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Hello, good evening. Good day. Good afternoon, good morning, wherever you are in the world. And that is literal this evening as we have 65 people registered from 27 countries. Welcome to the Black Belt Academy of Surgical Skills. And thank you very much for joining us this evening. And thank you to the 4238 people on Facebook, 685 on Instagram and the 1079 on Twitter. Or should I say X? My name is David Regan. I am a retired cardiac surgeon in Yorkshire in the United Kingdom. I'm the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And yes, we are accredited by the Royal College of Surgeons of Edinburgh and this will appear in your CPD certificates. I'm also a visiting professor at Imperial College London. Now I asked you this evening about your confidence, using the knife and the scissors and not surprising, you didn't feel that confident. Well, the answer is I wasn't when I started either and 50% of you preferred a knife and the other 50% preferred the scissors. What I was really pleased about is your rating of priorities with operating. You put anatomy first. And as I said, last week, Al Zawari said surgeons should know their anatomy. And I honestly believe a good surgeon can operate in any part of the body provided they do know their anatomy. Your solicit understanding variant anatomy, priority, identifying tissue planes and respect to the tissue with tissue handling. And of course, I was delighted that you talked about hemostasis in your not waiting. Diathermy only had 16 per percent. People advocate diathermy and to be honest, diathermy is cauterizing full grading tissue. So, increasing pain, increasing tissue damage, increasing problems. POSTOP this evening, we're going to talk about dissection. Now, anatomy and dissection must have been known to the cavemen because they had to get rid of all the green meat. In other words, the bowel and the intestines. If they were to avoid food poisoning, the cavemen wouldn't have lasted very long, cooking meat if they left the guts and gimlets inside. But when it came to human anatomy, when did the start? And the Egyptians were expert at mummification and they too took out the Giblets and packed the organs to now mummification for the afterlife. But it was Hippocrates who founded the medical school in Kos and one of his disciples, Praxis had a student called Helius of Chaldon, who in the third BC, together with a colleague Atritus of Clio started the former investigation and scientific anatomy and they used executed criminals. And by the fourth century BC, they were able to use cadavers. I was a little worried to read, they indulged in life dissection and V section of condemned criminals in Alexandria. It was Galen who took some of these studies back under the Emperor Marcus Aulus to propagate the science of anatomy. But most of his teaching and most of his dissection was done and monkeys, the barbarian monkey in particular. And it's for 300 years that his teaching and his learning stood the time because on religious grounds, there was a taboo interfering with the dead. But in the 7th and 8th century dissection in the Islamic Empire and Al Zawari, as we have mentioned, last week, foremost in this field in the 14th century French and Italian University started to use cadavers and started to understand and learn more about the anatomy. And prof of Mon Delua who was born in 1275 wrote in 1315, the Anemia de the anatomy and anthology. And it was during the RNA era that Galen's work was started to be challenged and people were inquiring more about the human body. And as one of the professors, the professor Andres Vus born in 1514 in Brussels, who ended up as a professor in Padua, he wrote the definitive text of anatomy, the Human Corporis fabrica. And this was the first definitive text of anatomy that really stood the test of time and this was in the Renaissance era. And of course, this translated to the artists of the time Michelangelo and of course, Leonardo da Vinci, and we're all familiar with Leonardo Da Vinci's drawings. But he interestingly enough, he was the first to actually draw cross sections of the body. It was in the 15 100s, as we previously said that the Barber Company of surgeons received a license to have four executed criminals per year to study the anatomy. And they of course, then got the Royal Charter and the foundation of the Royal College of Surgeons with the stipulation that a surgeon had to know their anatomy. Now the first medical school college in the USA in 1765 the College of Philadelphia introduced the rigorous study of anatomy and tried to correlate the observations in the laboratory and autopsy with a bedside. And this together with all the other medical schools generated a huge demand for cadavers and bodies. And hence the term body snatchers came about. One of the most infamous of them was in 1788 a doctor of the Society Hospital in America pass a window of a child looking out at the street and used a hand of a body to wave to the child. Apparently the child recognized the hand as the hand of his mother. And it was not surprising that a mob burnt his laboratory down in Edinburgh, William Burke and William Hare owned a boarding house and one of their occupants died owing them 4 lbs. They offered 7 lbs for the body and sold it and thought hm lucrative business. So the next 16 occupants died of intoxication and asphyxia. Of course, they were sentenced to death. The Anatomy Act of 1832 changed all of this after a long debate and allowed surgeons and students to dissect unclaimed bodies. And these were usually from the poor