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Ok. Hello. Good evening. Good day. Good morning or good afternoon. Wherever you are in the world and that is everywhere in the world of all the followers. We have a medal. The top five countries are the UK, Pakistan, Algeria, India and Egypt. Well, it's interesting the top cities of Bucharest in Romania above London, in the UK, Triply and Karachi and Lahore in Pakistan. I'm extremely grateful to you. The followers of the Black Belt Academy, the surgical skills. My name is David Regan. I'm a retired cardiac surgeon, 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. Yeah, I have been asked, why do we go round and round and round the syllabus and the same things all the time? It is because it is only through practice. Do you begin to realize the nuances of what we're doing? And it cannot be more evident than in karate where you spent years and years and years mastering an art? Only 10 s until you become black belt. But it's only when you become a black bear that you'd start to learn yesterday, we had a local competition and my son and I supported the club at the competition when we entered Carter and Black Bel. Late, the Carter was a Carter which is a combination of movements and techniques of our own choice. I have not won anything at these competitions to date. And it was my ambition to win something, but I was displaced in the Carter section by my son who's doing the same Carter fun second place and I got a third listen, treasure this my first bronze medal. I noted as I was doing the carter, the one of the moves at the end and it was the end meant that I had to step up with my back foot, bring it behind my front foot and turn aly to complete. And that simple movement under the circumstances being nervous, I fluffed, it didn't go as smoothly as I thought. And the thing about surgery when we're operating, we should always be looking at these little bits and learning from them. The second lesson was from the black belt elite. Now in the black belt elite, all those with black belt enter the competition and you go on to the mat and you have to facing off against each other doing a Carter that's randomly generated. So you could go on and do something simple or go and do something complicated. There was another lesson there. I didn't get any medal for that. My son got third place. The thing was, is that I was praying and hoping for one of the simple carters to come up first in the competition because the longest carter's got 92 moves and lo and behold, the simple carter came up but only flexion. It amazed me how nervous I actually was on one. I was now on stage and being watched by others. Secondly, is I practice all the difficult s and I haven't practiced the Simple Carter. So when I was paired up with somebody four times younger than me or Beit Ne is an instructor and extremely good and diligent in their practice and their movements. The simple car, I thought rif I'm gonna know this one. No, I didn't. And that is another lesson. Do not take it for granted and there's absolutely no place for complacency because we practice until we can't get it wrong. I've been doing karate for nine years, but I've been doing surgery for 35 years. And maybe if I continue my karate journey and continue to learn from each of these events, I make it better. And that is the philosophy of martial arts. You're only as good as your last counter and in surgery, you're only as good as your last operation. But at every stage, it is attention to detail and attention to the basics because if you don't get the basics right, the complicated becomes problematic and the basics need to be reinforced until you can't get it wrong because this gives you a framework for thinking critically under pressure. So even when you're nervous, you do it automatically without any problems. So the mounting of the needle, how you stand, how you mount the needle and the alignment we have gone through already. But to reinforce, we are standing with our shoulders, down, elbows, by our side, elbows, slightly extended and hands, palmer fleed. And in that position, you're removing all the major muscles of the shoulder girdle and upper arm and isolating those intrinsic muscles of the hand. The lumbrical it is in this position that you are able to affect the pronation and supination that you would see holding the screwdriver. And that's why we advocate holding the needle holder along the access of pronation supination because that is full and every position you put your upper limb, Dr Amanda Kley at Imperial College, Bio Genetics. And I were discussing this last week with a view to computerizing this view of movement and showing the relative position of the wrist. Elbow is proportional directly to the angle at which we hold the needle out. And that angle is important. The pick up remember is 1231 just beyond halfway. Two, there's no space between the tip and the shaft and three, it is angled out and that needs to be done each and every time. 123. Because in doing this, your needle's in the right position and the needle holder and you're now ready to affect a stitch. The stitch, remember the needle has to circumscribe a circle perfectly thin in and coming out. And to do that, we emphasize place point protect. And we've done that on a banana model on linear