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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 David Regan, Um, a cardiac surgeon in Yorkshire, in the United Kingdom. I was the director of the faculty of surgical Trainers, and I'm currently a visiting professor at Imperial College, London. Tonight. We're talking about partnership, and I'm delighted that I'm going to be joined by my son Alistair. As we talked about this partnership, I'd like to thank the 3256 followers on Facebook and the 480 six Forest on Instagram. If this is your first time to the Black Belt Academy, welcome. And if you're returning, many thanks. Indeed. What I like about the martial arts is the philosophy and the mindset that goes with it. So I have been sharing that with you with each of these episodes drawing on the work severe mood to Musashi, the undefeated samurai warrior of 16 43 and initially chapter in the Book of five rings called the Killing Sword. Inappropriate for the surgical one because your scalpel should be a healing scalpel There's a paragraph on things to learn when you face an aggressive opponent. And I reflected on this. Thinking of my training is a registrar in cardiac surgery at a hospital, unnamed with a surgeon unnamed who was particularly aggressive and very particular and not very pleasant to work with, and I refuse to assist. But on one occasion, one of the registrar's his blue eyed boy was away, and the only person available to assist was me. So with the degree of trepidation, I went into theater and set up draped, opened and waited for the cumulus numbers cloud to come into theater and start with lightning and thunder. None. Because I had opened properly, I'd drink properly and the operation started. And as the operation went, the surgeon will put down four steps, then touch because I lost the forceps and I passed the forceps back to him, and as he put them down, I picked them up, put in my hand, assisted, and the forceps must have circumnavigated the table many hundreds of times during this five hour operation. We didn't converse at all. He didn't say anything whatsoever. He had no reason to thunder or lightning and left theater, and I thought for me as a training registrar, that was a success because there's no criticism and no thunder or lightning. So in this paragraph, meeting you too much Ah, she goes on to say there's three points on which to focus the eyes. The two stars, the opponent's two hands gripping the sword or instruments peak and valley, the bending or extension of the opponent's arms. And when engaged, the distant mountains, the shoulders and the chest and the details are explain as we go anyway. The proper state of mind and all these items is to prepare yourself carefully before facing off with the opponent, not allowing yourself to be inattentive, and it's essential to make sure that you do not get shook up once the drooling begins. If you face off suddenly without mental preparation, the movies you've learned will not be forthcoming. The points of focus, however used for both aggressive and passive modes and these points of focus are essential when waiting and slashing. Your focus is on the peak. When exchanging blows, your focus is on the distant mountains, and as for the two stars, you should always keep your eye on them. But then he goes on to talk about the rhythm, and I think this is important to neither. Song, not dance, can be formed without knowing the tempo. There must be a sense of temper in martial arts, as in surgery, to see with certainty how an adversary sword is working surgeon's scalpel. How is handling it? And to understand what is in his mind must be the same state of mind is that of one who has mastered the tempers of song and dance. When you know your opponent's moves, I'd say the not opponent, but the surgeons moves and manners. Well, you can make your maneuvers freely so it comes back to this partnership and man as well. And I think assisting is a form of dance, and nobody has really explained during my career as a training surgeon principles behind assisting. And that is what we're going to do this evening because good assistance make good surgeons and good surgeons make good assistance. The other important thing, and all of this in particular human factors, is that your assistant is your partner, and the reason I say that is they have got to be able to say Stop what is going on? I do not understand. And I recall helping an eminent surgeon put in a stent this valve wondering about the orientation, because to me it looked wrong. But I thought too scared to say This is wrong And I said, Please say, Could you tell me? Explain the orientation of the valve. Yes, yes, yes, yes. But I'm busy. 15 minutes later, that same surgeon turned to me and said, I now realize why you ask that question because actually, the orientation was wrong. The important thing in this whole dynamic is that you're on a level. There's a sense of mutual respect that you're able to communicate, and that's the responsibility of the surgeon. More than the trainee. Suffice to say, have the courage. If it's not working, say thank you, but no thank you and walk out as I did the other important thing on being on the level, and I'm going to introduce my son Alistair. Now we have been training and martial arts do come in. And for those of you, remember when Alistair first started, it was this side and