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Hello. Good evening. Good afternoon. Good morning. Good day. Wherever you are in the world. Welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor with Imperial College London. I really want to say thank you to you the followers. 3283 on Facebook and 5016 on Instagram. But really a special thank you to medal. And Gabrielle, who's hosting behind the scenes this evening. We are able to reach so many of you across all countries tonight. We are represented by 20 countries and I appreciate the time zones Brunei, Bulgaria, Chechenya, Ghana, Greece, Hungary, island, Nigeria, Pakistan, Sudan, America and the UK. I'm extremely grateful. Thank you. I was delighted to be running the power aortic course of the weekend across and Hull. We have been running the periodic courses now for 23 years and this is really the basic skills of daughter of the carded courses that I've been teaching. It was a fabulous we can. But what I was particularly in credit training across the Manchester Liverpool David, who was on the Power Excellence course in September and joined the power of the aortic course November and you won the banana stitching competition for both the skills that he demonstrated were superb. I'm also delighted to be joined by John Taylor in Liverpool on the 26th of November as the Black Belt Academy goes to Liverpool again to teach the new generation. So this evening is called Get a Grip. But don't and I was looking up various sports and I looked up first of all, the rifle association, because I know to colleagues in Colleague survey are really quite senior in the National Rifle Association and looking at feel and the instrument that you're using the rifle association goes on to describe. You can feel the weight of the instrument. What I loved it followed that with you need to feel the weight of the responsibility of the instrument that you're holding in other words, the gun. But I think that also goes for your surgical tools, and you have to have a healthy respect for the potential or lethal potential that is in your hands and in instruments. Many surgical disciplines do not actually describe how you hold and use an instrument. This is a complete contrast. Too many sports. Take, for example, tennis. The palm of the hand is in the same plane as a racquet sagittal plane, so you can feel the shot initially to get the grip. You hold it in the non dominant hand and bring the dominant hand to it, as if to shake a hand and hold it with a V down the middle like shaking a hand. Gulf, they say. Put it in your non dominant hand, but laid diagonally across your fingers from the fifth finger to the index finger and gently fold your fingers around. Then you rotate you wrist. Such you can see the two knuckles and then fold the other hand over the top with the V s in the same direction. But what is important with this is that you're not gripping it. You do not grip the golf club. In fact, you encourage it to hold it like a tube of toothpaste with a lid off. So you're not squeezing it. I have to laugh because with the katana the grip as the golf club, and it's the lightness of touch with a gitana that actually helps you control this way. What's interesting also, with a hockey stick, you put the hockey stick on the ground with the toe upwards and apparently lay both your hands on the stick palm downwards with fingers touching the ground, and then your grip it in a handshake technique again. Everything. Every sport that use eonism instrument has no difficulty describing in detail how how you hold the instrument and why, and that comes to surgical instruments. You recognize these a pair of tongs for in the kitchen, and the way you hold them is to use the grip thumb on the top fingers underneath, and you're using your flexor muscles to grip, useful for tossing things in a frying pan that the hot and things on the barbecue as well. But that's not how you hold forceps. So if we go back to the beginning of your posture and how you stand, we said that you need to have your elbows by your side, the elbows down by your side shoulders down. And, yeah, it was flexed. The hands are Palmer flex as well and floppy. What you're actually doing is isolating the muscles of the hand, because in this position you cannot use any muscles of the shoulder. Girdle were up limb on the hands and some of the trainees on the course that was on in Hull at the weekend. We're into weightlifting and bodybuilding, and we're quite beefed up, and they were worried that it would affect the hard movement. It would if you lift heavy weights before you operate. But simply relaxing your arms putting in that position isolates the muscles of the hand. And the important thing is is to use that Axion. And as you have discussed before, the extension of the distal interphalangeal joint happens with the lumbrical. And as you remember, the lumbrical czar unique because they they're only muscles in the body. They then have a bony origin or a bone insertion, and what they do is extend the D. I. P joint. The opponents policies in there was for you to bring the pulp of the thumb together with the pulp of the fingers, and that makes it a unique and since feel is with a touch of the fingers with mark ourselves and medicinal corpuscles to maximize that simple movement there. Maximize issue. So what I'd suggest you do come over to our bottles is place the needle holded the forceps in your hand, bouncing in the first industrial space and on the middle finger and simply close your fingers around the forceps. And that is a vital importance. And why it is of vital importance is simply this. I have used forceps before coming on this evening, as you would inadvertently pick up the edge of the skin tooth, forceps, this side and DeBakey non term for sepsis side. The thing is that