to list a. Not me and many surgeons scoff that you are just a cardiac surgeon and do one incision. Yes, but Lewis Hamilton and Max Verstappen go round and round, but you try get 20 centimeters perfectly straight down the middle, and I'll explain why. First of all, it's a 200 process. The knife is at 90 degrees at all times to the skin because literally, if you don't do that, you will. Bacon slice and the bacon slice is represented here. This is a sponge and have taken a number of slices through the sponge. Here, the knife has slid through the sponge, and you can try this yourself and color the edges, and you see the blue dye coming through the sponge. I've done it a second time. Here and again, the blue dye is spilled on the surface. My third. Bring it together. There's the blue. You cannot see the dye on the surface, and that is akin to a scar. So 90 degrees is the perfect angle for incisions as well as stitching. Support the skin on either side between your index and thumb. Apply pressure and draw the knife steadily down the belly through the skin, supporting it, either side keeping straight. Now. The thing is, when you get to 10 centimeters, that's fine. But once you go past and said to me, people tend to start twisting around the hip and you end up with a curved incision. In this case, you should keep the elbow out. That must have been a very blunt blade. To be honest, I thought it was a fresh blade because I haven't gone through all the tissue in one go. I'm feeling that I'm putting a lot of pressure on this blade to get through, which is unusual because they've taken adopt the packet and I probably swapped that for another one. Let's try this, shall we? It doesn't feel correct. There you go. That's better. It starts to part. That was definitely a blunt blade. And with a sharp leg, you can go all the way through. Yes, feeling it lives and feeling the tissue That was interesting. That blade obviously was blunt, and sometimes they come out the packet they are, and I was putting Xs pressure on it, as the second later picked up was just right. Now, even for small incisions, you need to be at 90 degrees. And now, although we often do excision biopsies and we are given to 15 blade problem with the 15 blade holding it like that, you'll end up going around a curve literally turn in your blade and bacon slicing it. So thanks to my colleague and fellow sensei, I now have a barren blade holder, which is around Parral, which enables me to roll the barrel in my fingertips, and I can hold it like a pen. But maintain that 90 degrees at all stages as I make a fusiform incision around this lesion, ensuring that I maintained tension at all times but also ensuring that the blade remains perpendicular through all of the stages and we end up with a clean excision. Once you have made that, you may want to use a bigger bleed to cut the lesion out. And in this situation, I haven't gone completely through there. Yes, I have the, uh and clean Fusiform decision, which, if I pull together like that, will end up with a nice, thin line. And that's how Lange's did decided the lions, his anatomist, who went two cadavers with an ice pick and actually was making sequential holes in the skin and noticing if they stayed open or they fell back together. And hence he mapped out the whole of the anatomy in the form of Lantus lines, defining the tensions that are sitting in the skin. So how do we then take this feeling and development and practice at home because pick tissue is difficult to come by, but also it's kind of tough, and you need to actually feel your way through. So I have come on across a number of different things from the kitchen, and I'm going to do some of these by way of example, any fruit that you use. Tomato mushrooms, etcetera are fabulous to practice your skills, and what you need to be able to do is feel your way through the skin to be able to stroke the knife over the surface. Gently and practice incision so it goes through the skin. Only I get a pair of forceps. Yeah, my grape isn't behaving itself. I seen that up, but I'll try that again and another one on the other side. It's but as I'm taking my stroking, my life across the surface is literally the weight of the scalpel. Going through the skin. I'll make the elliptical incision closer, how he pulled the skin off and try not to go through the flesh itself. You can try that again as well on a mushroom. What does it feel like to take a knife to a mushroom? It's very soft and again. It's literally just the weight of the blade each time. But what I'm doing is I'm getting an appreciation of the field. We're going through the skin. See that side? I'm going through the skin this side. If I cut deeper, I'm into the fleshing of mushroom. Can you take the skin off the mushrooms similarly, for the tomato run blade over the surface without cutting the flesh underneath and with a sharp blade, it requires minimal, minimal pressure in the circumstance. Too tight just getting off. There you go and you're not cutting. Reflect mint. I'll go and place this. You can see that. Let's read going through the skin itself. You can turn it yourself further for even looking at a poached egg. I use the poached egg. In teaching colony surgery, I asked the students to make an arteriotomy over the yolk. The membrane on this egg is not as white as usual, but really what I want to feel, feel my blade. Just go through the surface of the skin without cutting into dang itself, and I'll take a few practices. I've got a bit too deep there, usual egg each time and see if you can just get the membrane off the surface egg of cutting it deeper. Of course, after a while, Blade ends up blunt, but what I'm getting there is a feel of the tissue. One of the common problems that we see. As I said, she's bacon