Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, good evening. Good day. 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 joining us at the Black Belt Academy, a surgical skills, you're most welcome. And if you're returning, thank you very much. Indeed. We have 3296 followers in 77 countries and we now got 580 followers on Instagram. It's been a significant weekend for the Black about Academy of Surgical Skills because I joined my fellow Sensei Chris Caddy and John Taylor at the Association's of Surgeons and Training conference in Liverpool. And we offered a walking workshop for delegates to test and try their skills and sample are low fidelity models. This is all possible. Thanks to the general support and clever marketing of B Braun s Club Academy in and we literally went bananas and I think the banana has now become synonymous in my preferred training model for scootering. Why? Because it gives you haptic feedback and also clearly demonstrates as we will show you this evening you're stitching and stitching ability. All of those who are at the African conference and have joined, say hi in the chat room like to know you here and I'm now giving away the secrets and how you can do 12 perfectly radial switches on a banana, which for the black belt Academy of Surgical Skills is the black belt for us ditching exercise. I'll explain the second down version when we get to the end. So what we've been learning and our recapitulate is set up, set up, set up. And if you don't attend to the set up with each and every stitch, the rotation of the needle through the tissue is going to be clumsy and cause damage. So let us refresh our minds by going back to look at the simple principles and very simply we need to pick the needle up properly each and every time or too often the needle is given to us with and 90 Green Mountain and not to the tip. And without thinking, we attend, we'll try to stitch. But because our wrist is low than the album, you will see that the plane of rotation of this needle is not 90 degrees. It does not sit on the table at a sagittal plane of 90 degrees each and every time you take a stitch, it is mandatory for you to go through a 123 check one. Ensure it's just beyond halfway to you. Ensure there is no space between the tip of the needle holder and the shaft. And three, we angle it out at about 45 degrees because you can see now that that needle is sitting 90 degrees to the table and the author agonal plane and new cleats perfect angle is maintained. This is of course helped by knowledge of the anatomy of the needle that the shaft, the middle section of the needle is cuboidal in nature. And the fact that you have now got it at an angle. I can pyra wait this needle over the top or the point and move it from backhand too forehand. If you lose control of the needle, the best thing to do is put it on the palp of your finger, maintaining that sagittal plane and bring your needle holder in at the angle. So you can feel that there's no space. These rules apply to all needles no matter what they size and each and every time you stitch you must attend to this. When I'm watching a training surgeon operate, I know whether they're stitches going to be accurate or not by simply looking at the 123. So one, it needs to be just beyond the halfway to, it needs to be at the tip of the needle hoarder. Such as there's no space and three, it needs to be angled out and that angling out maintains that 90 degrees to the tissue. It's what I call the belly bounce. The belly of the needle should bounce in the tissue. And for those who are in the banana stitching competition, you will now know that if you don't have it right, the tip of that needle was starting to mush the banana. So needle mounting is important and having got the nine mt correct, you now have to do two simple things. You line your needle 90 degrees across what you want to stitch. And this alignment dictates the position of your lower arm, your shoulder and your body position. As I'll describe in a moment place, we then need to use the needle as part of the circle of the perfect rotation. And we need to rotate the needle back point at 90 degrees into the tissue and a little secret in doing that rotation back from place to point. I'll share with you now because fluid motion is not being quick but removing or the hesitancies, we place it 90 degrees across what we want to stitch. And as our rotate back, I have unlocked the needle holder as I rotate back with the pro nation. My opponents policies has unlocked the needle holder. I still have control of the needle. Of course, because I can move it forehand and backhand, but I'm holding it and that the cuboidal nature of that needle is enable me to make the needle dance. I am now using the needle and it's full function to exercise a perfect rotation, forehand, backhand, forehand, backhand. And I have not brought forceps into this equation because the forceps will actually ruin the alignment of the needle on the needle holder and will also using your forceps to deliver the needle out of the tissue. It will ruin the rotation. So that's simple setup now applies right across the board. So what does it mean when we go round and round? How do we think about this issue? Well, in the conference room, I looked around and looked at people coming into the room and noted and despaired that we don't appear to have any clocks anymore. It is all digital for those who need reminding the clocks with the digital face had a 12 o'clock opposite was at six o'clock to the right, the three