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Hello. Good evening. Good day. Good morning. Wherever you are in the world. And welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the immediate past director with the faculty of Surgical trainers of the Royal College of Surgeons of Edinburgh. And I'm a visiting professor at Imperial College, London. If you're joining for the first time, Welcome. And thank you. And thank you to all the followers. 3287 on Facebook and 519 on Instagram if you're returning. Thank you very much indeed. I have a privilege and pleasure this evening of announcing a new sensor for the faculty, the Black Belt Academy of Surgical Skills. And I believe Christa Gara is joining us this evening from Candida. He's the emeritus professor of the University of Alberta in Candida and was presidente of the Canadian Association of General Surgeons Between 2015 and 2016. He's a senator on the University of Alberta. He was the professor of surgery there and director of Bariatric surgery. He was also director of the Surgical residency training program with McMaster's University, as well as the medical panels commissioner for the government. Alberta Chris. Thank you very much, indeed, for enthusiasm and joining the Black Belt Academy Crisp Ashen is history of surgery, and I do commend the book that he's written the history of eminent surgeons. This is available for 3 lbs 50 on Amazon. It is a good read, and what I like about this I'll summarize his mission and labor of love. History is the study of the past, specifically the people, societies, events and problems in the past as well as our attempts to understand them. History can take the form of a rolling narrative filled with great personalities and triumphs. And he concludes in his book, and I have to agree. The achievements of these surgeons, despite the challenges, continued to fill me with all and admiration, and I feel exactly the same about this. One of my favourite instruments in the surgical tray. Are these the McIndoe scissors? Before we go to the detail of McIndoe scissors, I want to share with you. The accuracy and precision are the ancient art of cutting paper with scissors, and this was done the scissors with large handles and bleeds, but very sharp points. But I hold this up as an example of accuracy and precision. Now the McIndoe scissors are beautiful. McIndoe was born in 1900 in Dunedin in New Zealand and went to a Targo boy school in New Zealand. He did his house jobs at Waikato Hospital, and coincidentally my colleague, friend and fellow Masturah of the Black Belt Academy is a cardiac surgeon at Waikato Hospital, and he's the clinical director there. McIndoe was the first New Zealand person to get a fellowship to study at the Mayo Clinic, and while in New Zealand, he was spotted by that other famous surgeon, lord Barclay Monaghan, who's bust as I've told you before s It's at the top of the stairs, at least General Infirmary. He was so impressed with the talent of this young surgeon he invited him to come across to the UK to study, and he studied with Road Barclays cousin Sahara Billy's, who is a plastic N T session at Barts Hospital. McIndoe, who was appointed consulting to the Hospital of Tropical Diseases and then a consultant to the R A. F in 1938. And I suppose that's where his frame comes from. Because in 1939 he started work at the Queen Victoria Hospital in East Grinstead at the beginning of the war. Now many Spitfire pilots sustained horrific injuries from Burns and McIndoe with his background with the ent and plastic surgery, invented and was the father of plastic surgery in this country with reconstruction of faces and burns. But what I liked about him in particular, he wasn't just a technician. He thought about his patient's in a holistic sense. In that regard, he invited all his patient's Turchie, wear their uniforms to maintain their respect, and also he appointed only good looking nurses to the hospital. But those who would not be shy away from the disfigurement they saw. Rumor has it a lot of hanky panky went on in the broom covers, a dean's grants at hospital, and some of the young fight parents actually married the nurses. His story reached the Sunday Times. I think about five years ago when the last of the Guinea Pig Club, those people who on whom he had operated were meeting and their numbers were so dwindled they could not meet again. The staff at the East Grinstead called him the boss or maestro, and in 1947 he was knighted for his services to surgery, and he was the founder of the British Association of Plastic Surgeons. Now the important thing of the McIndoe scissors, as we have described before, is to maximize the feel of your instrument by ensuring that the tips of your fingers are applied to the instrument with the lightness of touch, because the scissors are really going to be an extension of your fingers as a tool they use for cutting, separating or developing tissue stripping or scraping tissue. And there are two different ways of holding them. So let me take you to