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Hello, good evening. Good afternoon. Good morning, wherever you are in the world and 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. The 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 attending the Black Belt Academy, thank you very much. Indeed and welcome. If you returning. Thank you very much. Indeed. We have 3294 followers on Facebook and 540 on Instagram. These sessions are brilliantly powered and supported by Medal and Gabriel's in the background in production this evening and can take your questions in the chat room and will interrupt to answer this evening. I'm talking about rhythm and flow and essentially lightness of touch. And that is where the dandelion came in the picture. Because as you have all identified in the question before the session, surgical skills do matter. The human organism is built for tension, relaxation, work, sleep, we breathe and our heart beats. The principle of life itself is rhythm and rhythm is all around us. No, from a heart point of view, the actual contraction of the heart, the systole is fixed and it's the filling of the heart. The diastolic that shortens as the heart speeds up. So even when the heart is in tachycardia, the rhythm rocking motion in the chest is still coordinated and perfectly relaxed. And that is where I came across the concept of what I call diastolic learning because everybody focuses on the Axion, the Sicily, the contraction the needle through the tissue. But to do that again and again and again, you need to think about the peace in between and the peace in between is all about the setup and to set yourself up properly. One needs to understand the basics. I'm gonna deviate a little bit and introduce a new problem. So there is a question for you name the painting, put that in the chat room. I'm holding a garden rake for those of you don't know. The painting is called American Gothic by grant would that represented a farmer in front of the barn with his daughter and has now become an iconic painting. But why I've introduced this, it's the principle of Carry Sansui, which is the Japanese then Garden. They don't use rigs like this, that they use white tooth, wooden rigs where the teeth are large and set far apart so they can trace deep grooves into the sand or the gravel and draw out specific patterns. Now, for centuries, Japanese monks have been practicing this art particularly through the more Amati period between 13, 36 15 73. It came to the renaissance period. This is when Zen Buddhism was flourishing and the art of raking was adopted by the samurai and warlords who looked upon it as a doctrine of self discipline and such was the influence of raking that it faulted through to a Japanese style of art. Now, why I come to this is that you start learning by simply raking the garden. Now, if you think of karate kid one and karate kid too, Mr Miyagi had the karate kid doing a mundane activity, wipe it on, wipe it off, wipe it on, wipe it off in karate kid too. Put it on, take it up, hang it up, take it off, put it on, take it off and those were basic movements. They were translated into a pattern and a rhythm that led to the instruction of the martial art. You see you start by learning to rake and very simply you should rake straight lines. Now, straight lines are not easy but to extend that across the whole of the garden. And these patterns are called Choke You Simon. And if your garden has many elements, these simple straight lines direct your attention soothingly across the landscape as you got skilled with it, you brought wavy lines in to imitate water or a stream and you drink, drag your rake with a gentle wiggle to make it look like water. And this manning stream pattern is called Q Q salmon. Now, if you've got any rocks within the govern, they represent mountains and water represents lakes and streams and raking circles around the rocks create the illusion of ripples. No, you can also construct raised mounds and they caught Maury Zuna and they traditionally represent the water that visitors to the temple would use to ritually purify themselves. And most the gravel and sand is white to represent purity of shintoism. And what the artist did is combined the circles that rib straight lines, the ridges, the wiggly lines into patterns to reflect the seasons, straight lines for frozen landscape, curvy lines for the Russia water in the spring, in the shape of a fallen leaf in the autumn. But it's important in this practice is that as you're carrying out the movement, you breathe deeply and you really relish it. The piece remembering that the Zen Garden is more about your state of mind rather than the finished product. And I think of us training and surgery and teaching people to use needles skills. I've often emphasized to the learning surgeon, take a deep breath. And if you have exercise on a regular caped occasion, simply going outside and taking a deep breath through the nose, when I do my workout, deep breath through the nose, and then you almost get that tingle that goes across your limbs and there's a secret art to breathing and exercise. But I'd also say in Cedric, so you rhythm and flow starts intrinsically with how you are