slicing and the orange gives me a good example of a bacon slice, because if I cut this orange incorrectly, you see that is it came to a bacon slice. But what I want to be able to do is take the orange feel again with a blade, and I go all the way through the skin, but not into the flesh, keeping it perpendicular all the time as it goes around. How do I know I haven't gone in the flesh? Very simply. Pick it up and squeeze it. If I get any juice dropping on a plate underneath, I've gone through the flesh itself. But what does it mean for tissues? I've taken some bacon hill, and the bacon I found previously is very like tissues that you're going to be dissecting. And I'm going to swap blades because I'm finding those blades even after that short period of time or getting blunt, Mount another one and using the bacon way to this blade slice through. I want to be able to slice through it without slicing through the layer underneath. See that I've sliced to the bacon there, but I have not touched the layer underneath. So for the special occasion, as we're talking about layers and going through layers, I've made a special cake, and this special cake is layers of pasta with different food colored eyes on Mohammed juice. There you go. We're nine layers. They're not seven layers of skin. The nine layers and I've stack them on top of each other, and I now want to practice taking my blade through each of those layers and see if I can do it without covering the layer before now this is cooked pasta, and I need to be able to feel my blade through it. If you don't mind, I'm going to change my blade again, and I'm going to use the 22 blade. It's my favorite instrument in the dissecting blocks and demonstrate to you that even with a big blade, you can still achieve lightness of touch. Here we go. This is the great thing about live TV and see if it works. Okay, that's the first incision. Have you gone through the first layer? And I think I should retrieve skin Hook. Lift it off. Excuse me one moment as they get the skin hop, so lift the personal shoot up. There you go. One There. There's a second layer. There's a slight increase in there, but I have not cut through it. I can see where bladers. Let's try that to the next layer. These models are supposed to be challenging. There you go, Uh, and through the next layer, have you made any mark on it? I hope you agree. Looking at that, there's no mark on that surface. Let's see, Let's see how we're going. The blade is getting on the blood to side, but I am aware of that. So I have to just my pressure. I don't want to use another blade just yet. See if I can go through that. How many lives can we go through feeling it as the past has got colder, it is actually. Yeah, here's the next layer. And again I am cut through the next layer. So the idea is how many layers. Can you go through feeling as you go good? Another left again? I hope you'll agree. I have made my point. I'm cutting through each layer deliberately without damaging the layer underneath. So the next part of our life story in field is coming back to the port then because there's a different function for the knife and that is for dissection. And in this situation, I'm going to turn pork belly over, and I'm now going to use the knife literally like a brush with brush strokes, and to deliver blood. Brushstrokes are now holding the knife and opening it out a little bit on my fingertips like that so I can brush the knife against what I'm wanting to dissect and removed. And as I brush the knife, I am separating tissues. So let's see how we go. And this is where traction is important. You see, the flood of my blade is on the surface there, and I'm using that two separate tissue layers were literally brushing it against that. I'm not cutting into the layer like that, because that runs the risk of cutting the tissue. I'm sweeping my grade and as you get more confident. With this technique, you can literally sweep your blade or use broader brush drugs across the surface of the tissue. And you appreciate this is where having an assistant to provide counter traction for your house just to demonstrate. Look at that. I'm literally brushing this drug across blade across the surface and in doing so developing a tissue plane. And it's a very, very, very effective way after our section. Now, can you think of something we might do in a kitchen that is akin to this in preparing food? I'm thinking of the Master Chef programs. No ideas. Well, let's introduce another example. Another example. Yes, a piece of fish. And the idea is to take the skin off this. Fill it if it in a manner that leaves the flesh on underneath. Now this is awfully tricky because it's very easy to get on the wrong plane. But what you want to see and one of the best examples I saw blood in more Zan in Romania offered this example some time ago, and I think it's outstanding, and what you want to be able to do is separate that skin from the pink salmon flesh without how cheap having any disruption of the flesh itself. And without having any pink salmon on the surface, I think you'll agree for how many there. That's what we are doing. We are separating the flesh from the skin. Now these simple models you can practice at home and develop a feel for the tissues you can see here. I've cut in to the salmon flesh and is now sitting on the surface. And ideally, what I would like in these circumstances is counter traction, the other side to hold it up. And two points. I have been asking my assistant to hold it up with both those points where I can hold count attraction at these. So it is a challenge by yourself, but not impossible person. A rather fun exercise to do the the salmon is I'm using clean forceps and things will be going back into the fridge. And actually, I'm dogs. Love this