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Hello. Good evening. Good day. Good afternoon. Good morning. Wherever you are in the world. And thank you very much indeed for joining the Black Belt Academy of Surgical Skills. My name is David Oregon, Um, a cardiac surgeon in Yorkshire in the United Kingdom, the past director of the Faculty of surgical trainers for the Royal College of Surgeons of Edinburgh and visiting professor at Imperial College London. If you one of the 3276 followers on Facebook 516 followers on Instagram for joining this evening. Thank you very much for your support and for joining us. And if this is your first time, Welcome. Thank you. And I hope it makes sense again. I would like to extend my thanks to medal for hosting these events because it enables me to take questions from you to put them in the chat room and behind the scenes. We have soup Gibson this evening and a distinguished visitor Gabriella from Lithuania, who's going to be joining the Black Belt Academy. She's medical student but trained lawyer and wants to do sadly so. Welcome, Gabriella. We're going to talk this feeling about perfect practice now. Erickson talked about 10,000 hours and the 10,000 ours needed to reach the level of expertise. He subsequently changed that 10,000 hours. Because it's not 10,000 hours of mindlessly doing something repetitive, Lee, it comes down to perfect practice makes perfect now. In the 22 years that I've been a consultant and a number of years as a trainee, I have not come across any synthetic material that will give you the necessary hectic feedback of what it's like to take a needle through the tissue. And I note that suture pads get sent out and plastic set out for people to practice on, they find. But the limitation is it doesn't tell you if you are making an error, because perfect practice is practicing until you cannot get it wrong. Now there is a Japanese art form of making parts, and I had the pleasure of interviewing Michelle Rue Junior, who I was asking him about the polls between a master chef in a kitchen and a surgeon in theater, and one of his hobbies was this Japanese are we had to make 100 perfect little pots, and if number 99 wasn't perfect. You wasted the other 99 you had to start again because you had to get 100 perfect parts and reminds me of martial arts. Bruce Lee said. He wasn't concerned about the person who got a repertoire of 10,000 kicks. He was more concerned about the person who had perfected a kick and did one kick 1000 times. So the idea is to introduce you this evening to what I call a splash models, and my splash models will show you where you need to improve your stitching and help your line now. Previously, I've also talked about your posture, the angles, your hands relaxed. You're set up standing up straight. All these things apply. And last week we we went round at different angles and you'll notice you went around different angles. When you're stitching in to your stitching shoulder, that becomes extremely difficult. That's where you have to unwind from the weight on your right foot, turn it on to your left foot and now go back hand. Now the thing is, is that in golf the coach will put down a golf club on the ground colored sticks on the ground to a line your hips and shoulders, club and everything, and you practice with two of those sticks in the ground to show you and reinforce that alignment and the models then demonstrating to you this evening does enable you to put lines on the models to check your alignment. Firstly, just to reinforce your pickup of the needle must always be at the tip just beyond halfway and angled out. And that angle is an angle down here. And I find when I'm watching trainee stitch repetitive Li, what happens is the needle drifts. It drifts from that angle, dressed to 90 degrees and drift from the point. You cannot possibly expect your needle to circumscribe the perfect circle if you're not going to get your alignment and pick up properly. And we said the easiest way in the only way to align is your need was going to be at 90 degrees across what you want to stitch in 90 degrees into what you want to stitch because Night agrees, is a perfect angle because in any orthogonal plain, the opposite angle is 90 degrees to and 90 degrees is fourth part of a circle and that rotation happens with pronation super nation. And that is why the blackboard Academy they advocate your palm, the instrument such that the angle of rotation is between the middle, an index finger and the common flexor origin as the radius folds over the alma and, you know, holding a screwdriver that this action is possible in humans. Wherever you put your shoulder, open your out there and you know that with a screwdriver. And the simple thing about surgery is the needle is 90 degrees, and if you look around your surroundings at the moment, you see pictures, windows, doors covered. Everything is 90 degrees. We're hardwired to do that. And I did a study where people picked out the 90 degrees of two cards out of 20 between 86 94 and the reliability was 97%. And I think we're hardwired. So let me take you over to these models and explain how and why I believe they work. Can I help you with your stitching? We introduce you to the potato. This is microwaved. I do have to put a health warning on there that microwave potatoes get awfully hot. Do be careful and the microwave it such that the skin is very soft. If you look at the side here, the skin is flaking and soft, and the idea is, if you've got to rotate your needle into and out of the potato without tearing the skin. So I've drawn lines on here because the