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Hello. Good evening. Good afternoon. Good morning. Good day. Wherever you are in the world and thank you very much for joining the Back Mount Academy of Surgical Skills. If this is your first time to these sessions, welcome. I do encourage questions. And Gabrielle is kindly behind the scenes reading the screen and we'll ask the questions and we'll answer as we go along. So do feel free to interrupt if you're returning. I'm extremely grateful, as I am to the 3292 followers on Facebook and the 527 on Instagram. This evening is deliberately entitled, equal and opposite because we're going to focus on the principles of assisting many a junior Surgeons start out their career walking into theater with a degree of trepidation and called upon to assist but do not know what to do. The definition of the surgical assistant is someone who can provide continuous, competent and dedicated assistance under direct supervision of the surgeon in the operating theater. But I think with human factors and situational awareness today, there's more to it than meets the eye. The first thing you can do going into theater is understand the pathology. You're going to go and see what the operation and have some questions in mind. Surgeons are all delighted to describe the operation and questions, and as most of you said, you're going to go into theater and you can look and learn. But that looking and learning is not just watching. The process is understanding exactly what is being done, not to stand there blindly and take it off. One of the edge in Leeds was for the fifth year, trainees to tick a box to say they're being too cardiac theater well, with increased numbers in theater, you have an increased risk of infection, so I'm very happy for people to come into theater. But you need to go into theater with some questions in mind and and learning outcome of what you're going to get out of it. And the same applies with the system. And the most powerful question you can ask of a surgeon is tell me why now. These are my annuals that I had growing up when my at my son's age, who's kindly assisting me this evening do come in, Alistair. This is my son, Alistair, and for those of you who have been watching this series? Well, no. We started with him at this height, and now he's a good two inches taller than me. And the funny thing is that I've had to tie the lamp shade up, says she. He doesn't bang his head. There are two interesting assisting stories. Robert Liston was a surgeon born in 17 94 and died in 18 47 and he was known as the fastest surgeon in the West. You might recall my first instruction in theater from Stephen Westby was just be quick. But Robert Liston did amputations. And the quicker you were, the less the pain and the less the patient had to endure. And he would walk in with two assistants who quite burly people in bloody gowns. And he said, Time E gentlemen, that would hold the patient down as he whipped out a knife and slashed through the tissues, at which point one assistant had to apply a tourniquet to the limb. He got out of sore and then continued to slashing. The most famous mishap was that in doing so, he took off the fingers of the assistant and as he Li, he slashed to the coat of another look. Er, the onlooker died of fright, thinking that he'd been stabbed, the assistant and the patient died of sepsis and is probably the only the 300% mortality ever recorded. Not many of you would know that Maria Montessori, who was the first female Italian doctor in Italy. She was born in 18 70 died in 1952 and is better known, I suppose, for a Montessori method of education emphasizing child centric practical learning. She started her career as an assistant in Florence. Now, practical, assistant centric learning is what we're offering in this session, and there's some simple rules to abide by. And today we're going to done. By the way, here's a balloon for last week's not time session. I'm just only just come down. We can do it on an elastic tape over ourselves. Have you cut that? No, I haven't. Yeah. Whoopsie for the big. Yeah, it's got to be at Loophole. Yeah, it's a planned operation. There you go. You popped up behind you. So why do we put this on with these spaces? It's very simple because I call them the rules. of the road. You would not cross the midline of the road, and as you go around the bend, you would keep to your side of the road as well. And assisting in the first principle is like a dance per vein. If I step the left, my assistant steps to the left and our shoulders are parallel, the midline represented on the operative field, but his Christmas decoration maintained between us. If I turn to the right, my assistant turns to the right and you can see that the midline has also changed. In essence, to bring these closer, the surgeon is going to be operating with inside the operative field. Outside the opera to field is usually demarcated by the retractors and that systems hands are outside