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Hello. Good evening. Good day. Good afternoon. Good morning. Good night. Wherever you are in the world. And welcome to the Black Belt Academy of Surgical Skills. My name is David Reagan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and visiting professor at Imperial College London. If you are one of the 3279 followers on Facebook and 517 on Instagram who are joining us this evening and are returning, thank you very much indeed. And if this is your first time with the blackmail Academy of Surgical Skills, you are most welcome. Gabrielle is behind the scenes and fielding the questions. I have particularly cough this evening. I'm going to indicate if I start coughing to meet me while I take a sip of water to bring you back into the picture. So, apologies, this evening we're going to be talking about round and round. Which brings me to a fundamental point of going round and round and round and round and round and the principles of practice and the only way to get better and to improve your performance is to practice. It's a a simple activity that you need to repeat, and you need to focus on what to learn, what to improve on, and that is the only way you're going to become proficient. Andrea Proscar, who's a physician, said practice is effectively the absorption, mastery and maintenance of the skill, and my story only can come through focusing on the basics and mastery means that you can perform at will no matter what, under any conditions. Mahatma Gandhi said. One answer practice is worth more than a ton of preaching. And no matter how many times people can tell you do this, do that, etcetera, unless you actually practice it, it won't make any meaning at all. And I'm only here that some people think they don't have time to practice, and other people are saying that when they get home they don't want to practice. Many of the medical students and many of the surgeons and training have extracurricular activities in sport music, swimming whatever and they put in the practice and they put in the practice without even thinking about it. They make time they set time aside to practice. The thing is, particularly when you're playing an instrument. When you start playing, the sound that you get out is dreadful. But over a period of practice, it does get better now. Just Kaufman said that to go from knowing nothing to going to pretty good requires 20 hours. But we are not in the business of delivering pretty good because your basic skills translate into the outcome. And that is why we here lightness of touch, accuracy and precision deft flowing surgery translates into patient outcomes. That's a fact. So drawing on reasons why we need to practice and drawing on why musicians practice and translating that for a surgeon, firstly, practicing both confidence. So you perform better when you perform better. The outcome for the patient is better, and that's what we're here for. Practicing also increases your knowledge practice. It means you're actually building a better future for yourself. You're making it easier. But in practicing, we need to be able to relax, enjoy and feel good about it to be in the zone. And that's what the Blackboard Academy is trying to do. We're trying to Krul's for you to adapt on practice because unless you practice, you will not be able to adapt. And remember, the pathology does not recognize any anatomical batteries Northerns disease, and you're going to have to adapt. Practicing also increases your motivation. You don't practice. You're not motivated, but you start practicing. You become motivated practices. Thing is also a way of expressing yourself and finding peace and to practice. You need to create the opportunities now to invest in the future, because the future is not just your surgery. These are going to provide your future and your income. But practice also improves the fluency and paste and rhythm. It makes you more flexible and more adaptable and more able to respond and think critically under pressure. So the important thing to do to practice is you need to start acknowledging and recognizing the endgame. The end game and your outcome is the patient. The scar is the indelible mark that you are going to leave on that patient for life. They will look at that and remember you, it's worthwhile. Therefore, making that as best you can when you practice as well. Don't make it random. Limit the scope. Define the time and define the purpose. Use the models that we're doing in the Black Mount Academy and would be very useful for you to find a friend to partner up with and challenge yourself in these models and make it fun. We are hoping that the Black Belt Academy of Surgical Skills to bring that to you near you. So if you have a consultant trainer stays in training, do get them to get in touch and will help set up basic skills center near you, such that you can then take your home skilled surgery and demonstrate that to an experienced sensei and master the art of surgery. That is why your practice. And although I am a third down in karate, that's after 10 years and practicing every week. These are the belts here. Each belt recognizes a different stage, but I do recognize also having gone over the stages two black belt and become familiar with all the carters and things. It is only when you become a blackout that you really start to understand the neurons and the movement and the purpose of the reason of why you do it. And I'd say that's much the same and surgery that you go through all your training. You learn all the skills techniques, Carter's combinations, etcetera and drills. But until you put them into practice over the years, do you start to appreciate the nuance? But even with a black belt going back into the dough and doing Tokyo, which is the first course of great ultimate, is the first Carter or movement in karate? We do that repeatedly every week, and certainly in the third time. We did it about 50 times, and you do it until you can't get it wrong. You do it. Forwards backwards. Back forward three Backwards 44 