I was officially over 6 ft and the table height has got two mutually convenient for both of us. Now, Michael worked with me for six months. He was 6 ft six and I was the only consultant Tachy stand on the stool when he was assisting to label him to get the optimum position of your arm and therefore function of the upper limb. But the other important thing about being on the level is that I'm on this side of the table callouses on that side of the table. And if I use this as my line of sight and I'm looking down at that and, uh, this is looking down at that, those two coming in at 90 degrees. And if you think that every X ray we do, we should do it at 90 degrees to give you a three d perception because if I hold this up for you, you would say it's a block for the 10 at 90 degrees. In fact, it's a cylinder and is that important two dimensional view that is required and for the training surgeon should explain what to do and enable and empower the assistant to speak up and saying, What are you doing? And Why now the table And I'm going to just focus on the table now. I've divided into quadrants, and this is my operating area, and my hands are going to be in the middle of the plate. In the operating area outside this area, the bigger plate is the retractor. An incision and the operating bit happens in the middle of the assistants. Hands on the outside. And Stephen Westby. What reminded me of this in doing those fantastic films on route replacements? Because the camera was overhead and if your hands came in the middle, you were wrapped on the knuckles for ruining the film. But it was a useful lesson. Your note here that I put a red file, and this is to my right hand side. Most surgeons have a scrub nurse to their right passing instruments, and it's in this quadrant of the table to my right hand side that the sharp instruments, the needles etcetera will be passed. So if Alistair puts his hand into this area inadvertently and we're passing shops, which, by the way, should be in kidney dishes, there is a potential injury, and I make this as a no go zone so just be aware of the space between the surgeon and the scrub nurse with all the shots from past. So to illustrate this movement and dance, I have a elastic tape that we're going to put around your waist. Okay, you can see that. And if I move to one side, I'm just saying he has to move. Yeah, it was the other way. His eyes are in the distant mountains, my shoulders and the upper chest. To maintain the midline which are put in red as this between us and as you know, driving the road, you would not cross the midline. So not only are the hands on the outside put their hands on this side all the time as I move around and as we're demonstrating some of these, you need to realize that your shoulders, when operating a parallel to the surgeon all the time. So the next important thing is to realize that you have a mid line down the middle, and the worst thing you can do is cross your hands. So you need to realize when you pass the midline, you pass the instrument to your opposite hand. So there's a dynamic all the time keeping the midline and spatial orientation between you. So the first exercise this evening is part of what I call that equal and opposite. And what I have here on the plate is a massive strength, and I'll bring it closer. Bring your overhead, just zoom out a little bit. I have a massive strings and you see here the operative area, my hands in the middle, and I'll still be operating from the outside. So if I pick up a string, it's a black with a Geodon. Aniston needs to pick up equal and opposite. And if I'm coming around this side and picking up another string note that, uh, Crestor has swapped his hands and is picking up the equal and opposite as well as we're moving around. So I'm going to come back around this side, and Alastair is doing that fantastically well, and that's simple understanding of the movement is ensuring that I am getting equal and opposite retraction all the time Now. This is particularly important when we come to actually stitching, So you recognize my banana model for stitching that I've used on many occasions, and this is now taking it to the next level I have got here banana with an apple core out of the middle and an arrangement of staples around the edge. I'm just going to bring that into the middle a bit more. There you go, arrangement of staples around the edge. Now the staples are just gently put in the banana. And as I go around, I am holding one edge and understand will hold the equal and opposite. But this time also, he's going to assist and follow a monofilament, and the most important thing you can do in assisting is follow a stitch. Now the thing is, you never reach in and grab the stitch. You never pull the stitch. It's a lateral hold and not a pool as instructed to me by Mr Monroe when my first started cardiac surgery. So I'm going to start back hand at this point and I'm going to hold. They're as if simulating holding tissue. I'm going to come around and I'm going to take it out as a lateral hold. You hold it, you can swap hands up. Analysis is going to take it and hold it. And if I can just show you finger and thumb towards the vector. It came out the tissue such that if I inadvertently pull it, it slips out the fingers rather than get caught in the fingers and tear out the tissue. So this is going to hold it in that