the retractor, complementing the surgeon's hands. Working on the inside, there's another midline that you should not cross, and that's very simply your own midline. So if you have an instrument in your right hand, hit the midline, you passed your left hand and vice versa. Now that becomes a little bit more complicated for instruments, or you're following with one hand and holding tissue with forceps and the other you swap your hands over. So at no stage during this procedure, are you crossing your midline or you're working at odds? No, There's one area between the scrub nurse and the surgeon and incarnate surgery. My scrub nurse was usually to the right. Needles and blades were passed from the scrub nurse to the surgeon. So this quadrant, to my right on my operator of hand, is an area a bit like the landing strip at an airport. This is where the sharp instruments and things are coming in. Do not ever put your hand in that area because although the surgeon should not be slashing, as in, Robert Liston did, inadvertently putting a hand in this area when the surgeon's concentrating and taking instruments end up being stopped. So the other important thing about your system is that if you note amnesty is now two inches taller than me, and we've discussed at the very beginning of the Black Belt Academy posture is biting importance. 27% of surgeons end up with musculoskeletal problems because they're not standing properly, but you both have to stand properly for your limbs to feel comfortable in relaxed, shoulders down, elbows by the side Palmer Flex position, and that means that the surgeon and the assistant need to work out the ideal height Now. Michael trained with me for six months, and he was 6 ft four, and I was the first surgeon ever to stand on a stool to allow him to assist comfortable height. And as I'm looking at my son now, I might consider next time putting a two inch platform to stand on your assistant. Not only is providing dedicated, conscientious care throughout the operation, there's another very important principle that I'll demonstrate here if we take an operative field. We're both looking at it at depth. So I'm on this side and we're staring into this operative field at depth. And if I'm looking at it and peering down into the field, which of the camera angles working Very well. If I'm looking at it peering down into the field like that, I'm going to stand here and say, I can see orange and white, but I'm still looking at this Rubex kub from his side. What color's can You blew yo and right, and he can't see any orange in white. And if you look at the angle between his view. In my view, you effectively got 90 degrees, and that 90 degrees gives you that three D perception and is why we take all X rays at 90 degrees. So your assistant standing opposite is giving you a different perspective and a different vision. And this is particularly important if you're operating your depth, where depth perception can be lost under bright lights, and you need somebody from Alistair Side to be pointing out the different colors that you can see. So that's what I was saying on my side. And that's what he was saying on his side. Two totally different things. I also ask that my assistant in cardiac surgery First Assistant was because I want them to see the anastomosis at least as well as I do, if not better, in correct me if I'm wrong. The importance of the assistant extends beyond looking and correcting, and as an assistant you might feel a little reticent to ask the surgeon or point out when something's wrong. And when I started, I was working with Professor Pepper at the Brompton Hospital, seeing a homograft done for the first s templates valve done. The first time, and I asked him halfway through the operation. Could you actually tell me the orientation of this valve? Yes, yes, yes, was replies. We continued operating. I was seriously concerned because I felt the Post were including the coronaries. But we continued 10 minutes later, having put the valve down, he said, I understand why you have asked that question now because we have to take the valve out and re orientated to avoid the Korea arteries and the purse. So imagine is a bit of material, and the first function of any a system is to be able to triangulate. So Alice Step is picking up the other corners of triangle, and the triangle is actually pulled tort. This means that I can dissect along that blue line, or I can dissect along the black line because the forces and the traction and counter traction have triangulated the tissue. So if I swap hands and pick up the other side, answer is intuitively picking up the other side, maintaining the traction and counter traction that is absolutely necessary for operating. But even when you're stitching and I pick up a stitch and I say please follow and the following is important because you'll see that this stitch and all mono filaments have memory. And the problem is is that you will end up tripping suture. The idea behind the