o'clock into the left and nine o'clock. And in all, sadly, we are thinking in terms of the clocks and part of the stitching exercise is to understand that we are working around the clock now on a circle, stitching round and round, the radius hits the circle at a tangent at all the time. And this is circle theorems that you would have studied and I G CSF IgG and what you got to realize as you came around a circle, you need to present your needle 90 degrees all the way around. But you'll make that as I come here to five o'clock, six, there they come to five o'clock. Let's come out a little bit. Okay. As they come to five o'clock here for a right handed person, this is the most difficult stitch you could perhaps do. It's because you are now stitching into the right shoulder and it is in this position and in this position only that we need to change our stance because as I'm stitching right hand from there, there, there and there my body posture has changed and my weight distribution on my feet is now predominantly on my right leg. I am changing between four and five o'clock and in that position, I am going to change my needle angle and change my body position and I now come back hand and then from four o'clock to three o'clock, 21 12, I am back hand. Your note as I'm coming around this position, you tried yourself. And now on my left foot, this extreme and my weight distribution is gently changing to my right foot as they come round. And at 12 o'clock, I usually find myself equally bounced in high Shusaku, which is a Japanese term for standing straight, your feet slightly apart. At this point, I'm now tending towards my right foot and you'll find it's increasingly difficult to do a backhand stitch and therefore in that position almost diagonally opposite. I now continue forehand moving my weight distribution from left foot, too, right foot. So effectively over this exercise for a right handed person, I find that transition from forehand to back and is approximately half past four and it will do for you. It'll be within that region plus or minus a few minutes depending on your body habit, tous and how poor you are. But there you go. That half was forehand, that half was back hand. So simply putting a plate down and marking the it out. I would like you to try yourself with a needle at 90 degrees to the circumference at each angle, you can even put a protractor on that and line it on your protractor and note the body position that you need to be in. So when it comes to stitching a banana, you can put your banana in the middle of this and you have directions because what we need to think about when stitching, we're stitching around the clock, we're stitching in on the hour and every hour. So when you're stitching and learning and practicing just as they do in golf and many other sports, putting markers down will reinforce the direction that you need to be. So 90 degrees across what you want to stitch nine degrees into what you want to stitch and you simply retake the needle. And if you rotate the needle properly mark zoom down and this is where the economy of movement comes in is by understanding that rotation is, the needle itself will come out with a banana at 90 degrees. As you see that you iterated lee take the needle out of the banana till you just be on halfway and you apply your needle holder and you continue the rotation gently out of the banana. So is clean, you have not skidded the needle out. You then move on to the next bit again, check your needle position, align your needle place to where you want it to be. Rotate the needle back, rotated into the tissue, it genetically deliver the needle on the curve till is just beyond the halfway and you pick it up and you're ready to go again. And so you go on this exercise with a banana is totally unforgiven. And that's why it is an excellent practice model because it will tell you where you're going wrong. It'll reinforce you that lightness of touch and it will reinforce you the positions. So as you're doing this, I plead that you concentrate on your needle, pick up needle angles, needle positions each and every time because what people don't teach in survey is the diastolic element is all about setup. And as I'm talking there, I'm slightly distracted and the death distance from the edge is not where I think it ought to be. But you see now I'm on my right foot, heading towards stitching towards myself. My alignment with my markers on the plate enabling me to think about the position of my needle that now is it my shoulder? I therefore have to go onto my left foot and back hand. And what I notice is as you go from four hand to backhand, people lose Jed that little bit of alignment and the distance between forehand and backhand is lost in the spacing going round. In other words, it should be accurate distant from the edge and the distance between the sutures are the same. And my transition from a forehand stitch there and back hand not infrequently ends up with a bigger spacing because you have not thought about your place point. Rotate. The important thing is with this exercise that you're pointing the needle into the lumen, you're not dropping your needle holder into the lumen and you're using the circumference of the circle and the anatomy of the needle. This is not to be hurried. You need to do it deliberately and purposefully each and every time now simply putting your banana on a plate with these markers. Well, in a very short time, reinforce your positioning and your market of you Neil all the way around. And the conscious