when I pinch, you'll see my fingernail is blanching. See that branches, and that's because I'm pinching and the pensions is using your flexor digitorum profundus. And for the average male, you are generating 30 newtons of force by pensions. So if you take the physics equation, pressure equals force over area and the forces Dirty Newtons. And if you look at the end of these forceps, I would say the use of that four step is maybe five millimeters squared, said 30 Newton's over five millimeters squared mathematics for you, you end up with a pressure of six times 10 to the six Newtons per meter squared. Six million. I forgot about the six in there, six million Newtons per meter squared. Look at that. If you think of a conversion to a tight pressure that we are more familiar with, this equates to 725 p s. I. So if you take a car pressure at about 30 it's 24 times. Look, car tire pressure. So it's not surprising. Therefore, when you look at this banana and I lift up the edge and I'm using a skin hook because that's what we should use, that pressure literally has and are focusing closer because this is vitally important that you understand that the pressure on this is full thickness and is damaged in histological studies on bowel and blood vessels demonstrating the same. And the problem is when using the forceps, you're focusing so much on stitching, you're forgetting that you are squeezing and crushing the tissue with the opposite hand. Now I left this bit of proline in here because it's not only the tissue because Proline is a monofilament. And if I grab that monofilament with my forceps and exert that amount of pressure on it. There's a potential, well, not potential. I had damaged that monofilament at that point, and there's a potential it can break. Rule number one Do Not squeeze. And that's why, when I'm teaching stitching, as we have been doing of the past series, we are focusing on stitching with a nondominant hand behind our back. What I often find in these models, as soon as I put the forceps in the stitching goes a ride. And that is because of three problems. The forceps should be used for traction to actually expose and counter track between suture one side the surgeon for holding the other side and the assistance. Four slipped. And there's a Mercedes Benz like sign holding traffic ating the forceps forces across your dissection area. So to practice your stitching on the models that I've demonstrated to date, we're going to add a new dimension, and I hope you can see here. I have placed some staples regularly around this banana, and as I go around, I am going to practice my place point rotate skills, deliver the needle now very important. As I said before the tissue is holding the needle in position for you to continue the delivery, pick it up and do it again. You do not use your forceps to deliver the needle because you'll ruin the pick up and the rotation. Okay, every time you pick it up, the forceps are there to help you retract and in your stitching exercise. Now put the staples in and counter tracked as you're going around. But now your non dominant hand holding the forceps is retracting. And as you stitch, do not corporal out and effectively. You should be holding stable opposite where you're a stitching focusing on that. But you see, my left hand is just retracting, and it's not involved in the stitching process, because grip and drift and drag are the major problems, and I find watching trainings do an operation, focus on stitching and crush all the tissues and tear them inadvertently because they focus is elsewhere. So we need to learn in practicing precision. When you need to go in, we need to be able to pick up, and we need to place objects and hold. So I have an arrangement of Straw's bendy straws on this plate and rice. Now you'll see that this rice, the length of the right, is wider and the Dimetol at the end of this draw. So I have to rotate this around and drop it in the great thing about this model. So you've got two pairs of forceps. You can practice this both hands at any one time, picking up a bit of rice, rotating around such the long axis is aligned with the Lumen, and you're dropping it in. I think this could be rather fun. Rather fun. Game with four forfeits. And how well can you pick up little bits of rice, drop them in hand and left hand into the colors. Now Charlie's in Sienna has put on a website a beautiful model well suggested to do this to music. And we spent 48 hours producing a video to music, demonstrating rice going into colored tubes and really increase the tempo as we went along to improve accuracy. A precision. The rice is quite solid, relatively easy to pick up another way of practicing, and I like organic material, raided the kitchen again. I have a selection of seeds. We have pepper, coriander, mustard and fennel. Now with these again, you reach in the mustard. Seeds are particularly awkward. They're small and they skid across. Pick them out. Pick out a pepper seed. Pick out a fennel seed, which are those come down so you can see it closer. Pick up fennel seed and drop it in a spoon. And these little simple exercises don't take much time to set up and to actually do. But doing this on a regular basis, I can promise you you'll suddenly find that your forceps skills are becoming more deliberate, more focused, more precise, particularly if you use both hands. And as I said, those mustard seeds are an absolute challenge. It was rather fun with him. This makes for lovely fragrance as well. So doing this and there's a sort of aromatherapy that goes with it again. Do it with a friend and we know buddy ing up with somebody to do some of these exercises. Colleague is interested in surgery, and once the practice budding up and challenging you at each other is one of the most effective ways of improving your