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mostly Elizabeth. I'm live. Hello. Good evening. Good afternoon. Good morning. Good night. Good day. Wherever you are in the world. And thank you very much indeed for joining the Black Belt Academy. The surgical skills. If this is your first time, thank you very much. And if you're returning a bigger thank you too. My name is David Oregon, a mechanic surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers for the Rheumatologist Citizens of Edinburgh and visiting professor at Imperial College, London. I may have lots of degrees, etcetera, but the ones that I am proud of of my second Dan in karate and my second Dan in the I Do, which is the art of drawing the sword. And it struck me as I started my journey and martial arts nine years ago that there were many similarities between the deliberate, purposeful practice of Carter's in karate in I do and that of surgery. But more in particular was the mindset and the philosophy. And the shin too, is, um xango Buddhism involved in those disciplines, to my mind, was not too dissimilar to the state of mind that we should be approaching surgery. So hence the Black Belt Academy of Surgical Skills, because often you go into theater and they say, Not like that, like this, but that this is not explained, and you don't quite understand the nuance. And for going through my third down in a month's time, one has to learn the first nine. Carter's backwards and there's one movement in the Kata, which I hadn't really grasped until now, even having done for nine years. And that was going up on the balls of the feet, twisting to face backwards, locking down, locking up, kicking and turning around for a block. And when you do it, rising on the ball of your feet and turning that movement becomes a lot more natural and not more fluid, and it flows. And it only became evident to me learning this backwards. And to my mind there are lots of things, and sadly, that we do as experts. We assume that do not communicate and that simple at that stage, rising to the ball of my feet and twisting around for a block, block kick and back again for a block. I haven't understood that nuance, so It doesn't surprise me that much of surgery is still in the mystique, and I've been using the Book of Five Rings, which is a classic textbook. I, a Japanese samurai warrior of 16. 43 million you to Bashar she and he's liking the science of martial arts to carpentry. Now I have to smile to myself. There are many orthopedic surgeons out there and say We just deal with the bones. You might deal with bones, Yes, respect. But you have to get to the bone but getting through soft tissue. And if you handle the tissues properly in the soft tissue properly, perhaps the bones would do even better. And certainly the mobility of the patients postoperatively will be much improved. So, um okay, says as the Master Carpenters, the overall organizing director of the Carpenters. And I was thinking consultant and theater. It is the duty of the Master Carpenter. To understand the regulations of the country, find out the regulations of locality attempt to the regulations and the Masters carpenters own establishment and the Master Carpenter, knowing the measurements and designs of all sorts of structures employees, people to build houses, and in this respect, the master carpenter is the same as a master warrior, but actually it's the same as a master surgeon. So when sorting out timber for building a house, that which is straight and free from knots and of good appearance can be used for front pillars. That which has some knots but straight and strong, can be used for real pillars. That which is somewhat weak yet has no knots and looks good, is variously used for door cells. Lindell's and screens that which is not it and crooked but nevertheless strong is for thoughtfully in consideration of strength of the various members of the house they even knotted crooked and week timber can be made into scaffolding and later used for forward. So the Master carpenter directs the genuine and knows the various levels of skill and gives them appropriate tasks. This is like surgical training, and some are assigned to the flooring, some to the doors, the screen, some to the cells, lentils and ceilings and so on. And he has the unskilled set out on the floor joists and gets those even less skilled carved wedges. The efficiency in smooth progress, prudence in all matters, recognizing true courage, recognizing different levels of morale, instilling confidence and realizing what can and cannot be reasonably expected. Such are the matters on the mind of the master carpenter and struck me. That is true for the Masters surgeon and the principal of Master Arch is the same. And he says, If you want to learn the science, then take everything all right to heart and think over it carefully now one of the things that I actually thought was rather funny. Back in 2003, I was approached by men's health and a Christmas tissue to describe how your car for turkey I'm appalling of carving turkeys. But I looked it up and there is an art. And when you look at the cooking programs, Master Chef in particular, they have a section on knife skills, filleting a fish, preparing a rack of lamb or preparing a river beef and carving it and dressing it in appropriate fashion. And I've often smiled watching that program that Monica grimaces when she sees poor knife skills or unsafe life skills. And I see these knife skills when I give it to the butcher's and I brought in some pork belly this evening and watch the butcher sharpen his knife and expertly find the planes and layers to separate off the joint that you want to eat and cook. Then it reminded me of Shrek. You might be familiar with that animation, and the donkey and Shrek and donkey is