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Hello. Good evening. Good day. Good morning. Good afternoon, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is Dave Dorian. I'm a retired cardiac surgeon in Yorkshire in the United Kingdom. I am the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College London. If this is your first time. Welcome. And thank you for joining. You're starting in just the perfect place as you know, with tonight, we're going to get to the point. Thank you for all those who are returning for 4237 on Facebook and the 679 on Instagram, Chris Caddy, my fellow sense and I visited the University of Buckingham to deliver a stitching course. And we literally went bananas. What was interesting at the course, we had a whole lot of writer needle holders and we asked them to pick up the needle holder and we had a range of grips from index finger and thumb, gripping it like that middle finger and thumb ringing in some and few. Actually, extended the index finger down. Nobody knew how to hold the needle holder in this manner, which is necessary for the perfect rotation. We will come to that at the end of our session talking about needles. What's interesting that a another sensor John Taylor was sent this book and he was given it by the author at an orthopedic meeting. Earlier on this year, I sent for it on Amazon. It arrived, I read it in the weekend and I was blown away. It was published at the end of 2022. But what they're saying in here is what I've been saying for a long time. Now, Melvin Macklin is an associate professor at Saint Louis University and a plastic surgeon and Wendell is an orthopedic surgeon, both who've been training in National teams in martial arts. And that's why they say there's an intersection between martial arts and surgery with most of the sports, whether it's golf or football or rugby, you play them, but martial arts, you study and you need to improve over time. And that is the way the title of the book. So this evening, we're gonna be talking about needles. These are handmade embroidery needles made of steel. And what's interesting in the riddle of steel. The first chapter of Macklin's book, he said the only way to heal is with cold steel. And I thought of that and thought of the needle. I don't know if you're familiar with that film, Conan the barbarian. But Conan's father said to him, the secret of steel has always carried with it mystery. You must learn its riddle, you must learn its discipline. I think that is very true about learning the riddle and discipline of surgery. But the other part of the way in the riddle of steel is summarized by the founder of Ado Mohe Oshi. And I think this applies to character. Iron is full of impurities that weaken it and through forging it, it becomes steel and is transformed into a razor sharp sword. Human beings develop in the same fashion and I think surgeons likewise develop because it is a fusion of mindset and will as well as technical skill. Now, the first pointed objects that were used to pierce tissues were actually found in the Tsuru caves in South Africa 61,000 years ago. Later on, the bones of birds again, pointed were found in the in the caves in Russia about 50,000 years ago. And bone needles were found in the Potto caves in Slovenia. Bone ivory was used in the Zanu site in the Liaoning Province in China 30,000 years ago. And ivory was used in the Kinsky Pro Province in Russia about 28,000 years ago. But needles with eyes were found about 17,500 years ago. And Neolithic measles are being found in, in Turkey. Now, the idea of taking something sharp and piercing a skin to carry a piece of twine to join two bits of skin together to make clothes clearly was a universal need across Russia, Turkey, Slovenia, China. It's only when metal came in that things started to progress. And copper was used 4400 BC in the Garda in Egypt. And as you know, with wire, you can bend it over the end and twist it to make an eye to pull thread through iron. Needles were found in Bavaria in 300 BC. But it was only when the art of forging iron came from China in the 10th century that the harding of iron happened in Europe. It started in Spain in the Catalan furnaces and rapidly progressed to Germany and France. Interestingly, Leonardo Da Vinci made an instrument and machine to point these bits of wire into needles. In 1755 the first ever patent for the eye of a needle was actually registered. And in 1811, they made a machine to press out the holes for an eye. And I didn't know that the sewing machine was actually invented in 1845 by Las Howe and singer. What's interesting though is that one of the biggest needle producers in the world in the 19th century was in a town called Reddit in the United Kingdom. And they produced all the needles fish hooks and by the way, they also did motorcycle springs. But what they had was a number of needle me makers around the country and they formed the guild of needle makers, something similar actually happened in Japan. And there's the festival of the broken needle from the 16 100s. But it's the advent of steel that has actually made a significant difference to the production of needle because you could take something and make it thinner and thinner and