exercise, a conscious exercise of thinking about it and thinking about your position, you see that that was opposite. In fact, I might feel more comfortable getting my rotation with the needle and handling, moving my body position to the left foot and taking it out. But as I'm doing this, I'm looking at my spacing, I'm looking at what is happening. Now, the banana exercise, if I've rotated my needle perfectly into the tissue, the banana on the inside should not be mushed in any form of fashion because that means I am deliberately rotating the needle back to make sure the needle goes into the lumen and comes out and this is particularly important. Well, it's important in all surgery to be honest, to get that rotation and clean exit. What you see here as you look at it, the exit of the needle should be a clean pumped, um, should be a clean hole and not a drag and not a skid mark. I should not see mushing of the banana on the inside. It takes practice, it takes time. It means that you have to be deliberate once you've done that on the plate that's giving you that vision around the stitching, simply get a pen and with a rule mark your banana again, I don't expect to do it first off without practice. Simply give a rule and draw in 12 o'clock, six o'clock, three o'clock, nine o'clock and the hours in between. And then you can, you don't need to have a suture on it. Just the needle simply practice the lining. You have got that there is a guide, a guide to help you line the needle and you say to yourself and vocalize place, point, rotate each and every time because I believe from the anatomy broke. His speech area is sitting right next to your motor areas. By incorporating that vocalization, you're changing something unfamiliar that was strange and perceived by your right hemisphere of the brain. You now codifying it into regular Axion by talking about it and putting it in to the automatic motor area of your left brain. And why you learn something is always with the right hemisphere first, which is interesting because the right hemisphere is always there with emotion and surroundings. So that is why if we don't create safe places for learning and you don't create a safe place to practice acquisition of these skills then becomes extremely difficult. It's a somewhat therapeutic and engaging, doing a regular exercise like this as described last week as raking a garden, I'm going round and round as if raking the garden and the Japanese Zen landscaping with my banana and enjoying the flow in the rhythm. Note that nowhere in that process did I use a set of forceps to pick the needle up? Because that would quite frankly run the rotation of needle. So what does it mean to a banana? Well, it doesn't matter what size were dealing with vessel, bowel, whatever all you've got all the time are tubes and tubes and tubes. Big tube spacing is the same stitching to a smaller tube. The spacing is the same. But you noticed uh the distance between each ditch is being reduced, this is gearing and part of your feed dimensional perception is to understand when he's stitching two things of irregular diameter and not equal the round the clock applies to both. But there is a difference in the distance between the sutures. So as you come down the gears like gears on a bicycle stitching that to that, it's the same principle of around the clock. But you got a different distance between the sutures there as sutures there. And I recall Mr Lincoln when they made a venotomy to stitch to a top end on the order. He said, no, no, that is too small. Took the scissors brought it in and went there and made a two centimeter slipped in the vein that I had to stitch to a four millimeter diameter hole in the water. And I thought uh the way to do it is very simple. You got to think of gears. So at the moment, we are talking about joining things together in a two dimensional plane. But what about a three dimensional plane enjoining it? So let me just help you with your understanding because people going round and round, round and round, go round around and they're thinking, get lost. But like going around Basingstoke of Milton Keynes through all the red roundabouts. In essence, when you're looking at two tubes, you've got to think of clocks and I'm joining this one to this one. So the hours of the clock need to line up and match the six o'clock needs to go to six o'clock. The 12 o'clock needs to go to 12 o'clock. So, if I'm joining that, imagine I'm falling that over onto the do that again. From six o'clock, I'm falling it over a note as I'm falling it over those dots are joining. All right, those dots are joining. So, you've got to think when you're joining one to the other, the clock is as you would expect it, 12 high 12. But when you're stitching here, certainly in Korean Optimus iss and the order the 12 is in the opposite position because you're folding the two together. So what does it mean from a three dimensional point of view? So let's look at what I have here. Uh, a little bit of tubes, I've got two tubes. So there you go, red green. And that would be, let's say six o'clock and opposite six o'clock at the top here is 12 o'clock and these two tubes have got to join together six o'clock to six o'clock and 12 o'clock to 12 o'clock. But this three dimensional orientation now becomes a relevance because the simple principle of surgery is you always stitch towards yourself because if you stitch away for yourself, you will be tripping over the future, particularly monofilament as um vascular surgery. So, as I'm standing up