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Yeah, hello. Good evening. Good morning. Good afternoon. Good day. Wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Oregon, um, a cardiac surgeon in Yorkshire in the United Kingdom and the past Director of the Faculty of Surgical Trainers and a visiting professor at Imperial College. One of my proudest degrees is actually getting second down with my sword in June of this year. And what I like about the sword. It's the discipline of mindset. But what's interesting is that the precision is described and prescribed for every single move this evening, we're going to talk about the cut and the blamed and what's interesting with the sword. There are 10 horizontal cuts, fiver typical cuts and all of them are expected to be done perfectly. The handling and movement of the blade is precise and yes, this is a live blade, but let's move on to what we're going to discuss this evening. And before we do so, we'd like to talk through a little bit more from the Book of Five Rings by Miyamoto Musashi, who's the undefeated samurai warrior of 16 43. Great potential and great function. Everything has body and function. For example, a bow, it's a body while drawing and shooting and hitting the mark of functions of the bow. Elam is a body light is its function. A sword is a body cutting and stabbing of functions when the potential is unripe. However, the function does not manifest in all paths when concentration builds up and exercise is repeated, potential matures and great function emerges when potential freezes, stiffens up and remains inflexible. It is not functional. When it matures, it expands throughout the body. So that great functioning emerges through the hands, the feet, the eyes and the ears. And I think that describes the use of the scalpel that we are going to discuss this evening. If this is your first time to the Black Belt Academy of Surgical Skills, welcome. And thank you to 3243 followers on Facebook and 474 on Instagram. The prime importance when dealing with something sharp is safety to you. Your colleagues and your patient. There is a story of a 300% mortality from an operation when a surgeon took a knife to amputate a limb, cut himself and the assistant, the patient, the surgeon and the assistant all died of sepsis and is probably the only 300% mortality that has ever occurred. Let's come over and look at the scalpel in more general. Yeah, I have here a scalpel blade and thanks to Swan in Morton for their sponsorship and generous donation of instruments and a size 10 blade. You'll note that it has a specific shape and the blade handle has a groove and the groove is admits probably the end of your fingernail and it's into that groove that you insinuate the blade, but this has to be done as a control process. And I recommend that you have your hands on a surface that your blade is held carefully and securely on the blunt side in a hemostat with a large surface area to maintain the grip and simply slide the blade into the groove and pull it on to the. Here it clicks and the bevel is matched to take her off is the reverse is lifted off, apply your him step to the blunt side of the blade and simply withdraw. I've got both hands on the table and I'm pointing the blade into the table. Should it gets stuck or be difficult to remove? It is not going to come flying off and end up as a sharp missile. And blade safety is paramount importance. Likewise, in the dojo with a sword, if one is reckless, you could be disqualified for dangerous use of the sword. So let's come on to handling and handling of the blade. And I'd like to quote again from memo to Masashi and just talk about the grip as it says in wielding the long sword, the thumb and forefinger gripped lightly, the middle finger grips neither tightly nor loosely. Well, the fourth and the little fingers grip tightly. There should be no slightness in the hand. What's interesting is that your grip should not change at all with a strike or block or pinning down and your thumb and forefinger loan should change only somewhat. And I think that describes how you hold the scalpel. The scalpel needs to set in the palm of your hand, hold the knife like a knife and not like a pen. You note my thumb and my ring finger are gently holding the knife in a perpendicular sagittal plane. Whereas my index finger is extended down the blade, given me the direction and pro preception necessary to make a cut. They're all balanced on the pulp of the index finger, the thumb on on the side of the middle finger to give me the feel. And just as with the sword, it's important to maintain the feel. I do not want to see the blade held like a pen and we'll come onto special blades that enable you to hold this for final work. But in general, hold the knife perpendicular to the skin and make a cut. On my way of example, I got here a sponge and I've made a perpendicular cut in a sponge and colored the sponge on both sides. And you can see and bring it together, you see a fine line. Whereas on this side. I've bacon sliced the skin and bringing it together. You can see more ink. And I recall when I first started cardiac surgery or surgery in general in 1987 Mr William Water Frederick Southward would not allow me to do a pediatric operation until I could cut correctly and perpendicular two, the tissue without slicing it