direction, and I'm going to continue to stitch, having given him and just it's a lateral hold and not to pull and hold the tension. So even while I'm trying to understand, asked him how his Chinese lesson went this evening, he should be able to keep his focus on the tension and following all the time and let go, and Alastair takes up the tension in the direction of the suture. Now zoom back again so you can see that with the hands and I'll continue around that you like, and they hold it two thirds to fits 3/5. So I'm not tripping over suture. You see, this mono filament has got memory, so Allison needs to hold it a little bit further out. So I'm not tripping over suture in getting tangled and appreciating that tension and distance is absolutely critical in all assisting and I think I've gone around. Surgeons made an error here, not the assistant. And it usually is the surgeon and not the assistant. There you go and said, thank you and I am coming to remember when I talked about stitching When I reach the 10 30 11 o'clock position on my circle, I cannot go back ground, back hand, and now I've got to switch to the forehand. I'm turning my weight onto my left leg and I'm continuing my stitching forehand. A note that Alistair has actually swapped his forceps from right hand to the left hand and is now following with his right hand as well. And as I'm coming around on that circle, my position is changing. Just keep the tension and Cialis hands outside suturing area, so they're not in my way and they're not interfering. And it's a progressive movement, a dance, a dance per vein, as I described with the previous lecture of movement to enable me to go around the other thing, to bear in mind with this banana model if holding it out in the victim. And I know Dallas is very good at holding it out between his finger and thumb, because if I pull it slightly and inadvertently it slips out of his fingers rather than hook your finger around instead to demonstrate it. If I put it now, it starts to tear the banana. And that's if it was in a tissue. Would be tearing a coronary vessel or tearing a, uh, part of the bowel or bio duct or ureter. And it's that sort of tearing that can easily happen if the surgeon, an assistant, are not moving in harmony in synchrony. A note analysis holding opposite me all the time. And I think for somebody who doesn't do surgery, he has actually picked up these principles rather well. Now I have had my fun, and I'm now going to talk about how you can help as an assistant help the surgeon in dissection. So we're going to swap rolls now once again around this corner, a note that I'm switching into my dominant arm here between four o'clock and five o'clock to find Stanley, and I'm having to go back hand and Alistair has automatically without asking. Swapped his instrument to his right hand is enough following with his left hand because he's understood the movement and the dynamic around the table to answer your turn to have some fun behind you. You'll find just reach behind you, and we've got to put it underneath. All right, so here, we're going to just do some dissection, and Dallas is gonna use some scissors and a knife and dissect a plane. And I'll explain as an assistant what I need to do to help him dissect. So I would like you to start dissecting that plane, please. Knife or scissors? Doesn't matter. Yeah, that's four steps. You use a knife in the right hand. Okay? Inside, knife and fork. And remember to brush against that edge. Let me just let's take this thin layer first and see if you can get this layer off. So you hold him down there, right and brush it against the edge and what I'm doing here, and I'll just focusing a little bit further. Alyssa is love the technique of using the knife to brush. Just use it brushing against the flat edge. Hold it down there now brushing against the flat edge and I am retracting and maintaining the tension to enable answer. Keep it flat. So you're brushing it blade coming this way and that they get the other way. Open it up in your hand if I may show you if you open it up in your hand and you literally brush it like that against it. All right. Okay. Good. There you go. Off you go. So I'm maintaining the tension as you're developing the plane. We can cut that with the scissors. If you want. Just hold that. Okay? Good. And I'm maintaining the tension for you to keep going and I'm helping by retracting. Now, if you're going to be doing it for a long period of time, it might be useful to put some hemostats lord tissue forceps on these edges to hold their in your mind. As I pointed out before that, forces themselves do damage. So when you're picking up something as an assistant, remind yourself that the pressure equals force over area that your pinch grip is up to 50 Newtons. The area is about five millimeters squared and in essence, you could be generating six million Newton's per meter, squared with your forceps and therefore damaging tissue. So all the principles we have discussed with to date on how to handle instruments are applicable to the surgeon as well as it comes from this side. Shall we, as the assistant, sometimes necessary. I can hold it, but putting a hemostat on any vascular tissue keep going. And I think you will agree with me that medicine is doing a wonderful job dissecting of this. But that would not be helpful if I was not paying attention and