thinner, yet maintain its strength. And the strongest alloy currently used on the market today is by Ethicon who actually combine tungsten and iridium in their own recipe. And they make their own steel and years about the equivalent of 100 and six cars a year to make needles in their factories around the globe. The thread that goes with it over a year, the total amount could probably go around the globe 17 times. So this is an enormous business and it's important to get the needle right. And what are the principles of the needle? Well, first of all, it's gotta pierce whatever you're pushing it through. And those caveman, we're using it on skins and clothes to actually bring it together. It's gonna be sharp to be able to p it, it needs to be able to penetrate even the thickest tissues. And of course, in surgery, sometimes there's very fibrous and periostin, it needs to be made of a, a material that is rigid but ductile. So there's a degree of flexibility. The needle itself needs to be a stable composition that doesn't corrode and corrosion resistance, which we know steel is. But what do we want from the perfect needle? The perfect needle should carry the thread perfectly through the tissue, leaving no space whatsoever that minimizes trauma, does not cut anything and spreads the tissue but burrowing through the tissue, carrying a thread. But clearly there are different types of tissues. And therefore, the design of the needle has evolved with improved metallurgy and at the same time, improved material for using for closing wounds no longer the sinews and animal hides. So I'd like to just take you to the overhead camera and talk you through the various principles of the needle, which I hadn't quite appreciated myself until I started doing research for this. But what's interesting also, I found some questions that not even global ethic can answer at the present moment. And if you know the answer, please share that with us. So let's come over and have a look at a needle. So what I've got represented here is a needle and there are three parts. Now, first of all, we will recognize the straight needle, the straight needle still isn't news today unused effectively for skin stitches. I prefer this for skin stitches, but you'll appreciate pushing this through. Actually, there's an art and it's quite hard. So it's not surprising with a needle taking it through tissue and embroidery. There was a whole art in this with crochet, embroidery and thimbles and lovely embroidered boxes to store your needles and thimbles, the straight needle is in use, but you see the eye at the end. So that's where we're gonna start. We're gonna start our story at the end. First thing to notice that all these needles are curved and the reason they curved is if I put something there to stitch a depth, I cannot move the needle across that diameter depth. So as you quite rightly said, the ergonomics of stitching and the maneuverability of the needle was much improved by curving it because there's no way I can actually stitch a straight needle in that place. But of course, as soon as you did that, then you needed a needle holder to hold the needle to do that stitch the smaller hole, the smaller the needle. So as you can see here, I've got a 60 there 5 O2 0 and some of these larger needles I actually handheld. But if we look at the back end of the needle and the back end of the needle is called the suage. Now, this is a French term. So why we don't use eyes any longer? Now, you can see the eye of the needle. Yeah, is imagine fiddling trying to put a bit of cotton through that or thread through that. And indeed, in early surgery, that's exactly what happened. And you had an eye and then later on, there were two eyes and then there's a class like mechanism where you put the thread in and clasp it together. Swage is the back end where the thread is joining the needle. And the swage is a French term effectively. It was described in 1948 by the tolerant group who use this to join pieces of wire cable together. And essentially they had a cylinder, they put the wire cable in and then compressed it to hold it together, the forces like that. No. When did surgical needles start developing a swage that I do not have the answer for. However, in the beginning, what they did was ensure that the end of the needle was slightly thicker and with fines used to drill holes in the end such that they could put the suture in and glue it in place or crimp it as in like that in a swage. And you can appreciate that this end, which really was the distal third of some needles, but quite a significant bit was crimped and holding that suture. So that meant the diameter of this bit is the biggest part of the needle. What's interesting is that Ethicon now don't actually drill this. They use high powered lasers to literally take a cavity out of the end of the needle. And these high powered lasers can make holes in the smallest of needles in the back end at about six per second. And they've come out with a new needle where the swage is no more than the diameter of the body of the needle, which again is a testament to the incredible technology that goes into the development of this. So I'm gonna just take these needles off for a second and point out as