workhouses, prisons or asylums. And of course, that raises a lot of ethical problems. But today you can donate your body to an anatomy lab. And I would like to ask you in a poll, how many of you have done CAD dissections? And we're gonna put that off as a pole? Yes or no. Just a bit now. And as you're doing that, I'd like you to also to think and we won't discuss this evening, but open it up in a text poll. What do you think the educational value is, is it ethical? Is it safe since they informal it, what are the human values? How does this actually sit now with 3D printing virtual reality CT scans MRI. And of course, we now got somebody who put on display the plastic bodies. Well, this evening, we can't go into that ethical debate. And what's interesting, it's 5050 yes or no dissection. Personally, I think cadaver dissection is here to stay and the people who should be doing that are people wanting to learn surgery. I do believe however, that everybody needs to have a good knowledge of anatomy. Because when you put a hand on the patient or a stethoscope on the patient, you do need to know what is underneath. But this is not an anatomy presentation. And because we are entering the festive season, I've now got an interesting model for you to use. I've previously used a turkey leg and found that this is cheap from the supermarket in the UK 5 lbs 95. The whole drumstick is actually in a stew at the present moment and cooking in the slow cooker and this will go to feed the dog. I hope you appreciate the Christmas and Thanksgiving element with a Holly on the side. So as we do this dissection, I'm going to reinforce a few principles. The knife, remember we said it's incisions, it's gotta be clean and you gotta feel the blade. But before you make a mark on the skin, you've got to be sure that your decisions are correct. It's decisions before incisions. Remember to hold the blade with your index finger extended down cos that's giving you the pressure and the feel that the sagittal plate is maintained between your thumb and your middle finger. The incision is done two handed, supporting the tissue either side and you should be able to cut through Lez at a time without cutting through the skin and the tissue underneath. And you can only do that by feel. And I hope you appreciate that. I have actually gone through various thickness of the skin there without cutting the flesh underneath. And that is because I'm used to feeling it. No, often people would change the knife having cut through the skin because the knife actually BLS very quickly. And you can feel the difference. The other reason to change the knife after an incision is the theoretical risk of increasing wound infection because you've gone through the skin. But really you want to actually use something sharp and we're cutting with a belly. Now, I'm going to remove the skin to expose the muscle underneath. And I'm using the knife now a bit like a brush. So, yeah, I'm brushing against the skin here and I'm gonna brush against the skin or you might think about using and as a pallet knife. So this is the artistry of the knife is being able to take the skin off and I've opened the blade up and I'm now holding lacrosse my fingers and I'm brushing against the surfs with my blade flat against the skin. I'm taking off and this is a fabulous way of removing the a plane. Obviously, if there's any resistance, I need to think that vessels and nerves may be present. So we got a large muscle here and really one should not b cutting the muscle, we should try and splitt the muscle if possible because it is doing less damage. And II recall doing open cholecystectomies and cocker incision that cut right across the rectus. And in retrospect, in my training, that was one of the most painful incisions that you could inflict on a patient. I I'm not getting through the muscle there. So I'm gonna come round, I'm gonna take the muscle off from this side and see if I can get to. I hope as we found previously, the neurovascular bundle or the femoral canal of this turkey do ask questions and I am happy to answer them as I'm progressing here. Gabrielle will pick up questions. Obviously, when dissecting, it's a lot easier to dissect with an assistant helping you. We have a question for Grace. Uh When would cutting in planes be used in surgery? Well, there was anatomy book and I can't, I've asked previously of the audience, it was called Surgical Anatomy based on tissue planes. And it was the one of the most relevant surgical text, anatomy books that I'd ever ever come across. And it described the anatomy or surgical anatomy as you were doing it and exposing tissue planes. And it was a fabulous. It was a really, really fabulous book. And if somebody knows, perhaps you can let me know what the, who the author is and I'll look at the book, but it was fabulous and all surgery should really happen along tissue planes. No, when I'm dissecting and developing planes, I'm using a knife but on occasion when I think I'm gonna see a vessel and I'm gonna take you down a little bit as you can see in the screen there, a little birth purple end, there's a thin fascia layer there. I can slice that with the scissors. And that is a bit like taking the skin off a sausage note when you're using the scissors that I can, I've got them B on my fingers, the palps of my fingers, my ring thumb, middle finger are not through the rings and my index finger is extended down the scissors and that gives me direction, feel and control the instruments are really an extension of your fingers. And unless you're holding the instruments correctly, the knife and the