hustling Shrek about what sort of food would you like in yourself, too? And he turned around, infuriated and says, onions and the donkey says, Why onions? He says. It's because it is in layers, and if you look at this onion, it is all in layers, and we can separate bits out in layers. And if you look in nature, everything is in layers and they separate out quite easily, sometimes with a little bit of encouragement. But even the outer skin is a layer that peels off. And I used this analogy because embryologically everything is formed starts off of three layers, and then it folds and folds and folds again. And, of course, the blood vessels develop an angiogenesis into the three layers and invaginated into those layers as well, taking another layer on top of that. And I would say that surgery is a bit like layers and here's a clever garlic, and there's outlets in the layers and cutting the garlic along the layers. One in the onion You don't get the smell because you're not cutting into the flesh, you just separating the layers. Whereas if you start cutting across the layers, you start getting the smell of the onion and garlic. And I thought to myself, that is not too dissimilar to operating when you start cutting across the layers rather than respecting and separating the layers one instead of giving the smell. Well, if you're doing well, certainly and you've done something awful, we'll get a smell. But you would get increased bleeding and damage to the tissues. So the whole idea behind dissection is to understand the anatomy in the form of layers in different parts of the body. And I had a textbook. I thought it was last. It was surgical anatomy, defined by layers that you go through and our previous lessons. We have taught how to use the two important instruments of dissection the scalpel and the McIndoe scissors, but those are supported in the opposite hand, with forceps to hold retract tissues and help you define the planes So as we come over to the top, we're just going to revise some of those basic skills that we have attended to to date with our lands. So here's the layer of the onion, and developing these layers is fairly straightforward. They all separate with a bit of encouragement, and it comes out. We've got to remember that our neurovascular bundles, however, run in these layers, sometimes across them, and that is where our knowledge of anatomy is important. So that is a hard piece of vegetable. Our garlic is exactly the same. It is all in layers. But of course, an onion is also in layers, garlic in layers and the lemonades as well. But now you've got soft tissue either side. When we demonstrated last week with the use of the scissors, you've got to be able to separate these layers without damaging the flesh. Other side and dissection is effectively separation of layers and teasing them apart and exploring them to get to where you want to go. Because proper dissection following layers, it does not cause bleeding, so you can practice doing that. So one of my favorite models, four Sisters skills, is the sausage and this is the thin layer over the sausage that I need to adjust. The height of my table, which I hadn't done before, and I remember of posture is important the thin layer that all vessels take into solid organs. So the kidney, the liver, the lung, the anatomy of the arterial circulation is using very well defined in segments and practice developing the layers for these segments, I'm following them through. As you can see, my scissors is literally underneath that very thin piece of skin of the sausage, and certainly in vascular surgery, dissecting out vessels and in cardiac surgery they're sending out the side branches of the vein. It's important to take this layer off to secure the vessel with ligation, so that was the one skill there, and it requires patients and delicacy, and the feel of the instrument to actually find the other important skill is being able to use your knife appropriate. Now the knife needs to be used different to cutting, as described before you opened up the blade, you're holding it across your fingers, and I'm holding it out because I'm using the blade like a brush, and in this case, taking the skin off this bit of salmon and brushing my knife against the layer I wish to remove, and I'm trying not to cut the salmon underneath. So it's a combination of brushing separating, and this makes up the principles of dissection. This is not too dissimilar to muscle a muscle. It's better to separate it. As you can see here, rather than cut across the muscle, it's better to split it because it does less damage and also causes less bleeding. But good surgeons know this, and a good surgeon can operate in any part of the body as long as they know the anatomy. And there's some important areas of the body have operated on previously that you need to understand, for example, the phrenic nerve. It comes out of its roots, and then it forms In the anterior surface of Scaliness anterior in the neck behind the pre vertebral fascia, the sciatic nerve in the back comes out from the eyelid crest over the superior Gamilas. After radiation internus inferior Gamilas muscle, the quad writers, farmers and then behind the doctor Magnus muscle, the femoral nerve comes out on the floor of the femoral triangle, running on the surface of the idea. Surface area, soreness, muscle as well. So as long as you know the anatomy and where to expect these neuro muscular bottles that either run on the muscles or run through them, then you can appreciate your anatomy and would help the dissection. Now within the pericardial pleural and peritoneal cavities, the visceral and the peritoneal elements of this fold, as you know, giving different combinations of folds. And in thoracic surgery, the hilum of the lung is likened to the sleeve