we look before I do that, as we look at the curves that all of them are on a curve, the whole thing is on a curve and the length of the needle is actually from the tip, which is that point to the wage. And that length is part of a circle, but it's not the diameter, it's the cord and this is actually cord, the cord length of the needle. No, some of these ah under half, some of them are more than half. And this is again another interesting question because I did say why are needles described in eights? So an eight curve, a quarter is literally a quarter curve like that. 12, two, out of four, three eights, a needle is a bit further on the curve, 123. And then the five eights needle goes all the way around to half there, there's a half circle and a five eights needle there. So those are the standard curved needles that we see. And really the development of the curve needle is the, the deeper you go, the more curve that you need and the more curve you need to actually curve the needle such that the point comes out clearly. And you can see it, there are two other different types of needles which is part of these, there's AJ shape which is on a curve, but it starts off straight and then curves like that. And there's also a compound needle which it starts on a curve and then curves sharply like that. And again, those have specific uses, but in general, they are not the uses that we require. The size of the needle really is determined by the size of the suture that you want to use. So the smaller and thinner needles for fine microsurgery and when you put a zero after the number 50 is more zeros. Therefore, thinner, four zeros is less three zeros is less two zeros. Once you get to zero, then it gets bigger by 1234 and up. So the size of the needle is dependent on what you want to stitch and the suture material you use. And the suture material you use is gonna be dependent on how long that material takes to heal and repair itself and how long you need tensile strength. No, although this is depicted round and I'm just going to take my needles up at the present moment in time and move them out because I don't want them on in the way and I'll take that one out and we'll come back to the pick up in a moment. So we're looking at the body of the needle. Well, the thing is, is that there's simple physics involved here. In order to pick up something fine, you obviously need fine, a fine tooth. Yeah, to actually hold, to hold the needle, the bigger the needle, the bigger the jaws. But just think of this as a pivot, that's a pivot there. And if you think of force times distance from holding it there to there and force times distance with little force, you can apply a lot of force in the jaws and to improve the holding. Many needle holders nowadays have got a tungsten insert, tungsten carbide insert or depending on some fine sutures, even a dusting of diamond dust to hold the body of the needle to stop moving. Cos when you're using it, you don't want it moving around or giving you problems using it. So therefore, in general, the body of the needle is not perfectly round. In fact, what they've done is flattened it slightly and they flattened it slightly like that in order for you to actually secure the needle in the tip. And if you think of the force times distance, the further it is and the closer to the tip, it is the more the force of the needle being held and less likely for it to move around. So the first thing to say, and again, this is relevant to the how you grip it and hold it, the force holding the needle there is significantly less than the force holding the needle there and will come back to the pick up and angles later on. So the working part of the needle for your pick up is this middle third. And really, we should be picking up the needle just beyond the halfway at that point. But I think it's just beyond the halfway, but that's related to your ability to pronate the needle back. So bring the needle all the way back in this direction, such as this pointing perpendicularly down into what you want to do. And obviously, the pronation is variable on individuals. Some people are more flexible and probably can hold it further back. But the further back, you hold it towards the, the less likely that you are going to be able to point the needle directly into what you want to do, which now brings this on to the tips. So the first one is no point in a simple blunt end and the simple blunt end, you can imagine it just pushing through the tissues is not. And there's a dilator really. And you're using this when you're dealing with soft fiber tissue that would rip in tear. And this dilation is very useful when stitching solid organs like the kidney, the spleen or the liver or any other soft fable tissue. As Leonardo did in vent, he was able to make a point. So we represent that with a circle and we have a point at the top. So this is the next perfect thing you've got something that's pointy and sharp and can push and penetrate through tissues. And this is where you want that dilation to occur, but minimal damage to the tissues around such that there's no leak at all. And in this situation, you would look at that for coronary vessels, gi tract mucosa, the juror and sometimes you're using it for