like that. That's where your wound healing starts. And that 90 degrees is important. The next important thing to talk about is draping. And I would say beware because often miss surgery will come into theater and the patient is draped up and make an incision. But good surgeons know how to drape up but do so mindful of the anatomy and the fact that the skin can move over the tissue like that. And especially if you're using adherent dressings and you're pulling it from side to side. You can see that the skin and the tissue will move and distort the anatomy. The reason I've got these table napkins here is it's not infrequent for a new surgeon to look at the incision and inadvertently make it parallel to the edges of the drape. And the drapes might not be correctly positioned. And therefore, you would end up with a skewed incision. The principle of making an incision is straightforward. It is deliberate and purposeful throughout. I personally like the 22 blade, but I understand they're being phased out in favor of the 10th and they're bringing in disposable blades instead, Mr Southward was a Dhiman with a blade a bit like Zorro. So the skin incision is done and marked according to Bernie landmarks. But also with attention to Lange's Lions and Langer was an anatomist to use an ice pick and corpse and with around Ed red round stabbing them and noticed that sometimes the round ended up closed and other times open and hands mapped and described. Remember before you make the incision, you've got to be absolutely certain of actual decisions, the right person, the right side at the right time for the right reason with the right consent with the right instruments with the right people. Whereas the right theater under the right conditions because up until that moment, if it's not right stop, do not proceed. There's no harm in coming back another day because once you start to make the incision, that's it, you have started and there's no going back. So support the skin between the thumb and index finger with your non dominant hand, apply the blade perpendicularly to the skin and draw it deliberately across supporting it all the time. Now, in the Black Belt Academy, we do a five centimeter incision which is fairly straightforward to do. But when you get to 10 centimeters, there's a tendency to actually tilt the blade and start bacon slicing. And when you get to 20 centimeters, turn around the hip and hence curved the blade further the incision, I start abducting my arm and lifting my Albert up to keep that perpendicular. Now, as you look at this incision, I have actually gone through the skin only and this comes through feel. But you note that I scratch the skin there that will scar. So I continue to make use the full length of the decision by coming back. I do not turn it over and point the blade have made the incision. I used the full length. Remember the wounds heal from side to side and the small incision, the greater the traction, the greater the ischemia at the end of this wound. And if it's a long operation that will starve badly, so a perfect slice all the way through the layers too often. I see people scratch the skin and go through each of the five layers. And your challenge is to name those five layers of the skin before the hippopotamus and demas use the full length of your incision all the time. Make sure you undermine the edges and not actually leaving it short. As in this side, I have reduced the length of my incision because I have not used the full length. So use the full length of your incision. Remember that the skin is quite mobile over the top. So you can get away with a relatively small incision and move the skin of the top but mindful of that particular ischemic episode. So what about fine work and the 15 blade while the 15 blade can be held like a pen for fine work, an excision of lesion and I will make a lesion here. Uh huh. And we now need to excite it. The problem is with a regular blade. As we perform a fusiform excision, people tend to rotate the blade and therefore bacon slice. And this is where this blade holder, a barren blade holder you can see is a round bodied and you can hold it like a pen and pencil. And this is thanks to my colleague in Sensei Chris Cuddy who's a plastic surgeon, hand surgeon. This is loving for fine work. But with a fusiform decision, you need, again, need to support the skin at all stages of the excision and keep your blade and 90 degrees on both sides and avoid bacon slicing the skin. And that's difficult for having done one side. But if you're thinking about it, you're less likely to do it. Remember, wounds heal from side to side and not end to end. And what is necessary is for you to actually excise a lesion and imagine this is a bit like a segment of an orange. It's a good excision, my four steps on it on the shelf, but they're, you can see that will come together very nicely and evert and we'll come to closing later. The version can only occur, guess what? By 90 degrees into and out of the skin, beautiful excision too often. I see people cut a very small round, like an incision to take something out and the dust doesn't come together at all. Well, and a bunches up. I had a plastic surgeon to do that on the back of my hand thinking they're doing a very neat small incision. But then we're trying to bring two edges of a circle together and it