skills and talking your way through it. So I do encourage you to do that and invite you to send me pictures of you bloodied up doing these simple exercises. Well, each of these exercises and I'm talking. I'm very conscious every week that I am getting totally engrossed in this to the extent that I forget that I've got an audience and I start focusing only on the task in front of me. But I think that's a mark of a good model that it engages you, engages your concentration, doing it. It's going to be slow at first. These models are supposed to be difficult. They're supposed to be difficult and see, I'm using a very fine needle forceps here and picking up something with a fine forceps like that, particularly a small mustard. See statuses around the bubble, and you have to be slow and deliberate because if I suddenly went there and granted, it would ricochet off around to continue the theme of foodstuffs and accuracy in decision. That's relatively easy because it is in a bowl. What I do love to represent working at that, I've taken the slice of a pepper, and if you see in that pepper, we have seeds at the bottom. So this is fun. I'm working in restricted space. I've got to pick up the seeds gently off the end like that, and then put the seed in the straw on the right hand side, I've got a green one on the left hand side. I got a red one port left and I'm picking these seeds off and literally dropping them in the straw. And if you wanted to make a competition of it, you can buddy up. And how many seeds can we accurately put on each side over a minute or 30 seconds? Now, I don't teach speed. What I want to teach is accuracy and precision. But you can at the same time, make this a fun interactive gain. This is also quite useful for those of you who used loops operating to practice your skills at depth on something fine and using lubes, these little flat seeds likewise can fly around the inside of this pepper if you don't pick them up properly. There you go. Drop it in just to show you the diameter there on that Letterman and that seed. There you go. That's the seed. That's alumin. There's not much space, is there? We need to be pretty accurate to drop it in. And there you go. I've dropped it out. Get up. And they'd go drop it in, sir. Practicing a skill of pickup and decision. Okay. But of course, we want lightness of touch. And I'd like to thank Surah in Baghdad who sent a video of her model of lightness of touch. In essence, she took a potato and boiled it, so it was soft. And the challenge for this model is to test your lightness of touch, the lightness of touch in taking the skin off this potato without tearing it and trying to get as much of it off as possible. You can see it's very thin and very fragile and would tear very, very easily if I'm not gentle. But this is not too dissimilar to some of the surgery that we do. Removing dead tissue off wet infected tissue, also removing dressings of tissue. Thank you. That's a lovely bitch again. In this model, I find myself getting engrossed and testing myself to see how much of the skin I can remove and you can see it is very fragile. But also, the great thing about us is how much you can actually take off without scraping the potato underneath. So really, I don't want to leave fluffy potato. And I don't want to have lots of potato on my forceps because it means that I'm not picking up the right, Mayors says. Not only finesse, but it's also lightness of touch, and it's giving you feedback on your skill. And I do commend you do it. And I think, Sorry, this was a lovely model you sent in, and I'm so pleased we can share it with the rest of the world. But this really is a challenging model. Can you take that off without terron skin underneath, some parts will be easy. In some parts. Be rather difficult. No, I have to laugh and smile at all those programs that use synthetic material. I have not come across a single model in 35 years of surgery that represents organic material and mimics what happens in real life and these simple morals you practice on these I can promise you real tissue Well, mm And note the way I'm holding it. I'm using that movement. I'm not pinching. That's a pinch with blanching with the fingernail, and I can see the trainee doing that, and I can see the fingernail blanching through the glove. And I know they're holding too tight. We in peculiar times for many reasons at the present moment. But I think you just to contemplate this. This is from the garden. I don't get it. Can I have Berries from a pirate tenses treat? But the territory isn't blossom. That's what I expect in water. Um, that's what I expect in spring. We won't go into discussion about climate and Infect and the hottest looked over everywhere. But this was peculiar, but I picked these for two reasons. Let's take the pedal. I'm sure you agree that the petal is probably one of the most delicate, beautiful and this charitable, delicate and beautiful organic material. And if I inadvertently grab that, there you go. You'll see on that pedal that I have seriously crushed it and it'll develop. But I have seriously damaged that petal. Just imagine if that was mucosa or endothelium. So what I need to do in this bottle is I'm trying to take the petals off from the base gently, each petal one by one. You might think of those days okay. Daisey's. We picked the pedals off and do I stand here and say, she loves me. She loves me not. Sorry. David. Could you move the flower slightly? Oh, that's perfect thing. Thanks very much. Uh, it's nice to just be watching his own focusing. I'm just picking up as I'm laughing to herself. She loves me. This is just test your precision skills to pick these perfect solution. Thanks. I think the potatoes sticking to my first step making it sticky. Just give you one a little bit. See? How is the test? So I