soft skin fascia and causing minimal damage. So these two are considered effectively, although that's pointy, those are effectively called blunt needles. So we will then progress on to the conventional cutting needle. The conventional cutting needle, as you can see here is it represented as a cross section. Imagine that cross section through there is represented in a triangular form, not only is this pointy but it's triangular. So now this triangle is actually cutting three directions out to the sides and up to the top. So up to the top is there. So this is on the inside. So when you're taking the needle through the tissue, it's possible you are tearing more because of your rotation and cutting more, but also possible that you will cut the suture itself. And of course, this is going through really tough tissue and you'll find that the nose and oral surgeons use a lot of cutting sutures because of the nature of the tissue that they are going through to prevent that cutting. The opposite is what's called a reverse cutting needle. So the flat side is there on the top and the rest is fashioned. So now we're cutting this direction there and we're cutting out to the sides. And again, these are very, very good, very, very good needles, very powerful needles. And this is a sternal needle. And I'll see if we can focus down on the sternal wire needle because the sternal wire needle is one that I use regularly. So you can see the bevel and point, it's sharp on the outside, it's blunt on the inside, but the triangular shape is carried all the way through into the body. And in this case, the body itself is triangular two and that is actually quite useful holding it because it fits with the grooves. The other thing to say about some of the needles and big ones in particular is that the body of the needle itself might have grooves on it to help match the grooves on your needle holder. But there you go is the reverse cutting on the outside. And that is fantastic for cutting through tendons and fascial layers. But of course, it's kind of crude. So what they've done and certainly with the advent of alloys is refined the cutting. So now we have different tips altogether and we'll draw this one and you've got a Mercedes Benz type sign in the middle. So it's a pointy at the tip, but just cutting on the three edges and these taper cuts are, the cut is probably to the first millimeter at the tip, but then it goes to round. Whereas these, the blade continues along the whole of the point and that's the point. That's the tip. All of that is a fashioned end of the point. A bit like my katana. So that would be a taper cut. And there are different versions of this and upside down one as you see there, they actually get more sophisticated where it's a smaller, sorry, David. Could you zoom it out a little bit if you draw? I beg your pardon. Yeah. So the, the taper cut Mercedes Benz sign into round. So that's on the tip. The inverse of that taper cut again, inverse Mercedes Benz. But now they can make the cut even finer. So it's just at the point and these taper cap needles. Oh, fantastic. And I'll show you now that's it 60 curling. It's a six taper cut confined to the point only. So it's gonna have minimal tearing effect around. And one of my favorite sutures for dealing with calcified coronary vessels. That's the 60 and that is a point and that's the cut. So you choose your needle depending on the tissue that you're using. I'll show you examples of these in a second. So they have different forms as the ability to trim and cut these fine needles. There's another one, it's not three, it's cut into four. It's called the premium cut. And now the shaping the ends into a diamond cut. So all of these are different reflections of the tips of needles and they're really apply to all needles of all sizes and you choose them according to the tissue that you are. Excuse me, for stitching. The last of these, which is a sort of a spatula cut. This is a trapezoid shape like that. And imagine you've got a blunt end at the end like that trapezoid. And what that's doing is as it's going through the tissues, it's separating the tissues. But cutting side to side, the cutting is blunt there, it's blunt there, but it's cutting side to side. And this is a common needle used in ophthalmic surgery when you going through the fascial layers of the eye, but you don't want to cut them, you just want to separate the fascial layers themselves. So the principles of needles are all the same. And when you look at a box of needles or ask for a needle, you should really be thinking, what type of tissue are you cutting? What type of tissue are you going to be using? So they all come in standard packs and we'll just give you some examples. Here. There is a fiber and you can see that it's round bodied 17 millimeters is the cord length from tip tou and that is the point and it's 50 there's a 20 which we know is bigger. Again, it's to the point. This time, the cord length is 26 millimeters. But if you look at the circle that is 5/8 that's a half circle there. And that's 3/8 circle half three eights. Here again is the sixer with a point is 9.3 millimeters long and it's at three eights. This one is a reverse cutting 26 centimeters there, reverse