scissors, you're not going to feel the tissues note when I'm using the scissors, I can open up and I take the scissors out open and remove. I can put my scissors behind bits of tissue and determine is that a nerve or is that a vessel or, and deal with it appropriately? See, and this is a bit like the tangerine model that I've used is being able to separate this tissue and confidently dissect them without macerating either side. Now, I'm hoping we're going to come down to some neurovascular bundles in a moment. You can see the loose areolar tissue and this is what's fun about surgery is the planes are essentially bloodless, but on occasion, you will come across there there's a vessel there isn't there. So now I'm going to open, separate, open, separate and I can insinuate my scissors in that plane. I hope you can see clearly in that plane and confidently open, open that plane up and dissect the vessel out. And this, I think, and looks at things is going to be, there's a nerve there. Ok? I could feel it a little bit of resistance at the end of my forceps uh at the end of my scissors and I could see it was thickened and it's white. It's not that different to the tissue around it. But I hope you can see now that I've got a nerve at that spot and I am going to carefully separate the tissue around. I'm not cutting, I'm just separating my scissors. And once I'm confident there's nothing underneath it, I can cut and that is a nerve. Now, part of dissection is identifying and knowing when you are coming across a nerve, a vessel vein or artery. And what are the things you can do to help your dissection is used slings slings to hold things out the way. So I'm gonna use a mosquito and the mosquito again, open separate or my preferred tool for dissection is a la. But look how I'm using, holding it again. It's on the tips of my fingers with my index finger extended down and I can open up and develop the plane underneath. There you go loose. Heavier of tissue and to help that you can use slings. And here I've got a sling and I'm using a balloon, a white balloon and I can hold that out the way I've got here, a vessel. And again, I'm using it dissection and trying to develop a plane. There might be a little nerve on the top there. But no, you can see is loose areolar tissue, but I have a little vein just there. And remember I said to you that veins do not diathermy. So in this circumstance, I would actually tie off the little veins. So we're gonna tie that vein off and I'm using a bit of cotton in this circumstance. Remember it's simply dimpling the surface like that. That's all you need to tie. But my finger is on the knot and across the knot to hold that. Again, I am going to just put a mosquito on that for a little bit of traction and I'm gonna tie the other end as well. So again, using my leg here, I nt good. And if you are doing a Sephena Feer Junction ty, you will find there are lots and lots of veins at the top. Each of them need to be tied and you need to make sure that the vessel itself is clean, that there's nothing but the vessel in the ligature, you cut it and then you can cut your stays. So I'm using my ties as a stay for a moment to hold the vein out the way. So you can see there. I'm just developing the plane around the vein and tissues do not require force. You're in the right plane. It will all separate for you with a little bit of gentle persuasion. I hope you can see that. I've got a little bit of areola tissue there. I've got a vein here and that's probably another branch. And remember. Yeah, it is. So I can put my scissors behind it. See there. And I need to clean that off a little bit because I don't want to tie anything but the vessel itself. So there you go. I'm looking for my other mosquito so I can put there and I could put a mosquito here. Note as it typed last week, I've put mosquitoes facing each other and I can cut cleanly in between. And that makes it easier for your assistant to actually lift turn and separate, enabling the surgeon to secure the vessel, the one handed surgeon with no assistant. I don't have that luxury today. My son comes back from boarding school on the 15th of December and he said he'd be delighted to assist me on the 18th of December. So if you'd like to know more about how to assist, do join us on the 18th of December and we'll talk about that. Any questions at the present moment in time? Remember with veins do not ever try and diming them and no matter how small they are, you do need to tie them off, diligently. We have a question from a medical student. Well, and they would like to know what happens to the tied vessels after the operation is complete. Well, I'm glad you've asked me that and remind me that in a moment when I get to the arteries because I'll show you a little trick. You don't want to tie off arteries because arteries are all part. Of course, the blood supply and I can't find the artery here at the, just a moment. Oh, there it is. I think the arteries down the back here behind the vein. See that, I think it's there and I'm using non crushing forceps. There you go. All right. And I'm developing the plane so I can either use my scissors. And this is where you got to remember that there's a facial layer on top of all your vessels and you need to actually get into that facial layer and make sure that and be confident about using that F air. And this is where the Chipolatas came in. There you go. Now, I think that is the vein and again, the slings are quite useful and different colored slings and of course, it's a vein, I'm gonna put a blue sling on there and hold that out the way. So I'm using the