potato gives me across in the front, away from me to my right to my side and to the left side. And those are all the regular angles that you will be practicing in surgery. The setup of the needle and alignment is always the same. The difference is you need to work out how to position your arm and how to position your body accordingly. And it might be on your right foot, left foot or the weight simply disputed with a tilt on your right or on your left foot, which tilt the pelvis and the shoulder. So here we go, 90 degrees across water. Want to stitch a note? I've got that angle out, and it's at the tip. That must always happen before you make his touch 90 degrees. Rotate it back 90 degrees into what I want to stitch, rotated around and if I have completed the rotation, There you go. The needles should come out cleanly on the 90 degrees across. I'll take it out closer for you to see. There you go and across, and I got to deliver it out carefully just beyond the halfway. And as I said before, the Cuboidal shape of the shaft enables me to give it a little nudge, deliver it and take it out and they're the angle is maintained. I've lost it again. I am not going to take a stitch until I correct that ankle. With practice, you'll find that you're able to take a needle through the tissue, then take it out cleaning, pick it up, give it a nudge, and I've lost the angle. And therefore I need to do that again. One of the consultants I worked for, Professor Magnolia Cube. He actually reposition the needle every time he did a coronary stitch. Now they're demonstrating that needle has come off midline. I wasn't watching what I was doing, but it wasn't directly across, and I picked it up again, and you can see I've lost the angle, simply saying to yourself each time, check your pick up before you take any stitch is important of center. I've also noted I'm not standing correctly, so I'm going to stand properly with the weight distribution on my right and left leg and take it through again. Oh, it's off center again. They're back on track. And that's the thing about perfect practice. Is being able to do this all the time and talk yourself through it? A colleague I worked with, I used to when stitching Mr Simon Kendall. He actually won the Leonardo Da Vinci Award for Training Excellence in Europe for the European Association cardiothoracic surgeon. I remember him as a train knee as he stitched literally but like a golfer, saying Good shot, good shot as he is talking himself through each of these shots, and that was a bad shot, and I think it is useful for you to do the same. Now. What I'm also demonstrating here is probating the needle over the point to get the angle backhand, and I can do it the other way and you'll find that back hand is for many people, are not easier than beforehand. It comes a lot naturally, and they're I'm off center, so I'm going to take it back a bit, and you need to do this yourself and practiced till you can't get it wrong. The alignment in different positions is the same 9 90 degrees. If you just filled that up 90 degrees cross water, Want to stitch now to get to that, I work out that my elbows in the air and with my elbow in the air, I can now rotate the needle back and rotate the needle forward and take it out and take it the other way. But they're I've gone off. Excuse me, a little bit of a cold and a cough at the moment, but you see, looking at that how this potato on that edge has fluffed up. It's fluffed up just there as I dragged the needle out, and that is a model that is telling me when I'm not doing it correctly. So the idea with the simple potato is for you to recognize that what dictates the stage is the alignment of the needle of 90 degrees. And to achieve that, you need to get your body position and you are positioned such you can affect pronation and super nation without interference. and without running the rotation with practice also gently holding the needle, being able to urinate it over the top four handed backhand each time like that. So down this side, same thing applies taken out and you can see their tear and it pulls out. I love the banana model because the banana as it develops, it goes black. And what I've done here, I have taken a ballpoint pen and I put regular spacing 90 degrees to that outer edge all the way. Okay? And I've made an incision across that, and what I need to do is to be able to take my needle in and out and hopefully out on the line as well. And this is a kid now to a continuous ditch place at 90 degrees across. What you want to stitch tender backwards and rotated forward have come out on the line. Okay, so I'm happy with that and delivering it out same thing applies 90 degrees across what I want to switch to take it back and then you go on the line maintaining that angle all the time, maintaining my pickup and it's on the line and you can pretend that this would be a continuous suture. But how often I ask, do you check yourself when you're running a continuous suture and closing the wound? You see that I'm off site just missed on the line. So each and every time I'm holding myself to account for the position, tha make it more fun. I can put dots on either side and see if I can come I/O on the dots. I could almost set myself a target practice bull's eye. You can make a game of this, I think, or competition almost see that this has come out exactly on the dot, and this is a bit like the Gulf program putting clubs down to help your line, bullseye. Wonderful. And talk to yourself as you're doing it. Bulls, all right, know that I'm being deliberate. Bullseye was slightly off the dead touch. Now, once you're