words to backwards. Three. What does that mean? The Japanese, such as it becomes a natural because in real life and surgery under stress, you need to actually have a solid foundations to fall back on. To be able to stitch in a difficult situation and to this day is accounting surgeon aortic dissection with blotting paper, a water deep in the chest, stitching round and round, making sure your needle goes around around perfectly and round and round. To do an anastomosis accurately is essential because it just requires one careless taking. Take out for that needle to tear blotting paper wadded tissue. Then you got a breather and then you transfused. Then you spend hours on the table. You transfuse more temperature drops, wound infection, morbidity, mortality increases. It's getting it right first time, all the time, reliably, and that just doesn't happen like that. But getting in the zone practice is relaxing, and I hope the models that we give you makes sense. So let's get on to what we're going to talk about. You know, we come to our model at the top and got reality and tell me if the model ends up off screen and do please ask questions. We have previously said that your needle needs to be mounted, probably just beyond halfway at the tip and angled out as such. We also then every stitch, and every time you make a stitch, it has to be like that. Each alignment is 90 degrees. When going run, something is 90 degrees at each angle. Remembering as I pointed out at this angle, I am on my right foot, I'm stitching into my right shoulder and it's extremely awkward, and now I have to move to my left foot, mouth the needle in the same way backwards and continue moustache backwards all the way around and effectively when we're going round and round, we have six o'clock, 12 o'clock, three o'clock, nine o'clock, as demonstrated by these needles in this model here. But if I take that away and leave my model on the table, you see I have a circle 12 o'clock, six o'clock, three o'clock, nine o'clock. Even if I compress it into elliptical shape, that's spacing off. The clock is maintained. So the problem is when we are going round and round and horizontal plane, it's quite easy to see the changeover. Just imagine. Now I'm taking this plate vertically and as I take it vertically up, have a look Where that transition period is Now I take the plate vertically up. Take that up. It ends up at about four o'clock away from me. And that is important for two reasons has demonstrated here that is a vessel little bow and I've got a number of colored pens. The six o'clock is my white pin there. Okay. And on this side is a barrel vessel and you can see how the pins correspond because effectively. What we are going to do is join six o'clock to six o'clock and we're going to come and start at the four o'clock and work around and fold them together and join them together like that. But notice that the clocks are going the opposite directions, aren't they? Yeah, to fold them together. And that's what we're doing in the three d model here. Were coming in on the red, going out on the red. And this is a vascular surgery. In on the red, Out on the red, in on the green, out in the green, in on the white, out in the white, you know, in the black, out in the black And it is out upstream here because we want to bring the endothelium to the tissue. So what model do I have to actually show you? This this model is a hair of baby socks pink in the middle. They're going to show you the adventitia. And at the end of the Valium and the dark pink, the adventitia on the outside. And I'm going to start my anastomosis away from me because at this point there is four o'clock that is the deepest point from me as I'm looking into the operative field and the principal of all continuous surgery is u stitch towards yourself. So I'm going to stitch towards myself along the bottom and then I'm going to stitch towards myself over the top. I've put this arrow here to show this is the direction of blood flow, and I'm going to make sure that I'm coming inside out upstream to ensure the endothelium is held against the Amitiza. Now, if you come down closely on this, you'll see that the sock has got ribs in it. And I've talked about alignment before of 90 degrees to it, and that's 90 degrees to the rib. The other thing is 90 degrees into the tissue because unless you're 90 degrees into the sock, you will note that is rather difficult to get through. So this sock model is a simple alignment model. Now the other thing is as and dissection. The adventitia here is separated from the endothelium. So you started four o'clock four millimeters deep and there's no rushing in this. I'm making sure I get the corresponding side. Then I have to go backwards my needle perfectly and come back the other way at four o'clock because they're together. I can now do them together and through. Okay, I'm going to put a rubber shot on there for the moment so you can see how this develops most vascular surgery. We are using double and needle. So I am going to I'm just reminding myself which side I'm coming in. So I'm outside on the upstream element, true inside at the next point, because it's in two layers. I got to do it in two. And I'm using the ribs of the sock to ensure that my alignment is good. Jerry's needle back hand and now you can see I'm on my way. Okay, I'm coming towards myself on the inside. I still have to do this in two because the two layers are separated as we've discussed before, and now it's starting to come together. If I take the needle to the outside and draw through from the outside, it will start to Evert on the outside and for aortic surgery and major aortic surgery. I use the four oh, usually and, uh, four millimeters apart. Four millimeters deep. Yeah. Whoopsy. And you know what I've done there? You can see And I thought to myself, I've done it wrong. I've ended up twisting that going through. So I'm going to take that out again And even I wasn't watching. And the more astute of you know, my fellow sensei, Mr Carries probably watching and said, Oh, no, he's