incisions. And even on curved incision demonstrated on the banana 60 degrees between one end and the other. But the alignment each and every time has to be perfect. So what happens when you come to stitching in the circle? And we literally go round and round. And why I call it round and round is to emphasize the fact we're going round and round the syllabus. But also now we're stitching round and round because whether it's a vessel or Ureter or bowel or Bronchus, it is all a circle. And do we know how to stitch in a circle? So I have a question for you in the poll on which foot do you stand for a backhand stitch? And perhaps Gabrielle, you could put that up and I'd like you to answer which foot do you stand for a backhand stitch? Please answer. Now, is it the left foot on the right foot? And this is for a right handed person. I should say any answers. Yes. So they're just coming in. Uh So far more people are voting for, right? Um But it is, I can OK. Now, I'd like to take you over to the model. We'll come back to this question at the end. Take you over to a simple model to explain what we're doing and why go back to the screen. I take that off the screen and I'll take you over. And what I have here is very simply, I've taken a plate, taken a plate. I know it's marked out just round. I've marked out some quarters. And if I am standing here, the top is 12 to my right is three, the bottom is six and to this side is nine and you'll recognize and I need to point it out because most people are wearing digital watches nowadays and we don't have clocks on the wall. This is a clock and the clock phase helps you orientate and think about your stitching. So the most difficult stitching surgery is stitching in to your stitching arm. So if you're right handed, it's stitching into your right shoulder. Let me describe what's happening as we go around. Remember that the needle needs to be align, pick up properly such that the belly is bouncing on the surface because if I don't actually like it, hear the difference and that's a sound check that my sagittal plane is 90 degrees to the tissue. And remember 90 degrees is the perfect angle as its equal and opposite angle is also 90 degrees in every orthogonal plane. Sagittal plane confirmed note the angle out which is actually equal to the angle of the forearm from the horizontal with the displacement of the wrist down because we're operating at depth 90 degrees. And now I'm standing on both feet in this position. I've shifted my weight more to my right leg to maintain that position. And as I come around the clock from eight o'clock to seven, my weight distribution has now shifted here to predominant on my right leg more on my right leg at six o'clock and here at five o'clock between five and four o'clock, I'm now stitching into my shoulder. My weight is predominantly on my right leg. What's interesting in karate? All the stances and positions are stated with a weight distribution in percentages. So food is a back leaning stars with 95% on your back leg. And I will say in this position, 95% of my weight is on my right leg. I cannot defect a stitch further around here because it's coming into my shoulder. And the only way to affect the stitch is to unwind and I'm now transferring my weight to the back and, and now it's at my left foot. So my weight has gone 100% from my right foot to my left foot. I'm now moving around three o'clock and transferring my weight slowly the opposite way with alignment each time 2 12, 2 11. And I'm now reaching an awkward position here between 10 o'clock and half past 11 I that have to do and it's a good like ceiling and jiving swap my weight around again to affect forehand stitches. So what you note and I see with people stitching that across this diagonal, I've got here on the clock, usually between four and 5 10 in opposite 10 and 11 is the difference between forehand this side and back. And the other side when you come to practice. And this is the Black Belt Academy of Surgical Skills exercise. We suggest that you use the banana and you have used the banana to date because it's totally and utterly unforgiving and a bit like the golf analogy we've used, draw lines with the barrow on the pen marking out at 12 o'clock, six o'clock, nine o'clock, three o'clock, 12, 693 and try yourself. And I'll start at this position, please. 90 degrees across what you want to stitch on a radius, rotate it back 90 degrees into what you underst did and simply rotate out. Now, if you've done it properly, the needle should come out on the line, deliver the needle iterative, just be beyond halfway, kick it up and it should have that angle on it. Ready to go again, place 90 degrees across what we want to stitch, rotate it back, 90 degrees into what we stitch one stitch and take it out. See if you come out on the line, pick it up. Once you've delivered more than halfway, we take it off the humana. And again, and as I'm doing this and describing I'm changing the weight distribution to my right ear. Pick it up 90 degrees across what I want to stitch each time before I do this. I'm checking the position of my needle on the needle holder at the tip just down on halfway and there's no space between the tip and the shaft. Please. I'm pronating to point the needle into the tissue and supinating to, you know, take the needle out