didn't look at all good. The other blade you'll be familiar with and common blade is the 11 blade and this is used for in size in draining absences and barber surgeons for time and memorial have been incising and draining abscesses. But this is not to be used as a weapon to simply stab uncontrolled. The best thing to do to control the depth is place your finger on the side of the finger of the blade and then insinuated into what you wanted in size. And you can see I can therefore control the depth. I used this technique for aortotomy for insertion of the aortic cannula. It's, it's controlled and it can control the depth. So how do we actually practice? Are feel, let's try a few things, shall we? And you can get any food stuff at home, any fruit with a piece of skin. And essentially what I'm challenging you to feel is to feel your way through the tissue. Can you make an incision in a banana with minimal cut to the banana underneath? So feel the way through the tissue take um anger and feel your way through the skin. Not too hard, not to soft, but just right. You'll feel a gift when it goes through the skin. There you go. Have you cut the flesh underneath? No, we have not. Another good example for practicing. This is an orange and the instant feedback with an orange. It's quite clear one. If your bacon slicing, you can see what it's doing to the orange, try and get full thickness through the skin of the orange feeling the way through the blades. Now blunt so it becomes rather difficult and make a couple of cuts, feeling the blade and to see if you've actually cut into the flesh, literally squeeze the orange and see if you've got any juice coming out. There you go. I have no juice coming out on the plate and I'm feeling my way through the skin. So the model I'm going to show you now is that first and it's a first for the Black Belt Academy and I've got a whole stack of lasagna pasta. And my challenge is to actually making a decision through each layer or this pastor try not to cut the pastor underneath. That was one I think I'm going to have to get a new blade. You see that's gone through, that's too. And I haven't cut the past underneath. I'll go through the pasta all the way through. So you can see I'm not cheating. I've cut and you see, I've already cut underneath. So this is a rather fun model for you to actually practice at home and learn to feel the blade and didn't come through. If you don't get a right, you'll find with relative ease. You are cutting through all the layers of this pastor to the bottom. So there you have it how to practice basic skills with a knife. You too can hone your skills and I hope you're practicing. And the whole thing about the blade and with the sword is it's an extension of your arm, extension of your fingers that you're using your eyes and your feel and even hearing as you cut sometimes to determine the layers inaccuracy. So I want to announce a competition. I would like you to send in pictures of your most innovative model to practice any of the basic skills we have demonstrated so far that you're using at home and send us a picture on Twitter Taggers for Black Belt Academy of Skills or Medal, but also put a description and how it is used the best and top three will receive your own set of instruments, what they got everything that you require to practice at home. There is no excuse, none whatsoever. And I hope you, we'll find these not only challenging but fun. Thank you very much indeed for joining the Black Belt Academy of Surgical Skills. I'm open to questions and I'm grateful to fill who's behind the scenes and reading the questions, please fire away. So I don't have any questions at the moment, David, but as soon as some come in, I will relay them to you. If you do have questions for David, please just pop, pop them in the chat and we'll pose them, pose them to David, the lasagna model I have not used before. That's the first for you this evening. I hope you enjoy it. I think it's turned out to be rather fun myself and a challenge. Try it. How many layers can you cut through without cutting a deeper one? And I got through five there before I deliberately cut through the last two to show you that I was not gaining or cheating. This model, we are going to come back next week and do register next week where we're going to discuss the other important tool. This is this and put them together with dissection later on any questions. Ladies and gentlemen, we have one comment from John, which is truly a masterclass by a true masters. Er Thank you uh John, your number one follower. Thank you very much. Indeed. And I hope you are enjoying your practicing. What was a pleasure last week was to run a face to face black belt academy dojo in Sheffield and Doctor Vlad Morrison from Romania happened to be in Sheffield and joined the session. I am delighted to announce that Vlad is going to join as a sensei for the Black About Academy and we hope to have live dozers running in Romania as well. If you enjoyed it. I look forward to seeing you next week. Please put the word around and I'll put out a separate advert for the competition. Let your imagination run riot. I'd like to know what sort of organic material you have available in your country that you can use to practice. Thank you very much indeed for joining the Black Belt Academy. I wish you well and be safe.