the overhead camera and describe how I was taught and how I would recommend that you hold your scissors and knowing the story of McIndoe. I would like you now to hold his scissors with the utmost reverence and respect. You'll see that the scissors have a natural curve on them, and that curve needs to be with a curve of the wrist, because if you're holding the scissors the other way up like a spoon, the belly of this is is here could be cutting tissue while you're focusing on the tips, and I've seen that actually happen when dissection out the pro me artery. So your line of sight needs to be down your wrist and the curve of the scissors and the tips. Now I hold the scissors with my ring finger, and I suppose that's a throwback from the days of being a general surgeon, because what I used to do is flip it into my hand and I could effect a not by flipping it out again and then cutting the not. But the important thing about the scissors is that the tips of my fingers applied to the rings. Never should the D I. P joint go through. The rings should be held at the tip. My middle finger is stabilizing and my index finger is pointing exactly to where I need to go and what I need to do. So the curve on my wrist and the curve of the scissors are the same, and that regard as well that curve enables you, I will say, to gather material towards you, whereas this way you can't the next important thing. It's realized that you only open the scissors as much as it's necessary to do the job. No more and no less. And for the assistant that is often cutting sutures now. As we've said before, when two strings are held up on the not the surgeon, you is usually asking you to cut both the strings. The scissors are not to come in from behind the light. Zoom in, cut and a swish come out a bit like the fighter pilots at Coal Harbour saying tore it oratory, um, behind the theater lights they need to come in, deliberately held in place no more than necessary to do the job and cut. The surgeon will usually prescribe the length of the suture to be cut. In the most cases for raided suture, that would be five millimeters, but for modern filament, it would be longer again. The semaphore from the the surgeon would be either hold one end up, put a clip on that or cut it and follow with the other. If you have difficulty maintaining a steady hand going into the operative field, this is quite an order to use another instrument to bounce your four steps. Hold them steady, open it and cut precisely in a deliberate fashion and then removed from the field in the same way the Chinese were cutting paper. We've introduced these simple exercises in the Black Belt Academy of Surgical Skills. Firstly, take a pen and draw a single line and strip and with your forceps, see if you can gently cut along that strip without leaving dog ears and ensuring that you don't leave any blue or white on either side, so you need to accurately cut along the line. You can imagine it's a precision the artist for the Chinese cut out required, and my way of an example of how not to do it. We see there an irregular edge with white dog ears, etcetera, so simply cutting bits of paper will enable you to practice the skill. Likewise, cutting circles take uh, any cup or glass. Draw a circle and see if you can cut around it with accuracy and precision and use your forceps and put it on the ironing board. So, yeah, you're reinforcing your posture has previously described, and you need to go around deliberately and slowly now. These exercises are meant to be difficult and they're meant to focus the mind, and that's what practices it's perfect. Practice makes perfect, so that is the accuracy of your cutting and cutting of sutures. But what about developing planes? How can we model that at home? I have here a tangerine, and this is one of the more easy models to practice on. Note. The curve fits nicely with the curve of the tangerine. If I turn it up that way, the belly would be cutting the flesh. So, very simply, I am going to develop this skin incision and develop the plane. Now the important thing with developing planes is that you open your scissors within sight. You remove your scissors and close them with the inside. You never, ever, ever put your scissors in and close them when you can't see the tips, because that is exactly when you start cutting tissue. So this is a relatively easy, easier model because the skin of the tangerine comes away quite cleanly. Your next task is can you separate out in particular segment at the top Here we can see the pith extending into the middle, cut that gently and try and separate that, damaging the flesh on either side. Try and separate out too. There you go. If you are rough and not careful, you will cut into the flesh of that segment as you would if you're dissecting the lung or the liver or thickened. Very cardi, um, off the heart. And it's feeling those planes and understanding the field of those planes that is important when using the scissors. So I've not infrequently had to do a pericardectomy. And as a pericardectomy, what