happy doing that, you can repeat the exercise without any marks at all and go between two lines. So take it in, take it out. So if you can go to the same place, take it in, take it out. I'll come back to that in a moment and I'll show you. Why? Because the time the banana goes black. So you can almost check your grouping as if you're shooting arrows at a target or target practice with a gun or dots come down close. Uh, you can see my exit wounds on the banana there. It's given me a target, and I think I was probably off on the first two, and that's a much better alignment. And if you go up and down, up and down like this, excuse me. You will very quickly drill into yourself the concept of the alignment of 90 degrees to and 90 degrees in, and you can see the entry and exit wounds I can do. Score myself by drawing a little circle around there in saying how close I am, I in the entry and exit entry repeatedly. Good exit. Not so good entry. Good. Except they're better. So I'm training myself and talking to myself. And so doing this Now you can go through both things when they're lined like that. However, if I start separating the two edges, the last thing I want to do is to go through the here and try and force my way through to the other side. I now need to do it in two. But the alignment is the same. And coming from inside out, you got to think your needles coming at 90 degrees to the inside of you've been on that and coming out on the same point. Now, this becomes more significant when we actually look at Hey, elliptical incision. Well, I think I lost the zoom there. So the fact is for an elliptical incision and this would be particularly for vascular surgery. The same 90 degrees. You can draw your 90 degrees out to the edge, but you see 90 degrees to the opposite ages. Different? Yeah, 90 degrees to the end is Paulo to the two walls. So as I come around here, I need to actually ensure that at 90 degrees each time and now I'm starting to think how moving myself around the table and how my weight distribution is going from right foot left foot. But I'm not hurrying. I am actually trying to do it deliberately, slowly and keeping the pickup of the needle correct and the rotation of the needle. So the lines in this situation are helping me again. We can move to just putting simple dots on the banana and see if you can get your needle out exit at the dot. Do not compromise as soon as you start compromising. That is when bad habits started to come in. What I like about these exercises as I'm practicing, I'm actually saying to myself a good shot, bad shot and correcting it each time. And I believe that this is perfect practice. I have stopped myself there because I've suddenly recognized that my needle is not at the tip. Correct that before I continue. I don't see many surgeons actually correcting their needle position on a continuous suture. It's not a problem. It takes a moment. But it is a problem if you don't rotate the needle correctly. So there you go. There you have it. The fun one is the banana. If we come back to the exit wounds and the banana, you can see now they're quite dark and black, aren't they? And they actually show you that the delivery of the needle from the banana has not come out on the perfect circle. So I would like to introduce you to this new model. I'm not joking excuse the pump. This model is taking a boiled egg, cutting it in half. Okay? And really, what I want to do now is align my needle across what I want to stitch. And I'm wanting to stitch the white of the yolk only. And this is going to test whether I can actually rotate the needle back and insinuate the needle between the yolk and the white with the bank. And I delivered the needle out caffeine and I hope you see, I hope you see that it's a very fragile, But what is actually testing me is really am I actually rotating the needle bag and pointing it into the gap between the yolk and the white of the egg? Am I taking it out cleanly without scrambling the egg and the thing about models? I think there have to be challenging. And if you can get it on this sort of model stitching then becomes easier. Nothing will challenge you more an organic material. And you notice that if I'm too hard or drop my needle in, I start running the yolk and what I wanted to look at if I come down close on this, I'm wanting to ensure that my entry point between the yolk and the white is clean, that I haven't skidded my entry in. So the banana gave me a clue of my exit. But this egg is now giving me a methodology to test the entry of my needle into the tissue. If I have rotated it back properly and it is very fragile and it does take practice and it is difficult, but that's what you want a model to be. And to be honest, I am actually finding myself having to concentrate, and you'll probably find that I've also gone quiet and not talking as much because I'm thinking about what I'm doing. Let's bring on another model of a joke because many of my colleagues watching use much smaller needles. So here I have a poached egg. I was asked by Rich are one of my cards courses, but I used the post date to teach Corey anastomosis. How do you put an egg that is beyond the discussion this evening? But I did teach him how to poach an egg out of theater, so I've got a hardboiled poached egg and I'm making a little arteriotomy 15 blade in New York. All right, now I'm going to do the same I/O exercise with can Extra gave. Oh, and a six or a needle. Okay. And the same thing applies. Think of that fusiform decision. If I use the word elliptical, Mister Carrie, earlier on, I went to see a fusiform. Now, for those of you have done