slings now as a traction. Now, you asked about arteries. Now, I wouldn't tie off arteries at all. Was that the artery? And that is the, the vein behind? Yeah, there's a vein behind. You can see that that's the vein because it is purple. It's a thinner wall. And what I've actually got here is not the vein, but that's the artery. I'm gonna swap my sling import a red one around that because that is the artery. Sometimes in small vessels, a little bit of dissection will actually show you what is what. So there is an artery there. And this is particularly true when doing a, a femoral embolectomy or a patch. You don't want to, particularly in ischemic limbs. You do not want to be tying off arteries, you need to preserve them. So there is a little trick for preserving them and you use silk. But in this case, I'm using string and I'm going to, I want to preserve that artery because I'm worried about the ischemia of the leg. So I'm gonna put a sling around it and I'm gonna bring it round a second time. OK? See that. And I'm gonna put that off to the side and I'm not going to cut that, that is holding and occluding that branch. And I do the same for that branch there as well. I don't have a second bit of string, but I do the same for that branch as well. Now, with all vascular surgery, once you've identified the vessels, I would use slings top and bottom to hold things out the way. Now, having done that, it is possible for me to put clumps on either side of that vessel and open it up carefully to get to the inside of it. And shall we do that? So I'm going to put that under tension a little bit. Now, let us see if we can open it up and in this circumstance. Now I'm going to use a Barron blade and a 15 and this, I'm holding like a pen, I'm holding it like a pen because I'm going to use the stretching motion on the top of this vessel to open it up. It reminds me, ok, Corry vessels. There you go. I made an arteriotomy. I don't know. You probably use pot scissors, but there you go. There's my arteriotomy. I'll focus down further for you and show you that we've dissected out the femoral artery. You wanna use those forceps. Uh I've got another pair of forceps on here, but I might just show you by opening it up. We have a question. There you go. I hope you can see that is open. I can now secure that. And at the end of fixing this and sew it up, I would take off the cerclage stays on the vessel to restore blood supply, but I wouldn't drag them off. I'd lift them off and I'd actually cut them because if you start dragging them off, you run the risk of tearing the vessel as well. So I'd actually cut it and then take it off and that is the way you would preserve my vein is held out the way, way there. My nerve is held out the way and I've done an arteriotomy that there. I thought it would take me longer to dissect that out. Was I rushing? No, we're being deliberate and purposeful all the way through and of course, hemostasis happens going in. So it's slow in, quick out. So, question yes. Would this be the typical approach that vascular surgeons use for art artery arteriotomy? Certainly, I've, I've slung the vessel. The important thing with uh uh vessel surgery is you got to have control above and below what I would have are vascular clamps to gently put on there. Remember with the clamps, all you need to do is just have one ratchet, don't go and crunch it. That will actually damage the vessel. But this would be the typical thing and this is about the size of a vein ra radial artery that we typically use in cardiac surgery. So we'd be stitching that with a 60 or 70 and I could do an end to side anastomosis there. Now, the interesting thing with all veins, we talk about femoral sheath and carotid sheath and things. Well, actually the vein is not in a sheath. Ok. Just think about it. What happens when you exercise. What happens when you exercise, you gotta increase blood flow back to the heart and it's gotta be through the veins and the blood return increases with muscular contraction. So, if the vein was in a sheath, it could not expand, could it, we could not increase your cardiac output. So you'll note that in all anatomical situations, or the vein sits around a lot of fat and an empty space and that empty space is taken up when the venous return increases with muscle contraction. The vein is not in a carotid sheath and the vein is not in the femoral sheath medial to the femoral vein is the node of clo and lacunar ligament. So there you go. What we've done is reflected the muscle. I haven't cut it. It is possible to stitch that back on in closing this because you've maintained the planes. You have kept a nerve with a sling, a rubber sling on gentle traction out the way you are not gonna damage it. Remember with nerves though, some of these nerves are very thin, like and they are cutaneous nerves. So if you don't respect those very thin, there's a thin nerve probably off there. If you don't respect their, your patient will end up with anesthetic areas on the skin. I would close the sheath, the fascial layer over, bring that over the top. If there's any potential dead space or leave a drain in stitch that down, probably leave a drain underneath the skin. But just as an important point do not leave the skin in any part of the body. That's it because that will necrose. So part of your understanding of your incision is understanding the blood supply of the skin and where it is precarious. And of course of the tibia around the ankle, these elements on the skin would be at risk of devascularization and necrosis and damage. So we have done effectively a femoral embolectomy