assistant is to hold the future as electoral hold and not a pool, as gentleman Jim Monroe used to say. But the suture itself I hope you can see is offering traction as well. Now, with that in place, I'm going to hold tissue to maintain attraction analysis, picking up the other triangle. And now just take the loop out. Alister, please. Yet to come back further. There you go. Not so far, Thank you. So it should be 2/5 3 5th such that my operating length does not have any loops in it and the principle of all century is stitched towards yourself. Okay, so I'm going to be coming down stitching towards myself. But the traction and counter traction in that triangle has actually maintained If it's coming down the other side, Alastair is automatically swapping hands. I've moved to the right. Honest has moved to the right to maintain the midline between us. He swapped hands to now hold the string often the direction I've taken it and providing traction with his right hand as a nasty itch down the other side. So we'll go back again to emphasize that and without asking, Alice is picked up the tension again, and that is the fundamental element of assisting when stitching is to maintain that triangle. And this is a gross example. But the triangle of retraction, that man, it was me. Now to continue my settling down the side, I'll swap over once again, and your note that this now becomes a very dynamic process I've swapped over and I'm stitching down the blue line. Well done. That was excellent. Excellent. But this is important in Suta ring when you're changing direction all the time and you'll be familiar with the banana model that we extol in the Black Mountain Academy because it gives you fabulous feedback. But this is an adoption of it. What you're seeing is I've put staples around the whole of Lebanon to the idea is the four steps does not deliver suture. The tissue holds the needle. But when I protraction in on one side, okay, his follow honesty is providing equal and opposite traction holding. I've been doing so enables me to now start messages. So if he's holding it, we're holding the future with a finger and thumb on pan out, the finger and thumb are pointing in the direction sutures come out. Okay, so I'm taking it up finger and thumb in the direction it's taken out. So hold their again to fit 3/5. Please hold and just take a little bit of that psych out gift, and I'm going to be holding. So as I'm talking to Alistair, I'm also asking him to maintain the tension. So do not do, please. So I'm taking up the tension. Can you maintain that tension on that future as I go round? It's a lateral hold and not a pool. Now you will remember Greg around in the circle at this point, here are stitching into my right shoulder and I'm standing on my right leg. That is the most difficult stitch in surgery, so I'm going to go into my left leg now, and Alistair is automatically moved to his left as well, and is following with his other hand finger and thumb. Two walls where I've taken suture. Uh, and it's holding the staple equal and opposite providing the retraction. So as I am now straightening up and coming around, my stance is moving to a balance stance on both legs. 50 50 was interesting in karate. Many of those dances are actually described in percentages, and there Alice is automatically picked up the staple opposite. Important to keep the attention maintained for the Black Belt Academy competitions. I usually get people to do this themselves without an assistant, and it is awfully difficult. But it makes you think having an assistant following you and anticipating your moods is very, very comfortable. And you see, I'm now opposite that four. Alice Alice has moved to his left leg rights for pants here? Not just yet. All not just yet. Good thinking. Not just yet. But you are anticipating it, aren't you? And there you go. Uh, it's quite right and is so intense. Fantastic. In describing this, he's already assumed the position directly opposite where I am going to retract. Take the loop out for me. Thank you. Keep maintain the tension. So the other thing I do when testing people on this model, I would ask him How is your Chinese lesson this evening? Alastair. Not bad. But as he talks, I want him not only to pay attention to the tension, but actually be able to maintain a conversation at the same time. Attention being maintained. Now, Isn't it a pleasure to operate with somebody holding the suture such that you're not tripping over and note as we did that Alsa picked. Sit on the staples, I hope you noted he didn't creak any of them out at all. Now it was delivered and kind, or you're being honest out. But that that's still in the banana. All right, But what is teaching you as an assistant is to follow, but also maintain your attention of the future and maintain the tension on the tissue equal and opposite. So imagine these are all triangles. And, of course, a bit of circle theory. From the diagonal to the edge. Always substance. The circumference of 