approaching surgery and how you're breathing. And of course, we have spoken to airline pilots already and the thing is plan your flight and fly your plan. So before you go into theater, before you operate, you know, the steps, you know what you're going to do. But more importantly, it's part of your checklist and briefing, going into theater so that everybody in the team understands the steps and if necessary, if they complicated, rehearsed them with the team. And certainly when putting an aortic valve in, I had rehearsed the first assistant, the second assistant and the scrub nurse to all mount the needle properly such that I could call out forwards 45 degrees backwards, 45 degrees the needle holders place in my head. And I simply had sisterly no hesitation, deviation, interruption, repetition and could put an aortic valve in in 24 minutes. And people say you're rushing no smooth operating is fast, operating, slow is smooth and that is what we need to go to. It all comes back to the basics. So forgive me this evening, as we go through the basics again, and I try to illustrate some of these points to you and it comes back initially to how you pick up the needle. I'm gonna take you over ahead and show you this. So the first thing to say is that the needle has a particular anatomy, as we said before. The important bit, yes, the working element that you're holding is in fact cuboidal. And that is extremely useful when you're thinking of operating because that then allows you to pick up and use the needle forehand and backhand without using the forceps because the forceps will interrupt the position and rotation of the needle through the tissue. We said 1231 just beyond midway too flush. Such that there's no space between the shaft and the tip and three, it is angled out. Now, let's see how we can use this simply moving your needle forward and backwards without actually touching it. What I'm doing. I'm holding the needle without the ratchet arm, maintaining what I call the trigger point. I've taken up the slack, but I'm holding the needle and I'm per awaiting the needle over the top. So I can go from four hand at the right angle, pull it over the top and go to back hand simply doing that, removes the forceps coming in having to pick it up again because you've actually maintained that angle without actually holding the needle holder, holding the forceps. I am able to rotator's forward and backwards. A colleague, colleague, surgeon Sam know chef in Cambridge referred to this as sexy moves what I'm doing palm out. I actually have not got this on the ratchet note that my fingers are gently applied to the eagle holder and I'm holding it off the rack. It, I'm keeping my opponents policies separating the ratchet of the needle holder. That means that I can hold it, but I'm not gripping it. And because it's that Q bottle shape, it naturally flips into position. Now to practice this, I would recommend you use a larger needle and, but probably a needle holder with longer arms to give you that degree of flexibility. But let you get practice does this, you can do the same on shorter needle holder and smaller needles. Yeah, I've got it focused down deliberately as well because when you're operating, we are focused within a three centimeter diameter circle of that needle. And that is our working area. And the ability to control the needle within that area is going to significantly reduce your diastolic time. So the 123 of midway flush with the shaft and angled out is of vital importance. So that is the 123 we've said before that 90 degrees is the fourth part of the circle and a perfect angle as described by you clip because every orthogonal angle is 90 degrees as well. And therefore always check that your needle is properly in position. 123, then place it 90 degrees across what you want to stretch, rotated back by pronating such that the needle then is 90 degrees into what you want to stitch. And what I've done in rotating back, I have unlocked the needle holder. So the Axion now becomes smooth and I rotated through and maintain it at the 90 degrees as I said before, the tissue holds the needle. So take it through to just be on the halfway and again, with that subtle movement, slight nudge and you can bring it out ready to use again. But if it's not a simple adjustment is required, not with the forceps with practice, you'll find that your needle then starts to work for you. And without much in the way of effort, you can progress, you're stitching without interference with a force of forcep is very simply going to hold and retract tissue, the simple one handed, so to speak, stitching exercise I saw on Twitter today and I thought, gosh, somebody else is looking at this as well. We can imagine a long anastomosis or lots of stitches required to close a layer, simply being able to pick your needle up accurately. Each and every time means that you removed a lot of that diastolic movement. Now, Charlie it, who's a colleague and fellow Sensei in Sienna. And I have been talking about this and there's a simple rhythm to this 123 place point and rotate. Now, I know some people have put metronome is um here and the metronome is, can you keep up with the metronome? I am not setting the