you have is this thick s are almost the front of the heart very thick fibrous tissue that you need to gently tease off and dissect off a bit like the tissue on this orange. And that requires patience. It comes off and strips. It takes as long as it takes. But if you get on the wrong plane, you find you're taking off the epicardium of the heart and with it, the coronary vessels as well. So what? This model, then, to teaches you, is one patience to do not ever force your scissors into the tissue plane. They're insinuated you feel your way into the tissue planes and this dissection, as would any pericardiectomy, could take a few hours But the important thing is that you're practicing and understanding the feel of the tissue and work on many fronts in these situations. If it's difficult to one area start in the area that it's a little easier and work to the difficult area from either side, with patience and persistence that will develop and become easier. The way this orange skin is coming off, to be honest is very much like doing your pericardectomy. There will also be much the same, taking off a thick infected tissue or cortex on the lung with very soft tissue underneath. And if you're not careful, your scissors will cut the lum and you'll have an air leak. As I said before with these models, when I'm doing this, I find myself totally engrossed in the procedure, forgetting that we have limited time together in these sessions and I need to demonstrate lots of models. Indeed, I'm having to wipe in my forceps as you would sometimes then operating as well. My colleague fellow sensei Mr Candy pointed out last week as I was trying to skin a grape, he proffered a number of different instruments to help me with the dissection in picking up the skin and certainly in special theaters and plastics and eye surgery instruments, he recommended would be on a tray, but these would not be readily available at home. The thing about taking the skin off here don't expect to do it all in one. Go take it off and layers, take off the thicker part and develop the layers and then take off the thinner part. But the feel and the resistance is very much like the field and resistance that I've experienced as a cardiothoracic surgeon, and that's why I enjoy this model. And it is a model that should be regularly available for you to use at home in the same respect and see that the here now trying to develop the plane between the segments is going to be very difficult, but with patience and persistence. Every time I'd be able to dissect that out, all the vessels in the body I developed embryologically and invasion it into the embryonic tissue, and in doing so, they take with them different layers and when dissecting in solid organs the liver, the kidney and the lung, the segments are defined by the vascular anatomy and being able to dissect confidently on top of vessels becomes an important skill and what I have here the Triple A to sausages and are taking Triple A to sausages because they've got a very, very thin skin. Very thin skin indeed, and I want to actually develop that skin, and my scissors can be used as a blunt, dissecting tool in this situation. Once I've got the plane, I can use it and gently stroke it the tissue and get off. It's very, very thin membrane, but that thin membrane is a bit like the Advent issue that you would find on a vessel, and you need to get in to this plain and what I'd call clean the vessel off. And once you're in that plane, it's a bloodless plane. But also it enables you to find and secure the branches without incorporating extra tissue. The idea behind this model is to be able to develop that plane without entering the sausage itself. So if you look, they're, I've now got a board front of sausage, skin and tissue planes can be an R this thin, so this model will give you an appreciation of in contrast to the orange how thin the tissue is. Once I go with scissors underneath, I can gently sweep that off as well as a dissecting tool. The other thing is, on the other side of that you can see my scissors. So therefore, I'm not going to be cutting anything because I can see through that membrane and generally tissue planes at this level, a little herniotomy my hand, the repair and child. The hernia sac is that thin you need to be able to separate off or the testicular vessels in the vast difference gently, without damaging the blood supply to the testicle. So there's another way to hold the forceps, and this is used by ENT surgeons, particularly because they're operating at depth. And if I'm holding my instrument in this fashion, you will find it very awkward to operate a depth. You'll see my hands in the way, and I cannot get around my field of operation at depth. It's the way ent surgeons hold The instrument is the invest on in verse. Again, I've got the tips of my fingers holding the scissors, my thumb, my index finger or ring finger, and now my fifth finger is extended down the shaft and I can look at the tips and I can see the bedding. So if I hold the scissors now, you