90 degrees, right? I promised Alistair he could operate. So we're going to bring you another one. So, Alistair, you've got a knife. You've got a scissors. Let's operate to international. So Yes, Yes, yes, yes. So we're gonna come to that. And the thing about a skilled surgeon Good surgeons make good assistance and vice versa. So when I'm taking a trainee through an operation, I can use my forceps and say, Develop their play now among there. Wow. Do you see that? Answers helped me before. And look at the way he's done brushing that off. But I'm intuitively following that. Keep good. Very good. And I can actually help by putting my forceps underneath. And you might want to cut that with a pair of scissors. Huh? Uh, good, Hardly. I'm just going to take this out again. Just look at the way we pick out the scissors between the thumb ring middle finger index finger extended down. Beautiful, beautiful holding of the scissors. And the system needs to be competent as well. And holding instruments Note that we've only opened it up enough to cut, and then we go back to the knife. Let's continue seeing what we can do here. You provide traction and counter traction as in the triangle. You probably need to do a bit of scissors on that a bit, don't you? Good. Tell me any questions, Gabriel. Not at the moment. I just through an operation, when they have not done it before. I'd like to think this is almost but it's much better than robotic surgery, actually, because I have a very intelligent surgeon on the other end of this following my automatic cues. Okay, You might want to get a bit of scissors to that and just go sit up. You can see there. You've got a little perhaps a tissue, baby, you're nibbling along that very good. Wow. Yes. In the same way of good assistant instills confidence. The surgeon a good surgeon assisting interesting. It still has confidence, Um, in the learning surgeon as well. So let's try a different plane. Do you want to take the scissors down to that plane? Maitresse isn't Let's let's say, God, this this, uh, muscle here as usual. So the argument separate, uh, open and separate, uh, models. And I think we can cut through that little bit there. Good. Good. You can do that. That plane along there, all that's down to the bone, isn't it? It's if you develop that plane. Lovely use of the knife. Very delicate. Okay. All the time. I'm We haven't planned where we're going, but I'm applying the principles, attraction and counter traction all the time. Well, not side. What? Each time I am trying to set it up. That thought as well. You know what? Of course, we would be like gating vessels as we can. What I'm doing is providing traction and counter traction and facilitating the dissection. Okay, that's going to, uh, do that lot. You see a plane tissue plane developing. I love the way you usually one life. It's the most tissue plane. I'm going to focus in a little bit more. How is tissue playing? No. We'll talk to you that you can cut your scissors or life. I hope you appreciate as we have actually taken this chicken thigh apart, but we're taking each of the muscles off. Cut that property scissors. And I'm able to direct the operation as a surgeon and take my training through the stages by helping him realize the tissue planes. I can do that with a little bit of encouragement. One dissection with my forceps. Yeah, super. And we've really and truly, almost full it'd this with the chicken, taking off the individual as individuals of muscle. I think that travelers actually yeah, he does. He does very well. Yeah, right, Continue. You look like you've joined. It was all about traction and cap attraction. Now, when you relaxed in the system and the operations routine, we can have conversations and talk about all sorts of things. Plans for Christmas, Obviously, when things get tough, difficult the conversation, quiet things with focus. But this all this becomes automatic with practice. What does mean? They have good conversations, uninterrupted a theater and you'll find, and I've really enjoyed over my years, working with amazing people and having interesting conversations at the table. Professor might be Yaku, used to play music in theater, come through that and classical music and would quiz you about the composer conductor and the player of his favorite pieces. Jacqueline Dupree was one of them. Cello under present Daniel Bamboo Spine. And we learned these to be honest before we went in theater with Professor Yakubu because this was part of favorite conversations. Then he had gain an operation. It's an opportunity for you to get to know the surgeon are more relaxed and informal. That is, but be protective and some questions. So lastly, uh, you want to see if you can take some of the skin off with a pair of scissors. David, could you re focus the camera a little bit, please? Yeah. Let's see what we can do. Do you want to start developing a plane underneath the skin here? Alistair didn't know he's going to get this challenge. So do you want