for dinner. Very healthy for their coats as well. Again, to demonstrate this brushing effect, I'm brushing the blade across the surface, developing, uh, plane. See that, almost using a brush or palette knife of an artist, my blade is becoming blunt and that time is running out. I hope you can appreciate that. That separation. I have gone into the salmon tissue there, but not there. And I have a clean white skin above. This is what it's one about. You don't want to use salmon. Try a mango again mango. Feel your knife through and see if he can take the skin off, can you? A little bit here. You got a segment feeling the night through the man who has noticed soft as I'd like it to be, to be honest, but the idea is, and I'll support it on the whole. The next time is to try and get that layer off there of this Mangga, and this is one of those ripen at homes. So I'll come back to that. I hope I've given you some insight into how we can actually with practice surgical skills at home with a blade, I hope to like my incision cake, which I made especially with for you with layers of lasagna, pasta and food dye. It gave me haptic feel back as I went through each of the layers. If you do that on foodstuffs in around the kitchen. You've got some interesting examples. Do submit it for competition on innovation and innovative examples from practice. I hope this has made sense to you. Please. Is there any questions, Gabrielle? You ask them? Yes, we have. We have three questions today. Um, so the first one is from Chris. Katie, Um, and going mounting of the blade, He's saying that in their hospital, uh, the process has been bypassed. So the human factor system, um, has been removed The independent mounting of the blade. And he'd like to know your thoughts on this evolution of the process. Well, I think that anything that improves safety and human factors is important. You maybe in parts of the world where they do not have that luxury. Indeed, it's one of the examples and reasons for going single use. And there are blades that automatically retract and swan mortem have disposable blades that have a sheath that retracts to use the blade and to put back on the blade afterwards. I'm a little concerned about the single use. A material, especially as you know, Chris in the college were talking about sustainable surgery. And surgery is one of the biggest reasons for clinical waste. A lot of these single use sheet scalp ALS are made of plastics. I'd like to know if they're recyclable. They're not going to be available around the world. But I think the principles are mounting them on a huddle and understanding the bevel will be around for some time, and therefore it's important to include it in the syllabus from the Black Belt Academy. Thank you for that. We also have an observation from John, so he'd like to know your thoughts on pre sterilized blades on disposable plastic handles. Yes, they are quite useful in the wards for single use, only for removing searches and cutting dressings. The handle itself being plastic doesn't give you the balance and feel that I think you require for dissection and theater there. Very useful for simple single use on a ward removal researchers or cutting of drafting dressings or simple deprive mint. But to be honest, most surgical procedures should be done in a clinically clean area. Uh uh, theater. And in that area there should be sterilized handles and sterilized blades for mountain. Many people, however, might not be surgically trained, and you're quite right. Then it is useful to have a pre mounted blade, but again it's plastic. And I do think for the future we need to think about the amount of plastic that we're putting into the environmentals and clinicians. Thank you. And then our last question tonight is from Bobby Chow. Um, he's asking, how about going along or bear pen type color to the grain of the Salman flesh? Uh, he says that he does that a lot when opening letters, uh, to try and cut the envelope without cutting the letter inside. Uh, there's another good example of good use of the knife. Good suggestion. And yes, um, indeed, in the kitchen, cooks would go along with the grain of the meat, the grain of the salmon and would take it off for one particular direction. We don't in theater necessarily have the opportunity of picking the patient up or turning the tables around to get the right grain. So if we're using, that is just a model to help you feel and understand. You can use the blade literally like a brush to brush the tissues off and not cutting in to dissecting area but separating it with those broad strokes, and it's a very clean and nice way to do it. Think of it a bit like shaving. Yeah, if you're shaving and had a blunt razor, it really is uncomfortable in the skin. And it's a real pleasure to actually change your blade and use a fresh blade when shaving, because the finish is smoother and I think the same applies to the scalpel on the tissues. So don't hesitate to ask for a fresh blade when you're dissecting and you feel it is getting blunt. Even with a couple of passages through these fruits and bacon this evening, I could feel the blade getting blood. That's all of the questions. Thank you. Thank you very much indeed, for attending the Black Belt Academy of Surgical Skills this evening. We'll continue our series next Monday, as we talk about at the tips, and that is at the tips of the other surgical instruments, the McIndoe scissors. For those of you who don't know who mackin new is, I do recommend that you look up who McIndoe is, and I hope you'll agree with me that is one of the most inspiring surgeons that we've ever seen. So that's your homework. Look forward to seeing you next week. Wish you well. And thank you for joining the Black Velvets Academy of Surgical Skills.