cutting. And again, 3/8 here we have the Mercedes Benz sign. But within the circle is a fine taper cut and the length of that is 16 millimeters. So all of these needles are carrying threads that you have decided are useful and purposeful for the respected tissue. And too often needles are actually just opened on the tray and we don't prescribe what needles we require. So the pickup of the needle, the pick up of the needle is vitally important. And the three important rules in the same way that I am actually picking this needle up against the palp of my finger. I can't stand myself doing that, but I want to actually feel that there's no space between the tip of the finger tip of the needle holder and the shaft. So in other words, I wanted a maximum force. I want to just be on the halfway. Yeah, just beyond the halfway. And the third one, I'll demonstrate in slides is the angle. But I before I demonstrate the angle. Well, I'll do that. Now, can we just show the slides, please? Gabrielle. Yes, of course. Ok. So the first one is all now. So I've got the needle at the end as well. If my elbow and wrist at the same level and there's no displaced vertical displacement between my wrist and the elbow by all means, make sure that your needle is at 90 degrees because I can put the needle down and you can see and I'll show it on a bit of there you go. Can you see that? Go back to the the needle? The belly pushes that away. Ok. So if you go to the next slide, Gabriel, yeah, that's done. So as soon as my wrist drops, as soon as my wrist drops, so you can hear this. If I keep the needle in that plane, I lose the sagittal plane. So I'm going next to it. Do that. You see that? Go back to the scr my screen again. Gabriel. Mhm. It's back to your screen. I think we just need to resurface it a little bit. Ok. Thank you. So my first one was the belly is sitting there. But if I maintained that ankle, when my wrist and elbow at the same level and try and stand up, now look what it's doing to that plasticine and you can even hear it. The difference being. Yeah, because I haven't angled the needle properly. So if you go back to the slide, the second one, so what I need to do is get angle between my forearm and the horizontal is the angle I open it up. So if you look in the bottom right hand corner there and understand your geometry of parallel lines, the horizontal line and my forearm that green angle there is translated across the parallel lines to that green angle in the 90 degrees. And that is why you need to angle the needle out. OK. And the needle it needs to angle out such that the belly of the needle each and every time is perpendicular as you see there in the blue is perpendicular. Next slide, please. And that's the angles. So the perpendicular and red is the perpendicular of the sagittal plane of the needle. The curve of the needle is perpendicular to the tissue and that's the what I call the belly bounce and the angles are obvious. So proving that next slide and therefore, when you're actually holding the needle holder and the needle in the needle holder, make sure it's at the tip because it gives you the perfect angle, but also gives you the best force to actually hold it at that angle as well. Next slide. And we'll come back to that one in a moment. So if you mind coming back to the camera in this stage, we'll come back to that slide. So if I demonstrate that again, I've angled the needle out there between my nail and the point of the needle is that angle which is the same as the angle between the horizontal of my forearm and the belly of the needle is pointed down. Yeah, and I'm not squashing it. Whereas if I do it this way and don't angle it out and take it down, I am not going to get a rotation and alignment. So the next part of the whole principle of needle and why the curve is there and why you gotta pick it up just beyond the halfway is very simply one needs to be able to put it sagittal plane and be able to rotate the needle back. So you're literally pointing the needle into what you wanted to stitch. OK? I'll take that one out the way. So you can see that and we focus on this alone, I'll come down and focus a bit more. So the whole idea and you know this, when stitching a baton to a shirt or stitching a bit of cloth, you need to make sure your needle is perpendicular into what you want to stitch. OK? So if I'm holding it way back there, I'm not gonna be able to rotate it all the way round before I am pressing it into the tissue, I need to be able to hold it. So so that I can rotate the needle back and say that is exactly where I want the needle to go and being able to rotate it back is the point is getting to the point because that is exactly where I want my needle to go. No ifs, no buts it's not a random movement you have pointed to where you want to go. So the first part of your alignment of the needle is, are you perpendicular to the tissue straight line? When I rotate the needle back, I want to point it exactly into that. I do not want to see clumsy pointing, bad rotation, holding it far back. And you can see the damage that is doing to the tissues. You can't see it when you're working on tissues itself. You can only see it when you've got a bit of plasticine like this