to start developing the plane underneath the skin? Continuated underneath the skin and openness is himself. I don't think traction in tract count attraction would be very helpful here. Okay, that's it. I'm going to take that. Okay. All right. Thank you. So I'm assisting the surgeon by exposing the tissue planes in some respects, Form is conducting the operation as we get around. And this is where good surgeons make good assistance because they can bring their knowledge of anatomy, their knowledge of the operation of seizure Tibet. And I think that forms a very good platform for teaching surgical skills. I think you'll appreciate that. Alice has demonstrated this evening some exemplary knife skills, social skills and with very little instruction, understood the principles of assistant. It is a dynamic process. It means that you're focusing, and it's a rhythm and a flow. I often think of it I call it a dance pervade, but I often think of it as the surgeon and the first assistant, our dance partners and really as an assistant. You should not be stepping on the surgeons toes, but the whole flow and movement choreographed together. The trainee surgeon or the assistant needs to have the courage to speak up. You don't say Oy, that looks stupid, but simple phrases like, Can you explain what you're doing and why? Or could you point out the anatomy of this area? What are the principles behind what you're doing? And a simple, appreciative inquiry will endear you to the surgeon as well and enable you to get more hands on. The last thing we said previously is the assistant often is cutting the sutures. So we have been berated about using Makindo scissors to cut sutures, and I believe there was a paper out that showed on fine sutures. It does not blunt the scissors that the assistant needs to be comfortable using all the tools that we have described so far in the Black Belt Academy. Often will you hold the knife as assistant, but you always hold the forceps and remember the forceps can crush. You're applying traction and counter traction. You're often called upon to use the scissors, and the scissors are opened up no more than necessary to cut the suture. This must be done deliberately. Scissors into the field. Open cut, withdraw from the field. Yes, you've got to tremor or nervous. Use a pair of forceps as a fob and balance your scissors on there to hold. Lastly, the assistants hands are often the best form of retractor. There's some amazing retractors out. They're made of metal, but the metal itself, from the sharp edges can cause problems. The systems hand with a swab can provide good and gentle retraction that was in big open operations. Nowadays it's laproscopic, and one a little bit asked to do is hold the camera, and that becomes another skill in itself. And in the new year, we'll be talking about basic laproscopic skills as we build on the principles of the Black Belt Academy. Now I want to remind you that there is a competition. We would like to see a picture of the most innovative model that you're using to home your surgical skills. If you hashtag the black about Academy of Surgical Skills and Medal before the 16th of October. You, too, can win a set of practice instruments so you can hone your skills. Alison and I are visiting family in Cape Town over the next two weeks, and the festive season will be upon us. We will return on the Fourth of January 2023. Do look at the calendar and medal are populated with a whole series of lectures and demonstrations, and we'll be introducing new models in the new year. I have also, for the next two weeks have prerecorded interviews, one with a mentor friend who spent 40 years in cardiac surgery, who has many stories to tell, and the other with colleague and sensei John Taylor, who's 1/5 down in karate, who will draw upon the parallels and metaphors that we've been using the Black Belt Academy. Alice and I will be training tomorrow evening and Wednesday evening and on Saturday, and part of our training is cured drills where we practice defense encounter defense. Above all we equal and we're partners and we're standing opposite, and that is where the safety of an operation comes in. Thank you very much indeed for your detention, Gabrielle, do we have any questions? Not a question, but we do have a great comment from Chris. Caddy. Um, so he's saying that we watch the masterclass and how to encourage trainee surgeon to undertake an operation simply by assisting them using encouragement and blunt dissection with forceps. Bravo, Um, and then some thank use as well from other, uh, thank you very much. And I think teaching and training and assisting and first assistant and respecting the roles of fundamental to surgical skill education. Thank you very much for attending Gabrielle. Thank you very much for hosting this evening. Ladies and gentlemen, thank you for joining us from far in a field over the festive season. Wish you well be safe. Have a happy time and we'll see you on the Fourth of January.