on a Turkey thigh, attended to all the veins as we got in identifying the nerve, the artery and the vein behind. And I hope you'll agree. Turkey's offer a fabulous dissection. Now, Sra he said we'd like to share with you the techniques that I've learned from you. Where can I send them? Well, thank you very much. Indeed. I would love to know that. And part of that also would be, I'd be delighted for you to send me all your pictures of your practice at home. I'm just reducing the practice at home and this is gonna be part of a competition because the best competition, examples of innovation will receive a prize and the price. Let me just wipe my hands cos they're covered in turkey fat. Now, of course, I'd be having gloves. The prize would be your own set of instruments. And in this set, you've got the basic tools to enable you to do the job. A needle holder, mosquito, McIndoe scissors and forceps and what this will close at the end of January and what we want from you are examples of the most innovative or unusual products or things you're doing to practice and hone your surgical skills. We've talked about knot tying. We've talked about dissection. We've talked about knife skills and we talked about stitching skills. So, if you have got anything in your mind, that's low fidelity from the supermarket. I don't want any plastics. Do let us know, submit your picture to medal together with your name, email and your work address. The last time we actually ran this competition. Unfortunately, one of the winners in Abu Dhabi did not receive his instruments. They were sent back by customers on a number of occasions. So your work address, your email and your name and the best picture. So if we could put that in the chart, Gabriel and answer any further questions because re did not catch that. Sure, I'll do that. And it said JSA asked why tie the veins and not dieing them. Well, if you think of the anatomy of the vein versus an artery and why arteries diathermy because they got a thick muscular me and therefore they died of me. But I'd caution you anything more than a millimeter. I would not attempt to diathermy but ligate veins because a thin walled do not die theme. And although you might buzz it and it stops, it will not remain occluded and will open up and there's nothing worse than persistent venous bleeding, which will add to the pain because of the thrombus, add to the f fibrosis and the scarring and add to the immobility. So that is why I'd say that hemostasis and even the smallest vessels you need to tie off as you go through. And the endocrine surgeons, I know the thyroid surgeons and head and neck surgeons are really skillful at tying all of these off, secure and dry with better outcomes. Any other questions? Not that I can see at the moment. No, it said if I cannot tie directly, should I use undermining approximately? Well, to be honest, as part of your dissection, you should expose the vessels plainly and with a combination of scissors to open and displace and the areola tissue around, clean it off, you should be able to get a segment of vessel where you can tie approximately and distally on the rare occasions. You can't, it's usually a trauma surgery and I've seen a loss of control of veins in particular and in those circumstances, you were unable to tie them off and I would oversow them, but you'd only oversow them with knowledge of the anatomy that you're not oversow anything next to it underneath it or on top of it because as you see, the neurovascular bundles are in close proximity. So a knowledge of the anatomy of the area and also knowledge of what veins you can oversow is useful. Any other questions? Well, I'd really like to thank you for joining us this evening. Do spread the word if you have found it helpful? Ok. Uh Any other questions, do spread the word if you have found it useful. I look forward to you joining me next week as we're gonna be talking about wound infection the week after we're gonna be talking about gowning and gloving and washing of hands because I don't think that is described or done particularly well. And as with the philosophy of the Blackout Academy is getting it right all the time, every time and having a feel of the instrument and use the palp of your fingers and hold the instruments with the lightness of touch. To be honest, you don't need any more than dimpling as force for tying knots. That's all you need. Ok. So there's no force whatsoever. You're just allowing it. Now, the other thing is when dissecting is that you'll find there are natural pauses in an operation. There's one surgeon I knew who phonetically went like this all the time. And compared to another surgeon who the tissues would part in front of him. And then there would be a natural pause and at that natural pause while you got another instrument or another suture or change the blade, that was your opportunity to go round and do s smaller vessels and hemostasis. So you can use the natural pauses in the operation. Certainly in cardiac surgery, I knew how long it took me to do bottom ends. So therefore I could time the cardioplegia and that's the thing. Time is a friend if you are aware of how long it takes you to do things and be aware of things around you, but it's all rhythm and flare Gabrielle. Thank you very much indeed for hosting this evening and filling the questions and thank you very much for joining the Black Belt Academy. Please spread the word if you found it useful and I look forward to seeing you again and I'm delighted that we've had people really across huge time zones and from every continent this evening. Thank you for following.