metronome to ask you to keep up with it. I'm asking you to think about a regular movement and regular testing. I've just taken the weight off the veteran in which will have to attend to later. But we are looking at this 123123, place point, rotate, place, point, rotate. There's almost a rhythm, a waltz that comes out of this. Every practice with your needle skills. This will translate into efficient economy of time and motion. Simply taking a horizontal slash through a banana using the guides to line your needle translating that then into simple dots and very quickly, you will train your hand and I accordingly, once you're ready a bit like taking the stabilizers off a bicycle, you'll start naturally doing it and spacing it out yourself without any cruise place, 90 degrees across what you want to take, rotated by 90 degrees into what you want to stitch and rotated around. It is as simple as that. And it's a bit like raking. It's a simple movement, but it's the simple movements added together that constitute the flow and the rhythm of an operation during an operation. And as your operating, you'll find their natural pauses. When you start a task, you continue that task until it is finished. You're not distracted by him. A stasis unless's a huge bleach and you tend to huma stasis. When there's a natural pause, you need another suture or you're changing direction and simply attending to these diastolic elements of which there are many during an operation, it then becomes smooth. Now, I'm trying this for the first time this evening because Charlie's sent me a metronome picture that we are looking at and exploring. And he was saying that the pepper has now become the new model. What I like about this one curious is again, the tissue is holding the needle. I'm taking it through just beyond the halfway, I'm picking it up and usually you've got an assistant on these things. It's always difficult as a single surgeon. But that's why you have an assistant is to follow accurately. We will be covering assistance, assisting in a session on the 10th of April. So the important thing is, is you're not grabbing at the tissue, but you're not wasting the movement and you're thinking about your pick up each and every time. What's nice about this pepper model Julius? It is again unforgiving, but rather than a straight line, now, we're having to change direction and we'll come to it next week's session about going round and round because well, the, the needle itself and it's presentation to the tissue of 90 degrees across 90 degrees into the tissue is the same. What we'll explain next week is, in fact, my body movement is taking my um and my forearm to a new position to affect that's too much. And I find when I'm stitching like this as I am breaking a garden that the rhythm and the flow it starts to become apparent and what you can do a bit like the Zen masses in the Zen Garden. They start to think about your breathing to regulate your actions. I note that many surgeons when they start learning, hold their breath and in doing so, become hyper kept nick and in fact, make tremors worse. I often invited my training surgeons to sing a song at the time And I suppose there's some neurological reason to all of this is because when you start learning, it's the right hemisphere that is taking it all in to try and assimilate the overall appearance. But it's not until it is actually embedded in the automatic motor function of the left hemisphere. Does it become unconsciously conscious? And the one way you can help doing that is talking to yourself as you're doing it because the speech centers and Brooke is ever very near the merger areas on the left hand side. So what does this all mean for wound healing and tissue handling? Because you have all correctly identified that tissue handling is of critical importance when it comes to wound healing. And what I have here is what I call my incision model or layer model. I've got layers of bacon with pasta, lasagna, pasta in there. And the problem is with people when they come to closing and closing is often regarded as a finish the operation, coffee time and we leave the most junior person to do what I think is the most critical part of the operation. The critical part of the operation is the clothes because it's this respect of the tissue and lightness of touch and accuracy with which you put the needle through the tissue that determines on how well the wound will heal. So we are going to and they bake him is actually very good. And the other thing is you will note that if I'm clumsy with my forceps, the pasta is going to tear as well. So combining the two in this model is making me focus on the lightness of touch. The daddy line that I put in the picture, there's no rush, respect and accuracy of the tissue is of paramount importance in this. It's not 123, put it through to drag it together. Each and every stitch must be tensioned and pulled through with tissue opposition and not strangulation. Remembering that the healing edge is the lag zone of information. And the 3 to 4 days between the stitches and Dema of the tissue will mean that detention of the stitches increases and potentially cuts off the local blood supply. So please, when you come to