and I'm looking at this tube, whether it's a bit of bowel in the chest, but, er, they ought to, the hour of the clock that is furthest away from me. It's here, four o'clock. And that is where I start stitching. I start my first stitch as furthest away from me. Such from the back wall, eye stitch towards me. I come up to here and you'll see, then I start stitching away. I stop at this point and I take the suture again from here and come towards me there. So by taking it at four o'clock away from me on the posterior wall of this, I'm stitching towards myself from deep, too superficial across the back wall. And then I pick up the future for the front wall. And again, I find myself stitching from deep out towards me and there you go, I'll bring it together. It is as simple as that. But sometimes you have to just pause and think to yourself where it is. So these simple rules, I hope will give you some direction, feel on how to go round and round. Enjoy two bits together. Of course, what we talk about in surgery in vascular surgeon particular is a tube, but we don't see it as tube as a 12 o'clock and six o'clock. If that's the 12 o'clock, we see it as an ellipse, don't we? And as we see it as an ellipse, the 12 o'clock there is usually the toe and the six o'clock they're opposite is the heel. So as I take my tube and that alignment, what I actually do is think of it as an ellipse and then thinking of it as in the lips as a squashed circle. The same applies. I would start turn this way. I would start away away from me. That's away from me one to heal 124 hand all the way down to the toe. And then I've got just a few background sutures, but that's a way from my right shoulder and my stitching hand just that little bit is a way, but it's a short bit which you can cope with. But note at the heel in tone that the direction of 90 degrees is not, is a traffic ation. And what we talk about the vascular surgery is that traffic ation, an alignment at the heel of the toe. If you get them too far apart and pull it, you're going to squeeze the heel and toe and cause a problem with blood flow. I trust that makes sense to you. So here we go, we'd got to swap it 66 12 to 12, 6 to 6, 12 to 12. And we forwarded over to do the anastomosis. So a little deviation on this and to practice your alignment, I've introduced socks and I've put baby socks together here on the table and trying to simulate here, a bow anastomosis. And what we generally do in a bowel anastomosis. We have a mesenteric and anti mesenteric su chou which because the bowel is mobile, you can get alignment that simply moving those mesenteric in antimesenteric states, sutures over and orientated yourself. The great thing about these socks, I think is the natural rib within the sock is going to give you those invisible lines that we drew on the banana. And we'll get you to think about the rotation of your needle and your placement of the needle now inverted or everted. Really depends on how the needle is taken through. Whether it's pulled through from the inside or pull through from the outside. If you put it through the needle, the thread from the inside, you are going to naturally invert. And if you take the thread through from the outside, you were evert. But what I love about this sock mortal is the ribs in the sock that give you the alignment. So we now sitting round and round but in the three D plane towards you and I focused in. So you can see closely the ribs of the sock. So I can align my suture, a needle holder in my place position with the ribbon. The sock, the point needs to go perpendicularly into the sock. So I'm on the inside there. So I'm going to come out first and you've got to change the position your needle from the inside out. So, you know, just come in there, get a little bit of the mucosa and come on the outside need swap the needle position. I haven't used my needle holder, forceps to change that and come from outside in and I got to make sure it's 90 degrees at the same spot outside in, pick up the little Little Makuza and I pull the future through and I'm inverting this for as folding in as I do this. But as an exercise of alignment of your needle imposition, it is fabulous. It is fabulous because it has given you the direction that you need to go and remember it's 90 degrees perpendicular to the tissue. And with this repeated movement of I/O and I/O, you got to have your needle holder and needle working, enabling you to move from forehand to backhand without actually using the forceps to change it. It means that I'm not hurrying my stitches and I'm focusing all the time on the placement on the future and this is where the economy of movement and fluidity comes in. I'm not stitching fast far from it. What I'm doing is I'm stitching deliberately and taking it through the sock also is unforgiving about the entry. The banana was telling me exit point on the skid mark. The sock is unforgiving on the entry because if I'm not 90 degrees to the sock, my needle is not going to glide through, you know that from stitching a button on your shirt and there you go as I'm stitching that I'm bringing the mucosa together and I'm inverting the edges, the same would apply if I'm doing a vascular anastomosis or in a vascular anastomosis. We want the endothelium to touch and the endothelium is the white of the sock. Here. This time I've started and I've come on about four o'clock and I've come along the back wall and I'm going to come over the front and then we got the back wall that was the back wall there. I started at four