don't try this again. Have forceps to stop up. Forceps to Bakkies supposedly noncrushing Nantou. Forceps. See, that would do it. Grab it. And I'm grabbing it. Yeah, that's right. That movement. Not even a pencil grip. And I'm sure you agree I left last decrease. Yeah. See that? Just imagine if that was your endothelial Let's endothelial so genocide. That's, um Yakuza massacre. Please, please be back. Can't get demographic itself. Just imagine that flexible. Then you wonder why graft at your phone. So worries. Previously I've used grapes Sometimes as they things available. Can you pick his Berries off these Berries? of to see soft and the break using these different models different models to practice the same skill. And again, I'd like to see examples from your countries of different things you use. See if I crush it too hard bag. I've crossed the belly. Yeah, I want to be able to lift this berry off. No, crushing it. Not so easy. Okay? Yeah. Crushing Crush it again. Impression. I hope you get the drift break. Sure. In this morning, I'm actually saying to myself, How many Berries do you think I could get off that was actually crushing? Uh, now I've got to feel, and that's the important thing now. But the feel of this have suddenly found I've got the right tension, the right feel. I'm now able to pill the Berries off more consistently and more reliable, reliably but the feel of this tissue, the fear of the very so we need to understand that forceps themselves a potentially leave for insurance And to show you the difference between the two forces we're gonna hold now on the two Communist forces trust. This is called absence. Toothpaste. Okay. What do you have? Is a little rats tooth at the tip and on the opposite side, into digitate ing that it's another rat. Now I was always astonished that my colleague and trainings to link used to forceps from doing Crawley arteries. But he used that to retract the tissue. Never, never, never. But he used that to grab it. Because you've seen on the banana that causes serious damage. The little spike lint enables alignment. See that there was alignment. I've always thought, Wouldn't it be rather fun to make that shop such If you press too hard, you get negative fever because it'll spike of the finger? No, that is there to lighten ends. The obstacle Is that what? The debate now the debate. He is a He's a famous heart. The expression. And he was at loggerheads. Colic, Cooley, Denton Cooley brought out a similar forceps, and these are called crushing or non tooth forceps. What you have done on that plane, a two rows, fine teeth and on the opposite side you have a single, uh, and they get, like, this interdigitate other scale. Uh, I hope, you know, appreciate can cause coverage, but holding the force it in the operating field is one other element to force it that you need to worry about God, quite spear something. And I have seen damage into a liver under lung with poor patrol or four sets, and that literally skewered That's to you to practice. Will feel It's very simply because you need to understand the weight of responsibility on new surgeon to handle the properly to ensure that you minimize the damage tissues because you respect the tissues you'll get that you're willing to hearing. That's an option better itself. And that's really what it's all about, because mastery isn't doing fancy stuff at all. This is focusing on the basics and getting the basics right all the time. Practice until your curriculum wrong, but you practice. Mindful. As I said, rifle Association said, mindful of weight responsibility, Do you have holding that instrument? So hope now on, you have respect the tissues a little bit more respect. We hold them. No, I've got simple movement. Pro nation Super Nation is still there. Uh, the upper limit's perfectly adapt to get your hand to move in any position. For those of you who are assisting in forceps of your first time and obviously nervous you're very welcome to get it. Second instrument or put a finger head as a fob. That's what Sun writers had used the fob to steady the brush. Japan As you're learning you're practicing, it's quite reasonable for you to take another forceps. Hold it there to steady your hands. To course, confidence and practiced any tremor will go to work. Twitter compare. Focus on right left hand now becomes useful. It does not interfere. Operation Great work and issues. I'm very happy to take any questions from you. Find a way. I am delighted that we've sent up the instruments, Those people who won the stitching competition watch this space. I'm going to run another competition shortly. Both I'm most of it invite you to send a pictures, and I will send set of instruments to that person who comes up with the most innovative model to to practice on for four steps. Skills post the picture. Hashtag black belt academy hashtag medal together. We'll look at the picture and decide I'll send you a set of instruments. Thank you very much indeed for joining the Black Belt Academy surgical skills this evening Cabriole, Do we have any questions for me. Uh, not this evening. It looks like everyone were so impressed with modules. Well, please, I do need to We do need to hear from. You do need to feedback as well. I hope this has made sense. I'm going to continue the story next week as we look at knife skills, which is the next next step. And I was going to call it under pressure. But it's not under pressure. It's called. Can you feel it? So we have left this evening on feel, uh, you feel good. Practice the field. We'll see you next week and I'll ask you again. Can you feel it? Thank you for joining the Black Belt Academy of Surgical Skills. Yeah. Pass the word around. Find a partner to practice with because you'll find your development of your skills markedly improves as you share the learning