double cuff sleeve of the shirt, and that is called the problem. The ligament, but condensations of tissues could be found in many places of the body and the condensation of tissue in the axilla. The clavipectoral fascia is attached to the clavicle and the subclavius muscle at the top. It divides to incorporate the pectoralis minor and continues to the axilla as the suspensory ligament. That actually supports the skin of the axilla when you lift your arms up. But the surgeon operating in that area would know if they go through that fascia. They have now exposed themselves to all the clock work in the axilla nerves and vessels alike. long thoracic nerve runs down oversaturated Santeria. And if you cut that, you end up with wings scapula. So understanding the anatomy and being able to progress your dissection in such a way that you can separate layers. As you can see here, I have got no salmon on that skin, and I'm trying to keep the salmon itself intact underneath. And what I'm doing is literally brushing my skin, my knife against the skin and over the surface I'm never cutting into at all. And one of my favorite blades is this the 22 blade. So let's put the two together and let's see how we go when looking at some pork belly. So here I got some pork belly, and as I stood in the butcher's, I marveled at their technical skills with a knife was able to identify tissues and layers, so knowledge of the anatomy is important. The knowledge of the layers and how the nerves and vessels cross those layers is even more important than the secret to dissection. So here you go. I'm literally brushing like that, my blade across the surface. I'm not cutting. It's a light feel, and this is a wonderful way of separating loose areolar, a tissue and defining planes. When you get an area that is a little bit more difficult. Usual scissors, put your scissors in, open them up to separate the planes. You can pop your scissors behind fascial layers, and I'll take a closer to see if there are any neurovascular bundles so I can put my sister's behind there and you can see that is loose areolar a tissue so quite happy cutting it. The secret is when your dissecting through these layers. If you're coming across resistance, that resistance may well be a neurovascular Monday now said, arteries follow a defined anatomical pattern. Have the veins, particularly around the endocrine organs of the body. The adrenal head of the pancreas and the thyroid all have and very varied and rich supply veins to drain hormones. But veins not being thick wall but very thin walled do not diathermy, and even something that small you can see they're behind my scissors requires ligation and, like getting it carefully all the way through during the operation is useful Now. My colleague Ashok demonstrated that he sometimes uses his sister's behind there and carefully we'll see if we can do it here, pops his sister through the tip of it. Literature interest is, is to put it through. And Ashok, I go. There you go. Um, use my scissors. I'll try that again because it's out of picture. There you go. Got my scissors behind. You can see the vessel. I'm going to use my scissors to save time just to take that and just pull that through. I've pulled through and I can now my gait and those are the size of the veins you see around the adrenal thyroid and head of the pancreas. And if you don't attend to them, they bleed. Sure, an operation is not quick. It should be methodical, deliberate, attending to each stage, respecting the tissues, particularly with the non dominant hand making sure that you're not crushing tissues inadvertently with your forceps. And you can feel with your scissors and your forceps the tissues as they separate. And does that feel and respect of the tissues that was described by Lloyd Bicycling Morning AM as a surgeon not being a cure of fresh but caressing the tissues. And this is where the artistry comes in There I felt with the tip of my blade, another degree of resistance and I can put my sister behind. There. You see that condensation of white tissue? There is probably more than just a bit of fibrous tissue that indeed could well be a nerve. And the nerves do look white and hard like that. If you weren't confident in your anatomy, this is a point where you stop and suddenly think, Uh, is that a nerve? I remember as a message you're doing a diet section of the Axilla. And I knew the boundaries of the top and bottom and the fascia of the axillary vein and not to go above the axillary vein. But in the middle of the axilla in this very obese woman, I came across a nerve like that and cut. I thought, Oh, goodness me, That is significant. But on reflection, it wasn't because I was nowhere near the brachial plexus and nowhere near any significant nerve. And for her it was a an aberrant and nonsignificant structure. So there you go, forces behind. I would like to get it now. Tissue planes separate and, uh, very a vascular. So you progress your operation as far as you can, attending to the human Stasis as you're going along, you'll find that in any operation their natural causes, some people fanatically buzz and interrupt the flow of the operating to attend all of these. What I would do in this circumstance with this is probably put little clips on them as they go or Ligaclips to make it easier. Or the assistant could possibly try that as well and continue. But use your natural pauses in the operation to attend to human Stasis because hemostasis happens during the operation, not at the end. I remember that as a protein cascade of clotting is going to be significantly affected by temperature, and most people on the table exposed in theater, which is called under the light evaporating, will be losing temp. Dropping temperature and temperature and fallen temperature is directly