maintaining the traction on the tissue and exposing the area. Good. Use your scissors now, and you might want to think about developing in into that plane down there. So as a surgeon taking training through an operation, I can use my four steps as a blunt dissect er remembering if I stabbed me in that caused damage as a blunt dissector and point out the layers point out the anatomy but at the same time maintain the tension and the tissues to enable effective dissection. Because the assistant should not only learn to follow, to cut, to hold the tension, but to move in synchrony with the surgeon. And now I just keep going and doing a brilliant job there. Secondly, with the surgeon, and this is where I say good assistance, make good surgeons move around a little bit. Keep moving around and I'm going to move around with you. You see how the square and I have my hands in the way the square is maintained across the field and the dynamic is maintained as well. So I am watching his shoulders and watching his arm. Then I'm watching this dissection. Do you want to put that down a moment? And I'm just going to do one other thing. I am going to reverse this, and I'm going to do a continuous stitch. Alice is now going to assist. I got a vehicle and I'm going to close layers and I'm going to stitch towards you, and Alice is going to follow. But let's see if Alison's learned from a previous lessons. I'm going to tie this not and you see that without even asking. Alice has realized that I'm tired or not. That one end needed to be cut that I held up and he brought the scissors into the field, gently open them up just enough to do the job and cut the suture. And now he's going to put those down, ready to follow, and I change direction. But he's going to show me the edge by retracting. That's not only is he helping the exposure, we now hope helping with the surgery. And it's always a pleasure with operating with an assistant who understands these basics and facilitates your movement and helps the economy of motion. And it all becomes very fluid. And I hope you appreciate that without actually asking Alistair now the same, um, four of holding the suture up surgeons taking it away, holding the tension and my signal to actually hold it is just holding the suture street and ourself follows. And holes so very were both very happy to take questions from our audience. Now we have somebody from China understand? Have you got anything to say to them? You know, you're very good. And can you say, Do you understand in my room I could do about seven minutes ago, but not so much stuff in my head now. All right? You've forgotten stage flight. They meaning by mouth. I think again, I can't be sure it's right. Yeah. Naming, naming by mouth now audience in China, right? In fact, answer. So I hope the ladies and gentlemen that has given you an idea of the principles of assistance that it is. That is a very dynamic process, that it depends on synchronous movement between the two. But it also depends on that respect in partnership that is required. I went having a doing, a Korean operation would say to my assistant standing opposite, Who's looking at it at 90 degrees? If I put a bad station, I want you to say so. And I I have deliberately tried to put a bad stitch in on occasion to see if they're paying attention. And I am pleased that to say, Excuse me, that is not right. In which case I feel together, we are reducing the potential for error and also improving the flow and rhythm of an operation. I sincerely hope this makes sense to you, Phil. I don't know if we have any questions. Welcome questions from the audience or comments. We don't have any questions at the moment, but Bobby Chow is from Hong Kong, He says is Mandarin is not great, but he has confirmed that he got what you said So great. Excellent Mandarin, Bobby, Thank you very much. Actually, Alistair speaks much better Mandarin than that. I think it's a camera, but thank you for that input, Bobby. Thank you, John. One has said brilliant masterclass. As always, one suggestion would be possible to use a colored suture material as that would be easier to see. Ah, yeah, that is true. That John, you're quite right. And the vehicle I had is white and then died. But I hope that you see against the pink of the flesh of the wound that you can see it. But there you go. But your point is correct. Most Vicryl sutures nowadays are undyed because otherwise that tattoo but apologies there. You're quite right. Thank you very much. Maybe I should use a blue prolene in the future. Any other questions? Ladies and gentlemen, we don't have any other questions at the moment. Well, I'd like to thank you very much indeed for joining the blackmailed academy. If this has made sense to you, please spread the work and ask people to join us on metal. They are proving to be the most fantastic interactive platform. Know, thanks to fill who is the CEO of metal and is hosting this evening Winners. Thank you very much indeed. Fill. Next week, we're going to be looking at decision making and decisions before incisions. Film is going to put the link up in the chat so you can register now for next week's lesson. Spread the word, share the link and we look forward to seeing you next week. Thank you very much indeed. For joining the Black Day Academy. They say thank you to my assistant and thank you to you wish you well and be safe.