done it, He's done it, He's done it. You're quite right. And that's the thing about models and practice. It's better to do it here as you're practicing rather than right. So there you go outside. Good. And as I'm putting that together and averting, I hope that these sutures are going to disappear. As we're looking at this, I'm gonna do a couple more more and then choose something similar model that I use for balance stenosis. So remember, it's inside there. Yeah, put it through. And each of the time on each of these stitches, I need to take care of my placing. And I need to take care of the rotation and make sure I'm doing it in such a way that the needle is rotating cleanly through the tissue. And I hope you see now, as I pull that tight Uh huh. That the endothelium is joined to Endothelium. Now, once I get to this side, then I can come with the other stitch from the other side and simply come over the top and continue around towards me. So let me show you the equivalent for a bowel anastomosis again. I've used socks, and these are baby socks this time white socks for and the pink stock in the inside is the mucosa. Now for most violent or stenosis to help you, which is useful on the mesenteric side to put a stitch to hold it together. And on the I think it's enteric side to put another stitch to hold it together, because there's a simple thing you can do to actually rotate it over to assist your stitching this time. And there's lots of debate with dialysis, every single teacher, double future interrupted future. It really depends on the tissue and the blood supply, because remember that a continuous stitch is hemostatic and you could render render it the schematic. So we want to. I think this time I'm not going to pick up the mucosa because the prostate apparently is just picking up the mucosa gently underneath and then coming through and just touching it because of and then coming out about muscular part. Right? And you do need to be organized with sutures. Uh, Michael's It's not going to glide through the tissue very easily. I'm just going to use this a way of an example and hold it out. Okay. So Okay, you're due to see you. So I'm going to come from the inside, and I'm going to When I take up the tension, the seizure, take it from the insights. At the moment, I'm on the outside and then come back on the inside, pick up a little bit of the because, uh, right do the same the other side pick up a little bit of mucosa. Uh huh. That, and come back to the inside before I take up the tension in this. Remember their strangulation. Stitches continue stitches. So it's just a position of strangulation. Just straighten it out for you. Once you get going, it becomes a lot easier. Okay, so there I am on the inside. Uh huh. All right. Thank you. Makuza must have to live the bow right, And if models were easy, well, zip through it. But the thing is, with these models is. The idea is to make you think Marjorie orientation and you're still itching and your rotation. So if I pull that together now like that, what I should be doing is ending up with the mucosa touching on the inside as we do Asthma versus for. And the idea behind these models is actually make you think about what are you What are you doing? Um, the rotation. So let's put it together. Um, Evert inverting this and osmosis from the other side. It should be inverting as you see that the sock is falling in on itself and that's what you should get with an inverting bowel anastomosis. So how would you go about practicing your rotation? That sock is giving me the alignment skills and practice that I require to go around the sock, and I do commend it to you. Try it yourself and let you let me know what it is testing. But it's meant to be testing. The important thing is is that you are lining your needle each time with the ribs of the sock, one more from the inside. And to be honest, if if I don't take my needle carefully through here. My needle would get stuck and start putting this all about. So I do have to be careful to ensure I'm coming through at 90 degrees all the time. Maybe I should do some more of these seizures. Well, see before. All right. Decision Tonight. It up. So the Enbrel stitch is not really including the because, uh, it's just taking it down. It's not going full thickness to the rest of the full thickness. Ditch is to the muscularis. Mhm. Excuse me. You give me a seat. All right? Always said I would not operate with a bad cold, especially with the boss corner, because one definitely is feeling under the weather. And that definitely limits ones performance. And how often do we actually say No? I will not operate. We've done to you, which is growing, right? I think I just looked myself there. This is difficulty when you're trying to do it, but yeah, I did live by myself. Go. So what we've got is I'm bringing the muscular layers together, and if I pull that you can see muscularis is put together, and mucosa will come together to underneath. So one way of practicing you're I/O with your needle. And this is coming back to the banana model because the banana model is totally unforgiving on the rotation and what I'm going to do use my needle here and what I've done is partially called a banana spooned out the inside. So I just got the skin and on this model again, I'm starting at four o'clock. I want to come towards myself over the top and I'm going to practice. Take my needle I/O of the banana. I wondered this evening if this would work. So this is the first time to rotate the needle I/O of the banana without tearing the banana. The thing about the bananas we've shown before, if you let it develops over time, you can see your entry and exits. Each time you take a stitch, you should be saying to yourself, ever amounted the needle properly? I'm picking it up properly. I'm rotating, probably, and that's for each and every stitch you take. And the thing is, when people are doing continuous stitch is attending to the needle mounting and the needle position is often forgotten. I just found with this being rigid. It's difficult to reach