can see my hand is not in the way. And I've got a 3 60 view of my sisters, both the belly and the hips at depth, and that is the reason to hold your scissors in this manner. So at the bottom of a pepper, we have lots of pips. And again, you can test your skills in snipping off these pips deliberately one by one, or opening your scissors up slightly and literally using them to scrape off the surface a bit like opening your scissors as you were to cut Christmas wrapping paper. You don't cut at all, but you open them up just by the tips and you run your scissors along the length of the paper and it cuts. So the two skills you can use here cut each pip off or practice using your scissors literally to scrape the pips off as I'm doing here. And all these simple exercises are giving you a feel or what tissues that you will come across when dissecting. So let's go to some pork belly showing so pork belly is relatively inexpensive from butchers. We've used the other side to make incisions, but you turn it over. You have all these tissue planes, and I know most of you preferred the scalpel for dissection, as we discussed last week. But dissection is a combination of the scissors. And the scalpel, as I said before, is for developing planes, and you don't put your scissors in and close out of sight. Open, take out open, take out and you close them under direct vision. You never close your scissors if you cannot see the tips now, as you're going through tissue planes, most the neurovascular bundles will cross tissue planes, and you need to know when dissecting. Is there a new investor bundle or is it tissue itself Now? One trick is to put your scissors underneath and can you see through it and a lot of dissection is feel. And if you look at that there, I can see through my scissors and there is no bundle underneath. There's in here. Yeah, that is a cord like structure, slightly blue, and that is a vein, and you said before veins do not diathermy an important thing in surgery, and the one thing that would reduce your wound infection and improve healing is respect to the tissue and proper him a Stasis. Now this is an advanced level. Once I got buses on the other side, most people will get a humor stuffed to pick it up. But as Mr Cherry in pointed out to me, what he used to do is gently hold suture in your scissors and bring it round. And that means you don't have to put your scissor down to bring the suture around, and then you can affect your tie. It means that you have to hold the tip of the suture material gently in the tip of the scissors. It is not a cut, so literally grabbing it and putting it through, and that saves me getting it. You must that to put it round, so I'm going to show you what I did before. So my ring finger I can affect a tie with my sister's in my hand and then cut that and cut the suture. I was chastised by one of the audience. Previously, for using the make induces to cut seizures. But after he pointed that out. I found a paper that demonstrated for regular suture material, You will not blunt your scissors. The other thing is the regular suture. Cutting scissors are usually quite vicious and sharp and short, and you can't get your hand for the scissors into the operative field. So here we go. I'll bring this down further, and you can see my scissors incinerated behind that layer of tissue almost as a probe. There's nothing behind there, so I'm happy cutting that tissue, and that is how you progress in a dissection. You can use your scissors almost as a blunt, dissect er in the right plane, and it's a very effective, particularly down small holes, whatever broader area idea of the combination of a knife and scissors. There you go. Check nothing there quick, one says behind nothing in that tissue I can cut with impunity. I've got a point as well, and all this, to be honest, comes from the appreciation of the field, and it all starts by how you hold the instruments at the tip of your fingers because your scissors are effectively an extension of your fingers. I'm now going to use that scraping Axion opened it briefly a little bit on the top, and I can strip tissue off as well. So your scissors thus has a multiple functions. See open just the tip a little bit, and I'm scraping off the tissue. But actually you have to remember, particularly with adhesions. Adhesions are usually stronger than the tissue around them, particularly, and redo surgery in the abdomen. If you start stripping off adhesions, you will tear the bow. Likewise, if you start stripping off adhesions on the lung, you'll tear the lungs. Sharp Dissection is clean dissection, and I always recommend that you cut if you can't always mindful of the anatomy and beware of coming across new vascular bundles. That's where you need to know your anatomy but also understand the feel. Sometimes pathology does not recognize anatomical boundaries, and if you're not careful, you'll end up cutting vessels because you didn't feel them. I mean, you know, when dissecting, I'm working across a broad front. I'm not going down little