related to were an infection because it compromises the blood supply to the area as well. The last thing to say is not homeostasis should not be cauterizing and die faring everything inside, because quarterly is for grating tissues and causing damage. If you stick to the planes you operate carefully, there should be very little need for extensive diabetic and cautery in these planes. If there's a significant area afterwards that is serious all at risk of bleeding, then putting a drain in that area for 72 hours post off will reduce the risk of a collection dissection, therefore, is purposeful. It is a deliberate. You're feeling the tissues as you go in the wrong and knowledge of the anatomy. The relationship of neurovascular bundles to all these muscles and nearby structures will give you that confidence to progress an operation and separate tissues deliberately, un respectfully. Because that is what dissection is about and over large areas. You can see that I can progress this operation very nicely, literally by stroking my sister in the cross. I felt a little bit of resistance against that. My sister's behind it. Tease it out. Is there anything in there separate. Put my sister's behind. Have a look. Nothing there is that a neurovascular bundle that might be a little vessel, a needle, a gate and the rest is fibrous tissue and this combination of nibble, nibble, scratch, scratch, stroke, stroke at all times, respecting the tissue with your left hand holding forceps and your dominant hand using the blade or the scissors appropriately. But you can only do that if you understand the field of the instruments. So there you have it. Now. What's interesting is that even with the laparoscopic survey, they took a video of the laproscopic operation, and they shared it with 10 professors who are experts in laparoscopic surgery. And those 10 experts were asked to grade the operation and predict which of those operations they watched was more likely to have complications. And all they looked at was the flow and rhythm of the operation. And they predicted, quite accurately, the outcome as far as complications was concerned as they looked at the handling the flu in the rhythm. But the astonishing fact is they took the same 10 videos and showed it to 10 lay people who are able to see the same. And this actually reached The New York Times because lay people, I could see the river, the flow and the handling. And remember when I first started cardiac surgery, the first instruction I had would just be quick. I think that's a nonsense statement. For most operations, Quick is not. There is be deliberate respect the tissues respect the field and my mantle in theater is no hesitation, deviation, interruption or repetition. Just one last thing. Diathermy not only for greats tissues, but the smoke generated from that has been shown to be carcinogenic. And there's an increasing awareness of this and the need to evacuate from theater or the field carcinogenic smoke. So it's another good reason for you not to burn everything inside, so it looks like it. Take away barbecued spare rib, going back to the carpenter and my orthopedic colleagues. One good way to think about bone and separating bone out and putting plates on. Of course, the bone is separated by periosteum and cutting into their periostem. You can strip it off the bone and separate the tissues, particularly the neurovascular bundles in relation to the ribs. And that is what you do with the thoracotomy. I hope this makes sense. This is a culmination of understanding how to hold your instruments, how to respect the instruments, and it all translates into respecting the tissues. If somebody ever says you just be quick, you're very welcome to refer them to me, and we could have a robust discussion as to why that is not the case. That's not to say you should do oral. There's no hesitation, deviation, interruption or repetition, and you're caressing the tissue of the type, thank you very much and joining me this evening very happy to take questions and sues Delightful compare, and we'll read out some of the comments because my computer screen is a meter away from me. So we've got a minute is a lot of compliments for you, David. Um, Action says this is the most wonderful way to understand surgery. I'm enjoying learning this way so much, Thank you for this. And then, um, John says I to, um, spell bound by this master class in basic surgery. The martial arts philosophy can be applied in many skills. And as I passed my advanced driving test on Saturday, age 80. Well done, John. It's never too late to learn, but equally it's much easier with the guidance of a true master of the art Professor Regan. Thank you, Ahmed says. Wow. So it's gone down really, really well. But if anyone has any questions, then please put them in and we'll ask them. And the last thing to say is that I want you to start dreaming up models of practice at home. So I've used salmon this evening. A sausage pork belly. We've used, uh, onions, garlic, lemons. It's a bit like a recipe, isn't it? But that's why we're home in our surgical skills. Now the audience is international, and I'd love to see your take on these models. So do take a picture. Send it in with a description of what it's doing, and I know Sara in Baghdad, sent in a lovely description of a boil potato and peeling the skin off a boil potato with forceps without tearing it. You put that on Twitter, hashtag black belt, Academy skills and hashtag medal. And you could be a recipient of your own set of instruments. So the best three is judged by medal and black Belt could receive in the post your own set of instruments. So there's a challenge for you. I'll put that actually in writing, but it's our third week of saying it is now up to you. Please enjoy thank you very much indeed,