closing a wound, think about breathing, think about your rhythm, think about breaking the garden. And when you're doing a Monday task, next time, pause for a moment, repeated and repeated, focusing on the Axion, but focusing on your breathing as Mr Mayaki said in karate kid, when you're sweeping the floor, when you're raking the garden. And if you don't have a garden to rake, in fact, you can apparently by death, top versions of Zen Gardens and many executives have them within their officers for exactly that because the doctor breaking should be the art of peace. Now, this model, as you can see, my pastor has actually been drying out and I run the risk of retiring. The important thing is to get a position of the tissue and I'm not pulling that tight. If I start pulling that tight, it starts pulling out, putting out of the tissue altogether. I just made that along. So your switches should be nice and relaxed. Each and every layer need to be brought together carefully and deliberately to avoid and bunching up and to get perfect tissue opposition. Yeah, my past has been drying out here and you can see it is fragile and the thing about models is that you do need models. They're going to point out and tell you if you are being rough or clumsy. So there you have, it might take unwritten um and flu. What we're going to do is look out next week, look at going round and round because at the present moment in time, we have just kept to one plane. What we're going to be looking at next time is in different planes. It reminds me of a look at you pepper the Cialis suggested that this pepper also gives us an opportunity to think about how you line your needle at depth. And the reason why the modern surgical needle is curved is because we can now get it into small areas and use the rotation of the needle to deliver and put the needle through. What's quite nice about this model to Aurelius is not only can I use it to test my forceps skills picking up each of these pips, but at depth, I can test my ability to rotate the needle through the tissue without tearing the pepper. So I think that's a winner. And credit goes to Charlie's for suggesting that soon, no matter the trial you face don't lose the peace or the rhythm of life. A quote by Eric are I would say no matter the trial or difficulty you face in surgery do not lose the peace or rhythm of the operation in aviation when things are not going well. And weren't you to take a deep breath? And that deep breath is because you're taking it through the nose to your Ethmoid plate which sits near the Olympic system and it helps car being slow down, focus on the breathing your own natural rhythms and deliberately get the basics right. Until you put those together in sequential order, you will find your diastolic period will come down and your rhythm and flow will improve. They did a study looking at laparoscopic surgery and I reached the front page of the New York Times. Professors were asked to look at video of a laparoscopic cholecystectomy and rank them in order of propensity to infection or complication. And indeed there ranking looking just at the movement and flow of the operation correlated with the potential complication. But the story did not end there because they put the same video in front of late people who are able to see the same economy of time and movement. For that economy has time and movement, of course. And that natural rhythm and flow again all comes back to how you stand because to have the elbows out and the shoulders up, our fixing major muscles of the shoulder girdle, adding to fatigue, adding to tremor but not allowing those intrinsic muscles of your hand to do the job to the lightness of touch totally is and I are going to be exploring this further and we hope that we can introduce to you some metronome exercise is simply to get you to think about the rhythm. The metronome is not there to speed you up. The metronome is for you to count the 123 for the needle mount and the place point, rotate for needle entering the tissue. I sincerely hope this has made sense. Thank you very much indeed for joining the Black Belt Academy of Surgical Skills. Next week, we got to be talking about round and round. We're going to do the same thing. But this time with a banana, you can practice that yourself at home, but drawing radio sutures at 90 degrees out or putting dots in, taking around around. But in that situation, we need to be moving ourselves and I'll explain further in two weeks time. I'm delighted to be joined. Bye. Now, Dani, now was a cardio thoracic, a surgical trainee in 1999. And unfortunately, there weren't many posts for cardiac surgery at the time. Say he went off and explore did career as an airline pilot. He's now a successful captain in a lingus. He's just flown to New York this evening on his, a 3 30 and we're going to be talking on the 13th of March about surgery and airline business. I know we've covered this before, but this is unique because he trained his decision and now is the captain of an airplane. So please book early. Look forward to seeing you then and Gabrielle, thank you very much. Indeed again for the expertise behind the scenes. Good night, good day. And I wish you well. Thank you.