rabbit hole and developing the plane across different areas to progress. And here we go. Here's another neurovascular bundle. Uh, underneath. There's a little vein there. You can't separate the tissues and these little veins don't diathermy. And you find numerous little veins around the exocrine glands. Adrenal head of pancreas and not adrenal thyroid in heaven Pancreas. There you go. There's a trick of drawing the future through cabriole. Do we have any questions from the audience at the moment? You have some observations? Um, so I can read them out. Um, so Christa Gara has said that it's worth pointing out that there are many surgeons who would decry the use of McIndoe scissors to cut future, saying that this would blend the blades, which you have briefly mentioned, Uh, I agree with you, Chris. And there was certainly a paper that looked at it as that was pointed out to me previously, um, I agree with you. It depends on the size of the suture, I think for large sutures and repeat psa juice. Indeed, you could, uh, run into that risk. But this paper suggested they did a study, and it didn't actually blunted. But your observation is correct, and I would use them with care. Certainly respect back and, uh, mhm. That's great. Um, and then another observation was that in it's important to empathize uh, the importance of not opening the blades of the scissors too much or tissues will be torn indeed. And really, you're opening it up at that sort of point. You're not doing that. It is within the comfort of your hand movement. If you do that too much, you tear it. And that is certainly what you'll find when dissecting out and segment of a tangerine. If you are too rough and open up too far, you will start breaking in to that segment, and that gives you feedback again. That is a feel you can't measure it. You have to feel it and understand that at extremes you certainly will cause damage. Okay. And then the last observation we had again from Chris was that Tenderloin model could be also used to practice assisting, assisting. Certainly. And we're actually going to be using the assisting assisting on the fifth of December, and my son will come in and we'll go through the principles of assisting because a lot of dissection is very difficult when you've just got one. The idea of an assistant is to provide traction and counter traction, particularly if you have a broad surface and you used to forceps to hold it up. The surgeons contraction assistance, traction and your instrument are keeping that plane to enable you to develop the plane. And that is the important skill and the intuition that is required of an assistant at the table. When helping a surgeon dissect is to follow that movement and to maintain that counter traction, I'm grateful to be Braun, a scallop for giving me medicine. Bomb scissors and the medicine bomb Scissors are slightly thicker than the McIndoe scissors, but you get longer versions and these are nelson scissors, and what I enjoyed about the Nelson scissors is the tips are quite round, and I enjoy these to die session because they're not used that often. They're always sharp, but the important thing the tips around so it's less likely to injure tissue by penetration. So when doing a pericardectomy or taking off a cortex on the lung, I'd reach for the longer scissors not only because of the depth, because they rarely used a sharp ER and they haven't been used for cutting switches, as Chris points out. But the ends around and you're less likely to stab were injured tissue when using them. Any other questions from our esteemed audience? Uh, no. That were all the questions we had. Although John is saying thank you for another masterclass, Johnny to kind. I'd like to take the opportunity of thanking all the sensei of the blackmail academy who are joining the movement Medal has awarded us Exceptional Educator Award, and the prize is a coffee cup, and here we are. I'd love to thank Medal for hosting the Black Belt Academy and Gabriel, who is also sensitive for black Belt but in the background as a producer, ensuring that we can hear the questions and answer them accordingly. I'd like to thank you very much for joining the Blackboard Academy this evening. Next week, we're going to go on to talk about not time, and Gabriel will copy the link into you. And again, it's all in the fingers and at the tip of the fingers because you need to feel the knot down on the fifth of December. We'll be talking about assisting, uh, but then I'm going to be away for two weeks, and I have a couple of recordings to share with you for those two weeks. Thank you very much for following the Black Belt Academy. Do spread the word and welcome to Krista Garver are steamed and illustrious Sensor. His biography is on the website. I do commend his book and together we're putting a Wikipedia of instruments and famous surgeons because the most important thing with the instruments is understand how to hold them. But now you know who McIndoe is. Hopefully you give him to respect. Thank you. And I wish you well.