and trying it upside down. So let me just, and get a bit of play day yourself or a bit of any icing and just be certain yourself, the belly bounce is correct. I got it rotated back and I'm gonna put my needle in. If I haven't got the correction. There you go. Now, I've actually got the needle holder involved and that will, I'll show you why that's important in a moment. I haven't. And if I'm holding it further back, I cannot get it beyond. And as I try and push it in the tissue, you can see that I'm tearing it. So understanding the needle and understanding the pronation and super nation that's required to rotate that needle back to the cleanly in and out. Basically, I want to see a point in a straight line, a point in a straight line. So what does this actually mean? In practice? I'm gonna bring back my favorite banana model and I'm bringing back the banana model and this is giving you a clue and what actually makes good banana stitching. We're going to continue our discussion about alignment next week, but I want to place it across at 90 degrees what I want to stitch. So I'm gonna choose nine o'clock on this and I'll come to orientations and alignment next week. But nine o'clock across what I want to stitch. I now want to actually rotate the needle back and point it in to the lumen and continue the rotation iterative. So it comes out and in doing that, I have not touched the banana, my needle and my needle holder have not mushed the banana and I'm taking it out. Do you see that it's came out at 90 degrees? I'm delivering the needle delivering it out. So, and the tissue always holds it in the right place and I take it out. So I'm just beyond the halfway my sweet spot, I can apply my needle holder and I continue the rotation out to cleanly take the needle out. And if I'd done that properly, my alignment of my needle and my pick up all become one fluid motion. And it's a simple exercise. You can do yourself with a needle and a needle holder at home and we'll go through that you can do at nine o'clock every day. As on the clock on the banana, I am going to do this and take my needle through, pick it up and make sure I pick it up. So I'm aligned ready to do it again. And I'm letting my needle do the work and imagine that I am lifting the banana from the inside. I do not want to see what commonly happens when people are stitching. They push the needle down, thrusted across, rip it out, tearing the tissue and mushing the banana. That is just dreadful stitching. And it is not the accuracy and correctness that we want. And it's the whole point of this is you're pointing into the lumen in this case. So, yeah, ok. What does this mean? And we'll come back to the last slide in a moment. But let me show you what this means on this other model and this is a perch dig. Now the poached egg, my registrar said, uh Mr Regan, how do you poach an egg? But what I've done here is made a little arteriotomy in this egg. Ok, in the membrane of the yoke. And I'm not yoking on this exercise. It is extremely difficult, but it's the same as the banana. But for fine needle skills and what I want you to be able to do is understand that you can use the tip of the needle to lift that wall out and gently pick it up. Try not to tear the skin. I'm not at the right height. So I gotta lift it, man. I haven't practiced a little while, but this, I can assure you is extremely difficult, but it's the same principle. See, yeah, tearing it. So I'm not quite got e rhythm, right? And if you can actually take a needle in and out of this, not tearing it and picking it up and go all the way around your coronary stitching and fine needle skills will improve very rapidly. Indeed. And it doesn't take long if you're wanting to do fine work on this model to earn your skills. But the other thing is, don't be afraid of the point. I can use the point if you've taken splinters out before with a needle, literally use the point to lift the edge up to highlight the edge and take the needle through. All of these are extremely important skills that you don't need to be in a wet lab. You don't need to be practicing on the patient. So there's one other thing. So if we're holding the needle properly at the right angle and we've got it angled out and you can see I'm pushing it back and I can point it in the top. If you go to the last slide, please, Gabriel, not the last one, then the one before that, please. So the whole thing about the place 90 degrees across 1 to 1 stitch and if you look at the right hand side, I supernate my hand, an arm and I'm now pointing. But what I've done in that movement is sulfonate. I've unlocked my needle. So I've placed it down in a locked position. I'm super and I'm naturally unlocked, but I'm still holding it in position. So this means that I can let go of the needle as you would let go of a ball throwing it, you don't stop your hand movement as you throw a ball, your fingers open automatically and the ball continues on its flight. But if I take this back, come back to the main screen, please, if I can't take this back, there's another important element that you can practice is being able to move your needle forehand and backhand without actually to touching it with the forceps. And that cuboidal shape in