coronary surgery, I can assure you very thin coronary vessels or not too dissimilar to this. And if you can actually rotate the needle through a coronary vessel and let's look at this, I can use the point to lift up. See that I'm lifting up the edge. The point is not going to hit the poster war point I'm actually using to lift the edge away. Mm. I'll rotate it back. I can actually lift the edge up. There you go. Mhm. I was telling, um, well, about this beautiful camera that average life sciences have given me through Kevin Austin or wet lab. And I hope you appreciate now the magnification of this camera, which enables me to get around now. When I started cardiac surgery, the first instruction I had was just be quick. No, Thank you. Okay. I'm almost around this anastomosis. I'm not looking at the clock, but I am concentrating on getting my rotation and alignment of my needle correctly. So even on this poached deck, the principles of alignment pick up rotation, place, point rotate are exactly the same. So there you go. I think I've got one more stitch. The last one I actually grabbed and I might have torn out. So I know the eagle eyes of you will actually probably spotted that. I think I did. No, it didn't. It wasn't broken. Thank you. So I have now been around that osmosis. What? In about six minutes or less? I'm not teaching speed, but I'm teaching accuracy, lightness to touch, deliberate, purposeful rotation of the needle, which I hope you can now see the small needle on approach deck. And for all those cardiac aspiring cardiac surgeons and microvessel of people do try this. It is challenging. It is difficult. But that's what a model is supposed to do. Is actually to challenge you to push your skills further. And because it gives you feedback, is offering you away of deliberately practicing. I'm very happy today. I think Mister Carrie has just said my view using HD camera may not be good as yours. Okay, um, I didn't scramble the egg. And if we go back to our bananas, as you see over time, the banana develops, doesn't it? Okay. And I can see the skin marking in the skin mark out. Which brings me to the competition that is going to end of next week on the 28th. This is a global competition. Tell your friends what I'd like you to do is get an apple core up, take a home out of the banana, and I want to see 12 perfectly radio sutures. But I don't want to see Byron Marks so you can practice as I've certainly here. But I don't want to see Byron marks 12 perfectly radial stitches around that, Or you can try stitching a linear incision in the banana. And for those of you who have tried it before, may I suggest that you take the banana out under the inside because trying to pull the two edges of banana skin together Well, actually, tear the banana skin and you lose points. So what I suggest is you open it up from the other side. Take the banana out, eat the banana. You'll need the energy and then stitched the skin in itself. So on the website, we have given you examples of banana stitching. We've had a couple of entries and one very innovative entry where the person's cut the banana in half, rotated around and joined the two together. 10 out of 10 for creativity and innovation. And I get to score the stitching. But what a wonderful example. I want you to go bananas, churchy. Offer any examples of good stitching on the banana? What you need to do is then put the photo black and white high definition on social media and hashtag metal up and black belt be be a double s skills. We will look at the entries and the top three will get their own set of instruments like this. And I look forward to posting this to you wherever you are in the world. And what you get is a rider, needle holder, scalpel, blade, McIndoe, scissors, house, dead and a set of forceps for yours to continue practicing. I look forward to seeing your entries do get them in before next Friday because the closing date is midnight next Friday and we'll go through the judging. I look forward to sending lucky winners their own set of instruments, and I hope that I'm posting them too far and wide to exotic corners of the globe. Excuse me. I'll take any questions if anybody has any. Please, Gabriella, I know you're in the studio looking on, and this is your first time watching Sue and I know my fellow sensei. Mister, somebody is watching as well. So and good friend and Yoda, my mentor and sensei. Ashok. Cherien. Any questions? Ladies and gentlemen, please, To Are there any questions? No questions. No questions, no questions. Although we did have a little John and I had a little chuckle when I put excellent work, David, because we put egg. Excellent. So I thought there would be more egg jokes on the chat, but delegates let me down. There were too interested in watching your stitching than joining to Yes. You're cracking work. Excellent cracking work. It's no yolk, David. It's no, You know, I wanted to show these out, right? Okay. I think we've done the egg egg puns for this evening. Thank you very much and need for joining me. Look forward to seeing you next week because we got to get round and round. Yes, we're going to talk about the needle going round and round. But then we're going to put it in to what it means going round and round with your joining tubes together. Bowel and blood vessels, ureters. And what models do we have and what principles we apply? Funnily enough, 90 degrees in 90 degrees out. Do it in two. But we will reinforce the principals. Thank you very much for joining the blackboard. Academy of Surgical Skills. Really Look forward to seeing you next week as we go round and round. Thank you.