o'clock again demonstrating that I have to pause for a moment and orientate where I am from deep. The four o'clock on this vessel was at the back wall there four and I'm coming along the back wall here towards myself. And that is the one that because vessels are not fixed or fixed and do not move around, you've got to make sure that that back wall is as secure as you can possibly make it because very often you're not going to be able to see it again. I'll get to it. So in this case again, but like a dissection, the endothelium has separated from the adventitia. It's two layers. And unless the two layers are sitting together perfectly like that, you should take them in two 90 degrees across both same dissections. I would take equal spacing of that very soggy, fragile and to see him and then come through intake, a teacher of the urban Tisha and take it through from the outside and by taking through from the outside, we hope that we are everting the sin osmosis. And at the same time ensuring that the endothelium is sitting clearly together the simple moat model with a sock, yes, rehearsing your alignment for your anastomosis. Not any that if you don't go through at 90 degrees, the entry of the needle to the tissue will be problematic. You will note now because I'm using a monofilament without an assistant holding my stream straight. It's becoming a one handed nightmare and a problem to demonstrate. But as an exercise of thinking orientation in getting your head round, round around conundrum and organizing or switches, I sincerely hope that makes sense. Have you got any questions? Please put them in the chat room, be very happy to answer them. Even now in emergency situations, I sometimes have to step back with a dissection of reimplanting. Connery's have to think back and re implanting head vessels and you at the back of the chest, starting deep, working towards yourself. Each and every time the place point rotate is of critical importance. There was a paper in the journal of Cardiff forensic surgery. And the only one I've seen described of the 90 degree principle by an aortic surgeon doing diet sections because that wet soggy aortic tissue is totally unforgiving when it comes to pour rotation. The only other surgeons that I understand really appreciate the 90 degrees where it's literally visible or should I say invisible? Are those are thermic surgeons putting regular switches in corneal transplants? Think about it. If you're not perfectly radio or your sutures are not going through the cornea in 90 degrees, you'll end up with blood vision. That is very real and very visible. But the same principle applies to stitching all other tissues. It is all about setup, understanding the anatomy of your needle. 123, halfway, no space between the tip and the tip of the shaft of the needle. And I googled out and then it is place quite rotate. And Harrison Sienna and I are talking about the rhythm of surgery. And then when you're talking to yourself doing this, it is 123 place point, we take 1 to 3 place point repeat and there's a natural flow in rhythm that comes with it. The great thing about the banana is over time. You can see it diverse. So your exit wounds become even more visible and the white of the banana contrasting with the black of the edges. That is why I do believe that this ends up is the most reliable and interesting reproducible stitching model that you could possibly use. I'm told that the biggest banana trees are found in Papua new guinea and the tree can reach the height of a coconut tree and the average banana on that tree reaches the rate of 3 kg. That's one hell of a banana. I think we went bananas and asset I do commend it as a model and I did say I'll tell you about the second done model for stitching because the bananas teaching you about the rotation of the needle and has taught you about the exit of the needle, as evidenced by the skid mark and whether the flesh of the bananas intact. Once you've mastered that, it will take you another couple of years as it does in martial arts to get your second done. And my second dad marble becomes more challenging. Again, in this circumstance, we boil an egg, we cut it in half after peeling it. So you got the yolk in the middle as a hemisphere and the white. This stitching model test your entry of the needle into the tissue. As we saw with the socks, you need to now place your sutures, Ray Villy between the yolk and the white and rotate your needle out without scrambling the egg. It's a difficult exercise and I'm not joking. Excuse me, I've rehearsed these pans and these models for a few years. I hope this has made sense. And I certainly look forward to seeing you again at the Black Belt Academy of Surgical Skills for his next week. My colleague friend now Downey, who was a training cardiothoracic registrar, a couple of years behind me decided to change career and now he's an esteemed pilot and captain with a lingus and running a human factors course we're going to discuss in compare contrast learning to fly, learning to operate than the value of simulation. The following week, we're going to start on another essential tool and the central tool will be the finest cut we will be exploring how to use the scalpel and hopefully get you to understand the feel of the instrument a bit like the theme that we had an asset. And as described by being braun, is this all about the feel and we hope we're making a difference. Thank you very much indeed, for joining the Black about Academy tonight. I wish you well and we'll see you next week.