the middle of that needle in the body, as I described will enable you to learn to get your needle to literally sing and dance for you. As I take it from forehand to backhand, I can petted over the top beforehand. I'm not using forceps to do this and you can do the same with the smallest of needles. So with the castros, see if we come down, focus a bit further. There you go. Have I got it angled out and the first thing you do, no matter what size your needle is actually ensure that you can press the belly down against the surface. It's in the tips. It's just beyond halfway and you've got that angle. But even in this situation, I should be able to, I've got a week practice moving my needle round. And what I might do is actually do it on the egg because it's catching on the surface. So I might do it on the egg just, just light bit. Thank you. Bye bye. There you go. I am gently moving the needle to forehand and backhand on a wet sticky surface by peru it over the top. So the same needle skills apply for the smallest of 60 needles. And I'm not actually using my forceps to grab and hold and stabilize the needle. So now the needle becomes an extension of your hand, an extension of what you're doing. And if you keep it within a three centimeter area of focus of stitching, practicing these simple drills and skills, we give you control of the needle, control of the rotation but also remove any unnecessary movement. There you go forehand to backhand over the top on a wet sticky surface of an egg. So there you have it. Ladies and gentlemen, once you understand the tools that you are using, how they're made, how to hold your instrument, then it becomes very important. So to get the best rotation of your needle holder is not unlike a common instrument that you use is a screwdriver. You hold the screwdriver in the palm of your hand with the index finger down and you're using pronation super Nation in the same way to get good rotation of a screw and get good rotation of a needle. You line your needle holder along the axis between your index finger, middle finger and the common flexor origin or middle condyle. You fold your ring and fifth finger over the ring and you use your thenar eminence, your a doctor policies to take your needle on and off this again. And how you hold a needle holder will give you the better control and rotation of that needle to use the body. Remember if you're superficial, you only need a half circle needle or when you are deep, you probably need something that enables you to move it around in a deeper hole. Likewise, for the castros, you hold them like holding a forceps. So I've got them balanced on my main finger and I'm caressing the barrel between the pulp on my thumb and my index finger. And the movement required is literally very small movement. Indeed. Imagine that you're rubbing a little bit of salt to your cooking. Not too much, not too little, but just perfect. And all these little nuances can be practiced at home and broken down in skills. And I hope I've given you a flavor of how to do it at home and what you can start now looking for in your stitching cause if you get it correct now and you drill your technique now it means that your surgery will improve all the way along. So the very important thing is, is understand the needle. Why are you using that needle, the features of that needle? And you decide it according to the tissue and the, the suture that you're going to use, you pick up the needle with three important points. One just beyond the halfway, not too far because you won't be able to pronate it back to get 90 degrees into the tissue. Two that there's no space between the tip of the needle holder and the shaft. Why? Because that gives you the best angle but also the maximum force of the jaws to hold the needle. And lastly that you have angled it out at the University of Buckingham. At the end of the day, I got everybody to solemnly promise and swear that they will uphold the principles of needle Mountain that they will understand the anatomy of the needle and hence forth to the utmost to ensure that the needle glides through the tissue with minimum trauma and maximum effect. Thank you very much indeed for joining the Black Belt Academy. I hope this has made sense. We're very happy to take questions. You have been very quiet next week, we're gonna talk about the alignment. I have got a competition for you and ask you to test, test that beforehand and we'll see who the winners are. Gabrielle. Any questions? We don't have questions, but we do have thank yous. And John R is saying that this talk should be a compulsory training for medical students, which I completely agree. John, that's very kind kind as one of our supporters in Rinu. I hope it's made sense and thank you very much for being a regular. I'm delighted that you're putting in practice and what Rinko has done, which is I think is a first set up a Google Drive and has videoed herself doing some of these and has asked for comment on this. I'm, I'm happy to explore that with you. If you wish video yourself doing it, ask for comments, these models give you feedback and tell you when you're doing it right. And what we've gotta do is practice until we can't get it wrong. See you next week.