inside to get the banana to get the needle, Take it out. But this banana skin is not forgiving and the same way I've demonstrated previously. And his skin marks and poor rotation and will be reflected on your entry and exit. Uh huh. I hope you appreciate that. These models are meant to be difficult and to test your skill. But if you're learning to stitch, it is not a good idea to go straight into this sort of model. It's best to get your basic alignment right and your basic pick up right. And once I've gone around the corner across over the top, it does become easier. But you do need to think about those position of the upper limb. Wait, you're standing on deliberately. Amount a needle accurately every time each and every time you take a stitch going around the cycle to to me. To be honest, I find these models very immersive and so far as that very quickly find myself concentrating, focusing, talking myself through the alignment, etcetera. So let's see and have a look have done onto the banana, and you can see the entry and exit marks already. What you want to be able to see and what did they look like underneath? They're good. I avoided that bit because of the ridge. Avoided that rich. But this entry and exit that alignment is not very good. But the other alignments. I'm looking at it. I'm not unhappy with. I'm just looking for my pen, which I put down because, yeah, I'm looking at the entry in the banana. Pinpoint. 90 degrees across. Yeah, that one skewed. But it's good entry. Good exit. There you go. That one there, that's a bit of a skid. Good and very good accent. So as I go around that banana, I can see my entry necssit. And that's given me feedback on how well I've actually done on my needle rotation. And all that is done is translated what we're supposed to be talking about into three dimensional shape, simply going in and out in a vertical plane and you'll find that I/O. And the vertical plane does become awkward between four o'clock and five o'clock. Which are those stitches there because you're operating furthest away from you, you got the extremes of angle in beforehand and back hand. And this is the area you need to concentrate on to ensure you get excellent alignment. I hope that makes sense. Very happy to take questions. Excuse me? One. I just take a bit of a cough. I'm getting my so apologies for the cold and the cough. I hope that makes sense to you. Hope of demonstrated with these two models that the principles of place point rotate apply not only in the horizontal plane they apply in the vertical plane that in all circumstances you're going round and round and round and round. But as you get over the top at the four clocks and coming towards yourself and coming over the top towards yourself, furthest away towards you, the angles become challenging and difficult. Unless you start thinking about that and start practicing those angles and practicing the rotation, then you'll find it very difficult. God, the banana model scooping out the banana is very good because that will give me immediate feedback of the accuracy of entry and exit. E version happens when we take the future from the outside and it's diverted. Endothelium sits together and you don't see any stitches. inversion that way is when you take your continuous suture through from the inside and you don't see any mucosa and mucosa. Sit together on the inside both ways is important to remember that your continuous suture is a hemostatic suture. So for balance pharmacies, other enteric anastomosis and bronchial asthma is important to beware of the blood supply. And beware of the areas of the bow and bronches in vessels where the blood supply is poor or systemic reasons why the amount of blood being delivered to that in most pharmacists might be diminished because you change your suture technique. Simple, interrupted sutures are not hemostatic and are just as efficacious in these circumstances and and osmosis of vessels. Remember, you need to come inside out upstream to ensure that the endothelium is setting against the adventitia, and particularly in dissection with the salt model. That and I feel it is often a long way from the adventitia, and you do have to bear this in mind as you are looking at bringing this together. Each have got to be done and to remember unless it is together, you have to align your needle at 90 degrees to both edges. Gabrielle, do you have any questions and any questions from the audience? So we don't have a question, But we have Chris saying about the first module that you turn the challenge into learning opportunity. Bravo. For that, um, to the second module. Osama reacted, saying that, um, he would say that taking care of rotation is by preserving inside, inside and outside outside. Correct roll. Doing correct. Correct. Correct. Uh, yes. Sorry. Go ahead. Uh, we also had 10 asking where he can watch the recording, so I just clarified that he can find them on this lovely platform. Um, and then John is just wishing you to get better. So the last thing I want to say is that we ran the banana competition, which finished on the 20th of October, and it's my pleasure. Here we are. Pack and ready to go to the post office. Tomorrow is a set of instruments to are worthy winners. And they are Matthew and Darby, Cherie and Sylvia Slovinje Mall and Abu Dhabi and Gabriel, who's hosting this evening. Each of you will receive in the post your own set of instruments. Do ask that you acknowledge receiving them on social media and post picture. Thank you very much indeed. For watching the Black Belt Academy of Surgical Skills next week, we're going to be talking about getting a grip and focusing on forceps skills. Because what I have found previously, as soon as they introduce for sub skills to the stitching people, stitching goes backwards. That is why I've separated the learning of both before bringing them together because they have separate principles involved. I hope to see you next week. I wish you well be safe. Thank you very much, Gabriel, For hosting this evening and thank you very much to the audience.