of the tissue. Now, my next stitch is going to be into my right arm. I'm now transferring all my weight from my right foot to my left foot to affect the backhand stitch in this position. Now, what I often find on the benign model without the lines that transition from forehand to backhand usually leaves a significant gap in that space between the five o'clock and a four o'clock and I can continue around and simply putting the line there even points out small margins of error. And that was what it was in the karate competition with the carter. There was these little margins of error that compromised the whole con and a medal was lost. That's why you got to practice and practice and practice till you cannot get it wrong because even though small margins are important in practice, and then you have it. OK. So there you go, small margin of vera less than a millimeter that counts and is important. So once you've mastered that, I suggest, then you try it without. And why I like the banana model is because it is possible to see your ait and this Axid each time gives you a clue on where to do it. So even without a stitch, just with the needle holder and the banana, either the drawing lines or with that imposition, the alignment is described for you by that hole, 90 degrees across what you want to stitch, rotated your back, say 90 degrees into what you wanna stitch and rotate it out. And the important thing is in doing that, hers, the needle come out in the same spot as before. In other words, you are demonstrating consistency. There is a Japanese art of making pots that you need to make 100 perfect pots exactly the same. And if 99 fails, you have to start again. There you go. Three in a row. The needle is coming out on the spot. So what does this mean? We are stitching now in a two dimensional plane but circles and going round and round is not necessarily in a two dimension on the plane. On the contrary, but before we go into that, this practice, just to show you can also be translated into cardiac surgery, stitching. And I use this banana model on a 50 Castro needle ca gave a needle holder with a 50 suture to mimic doing the top ends for coronary surgery. The setup is exactly the same. You have a banana, the angle and a fine needle hold it and the small needle is exactly the same as well. The idea is to take the needle I/O of the banana in a similar fashion. And even with a small needle, you'll find that the banana will invert com develop over time and show you the entry exit rooms. But the principle is the same, you focus its life with David. Thank you very much. I do that. Ok. Thank you, sir. Place. I'm rotating back this time rolling the barrel of the CASS with my fingers and rotating it through again, delivering it just beyond the halfway, picking it up, delivering the needle. And I should be in a good position ready to do the next step, take place, rotate it back. I let me take it out and even with a small needle like this, you can see the exit wounds and so to speak, developing on it's been on. So these models are telling you and giving you instant feedback when things are not being rotated properly. But of course, we are doing this with it flat on the surface and that's not what we're normally doing because it presents itself as a circle in all forms of fashion with every angle possible and that's where it becomes challenging. I'll show you an example. This is the model that I've developed with Kevin Austin of Wet Lab to teach aortic valve replacement. Now, at the bottom of this is the aorta is usually pointing over one's left shoulder as you're operating, that would be the right coronary artery that's left coronary artery. And these scalloped areas, the commissures of the aortic valve and I'm can focus down a little bit. I'll just look at it from the inside, but there's a circle. Ok. There is the circle now, although it is called an annulus, it is not the aortic valve is commissars and the scallop between the commissures and the tricuspid valve. But what we practice on the course because the aorta is at a funny and oblique angle is how to position yourself for each and every one of these stitches focus down. So what without the needle, where do you stand to actually make it 90 degrees across 1 to 1 stitch rotate about and 90 degrees through your what you one stitch. And here again, the feel of the tissue should feel like leather as you take the needle through. But if you look carefully and I've left some sutures in there, what we need to do is make sure the sutures come out exactly next to each other. And underneath the alignment is like horizontal mattress sutures going through the annulus. But you can see that this is an awkward angle and you need to get 21 to 28 mattress sutures perfectly aligned around that. For those who join the para excellence and para aortic courses, we've adapted this model further such that this is now translucent. And the interesting thing is we can take it out and look at our sutures from underneath, having put the aortic valve in because the paraprosthetic can only be seen from the ventricle side and can never be seen from the top. I've digressed a little onto my favorite subject. So if we imagine that that is a circle, OK, that was 12 o'clock at the top there and I, I'm tilting it up. Ok. What we're wanting to do is, hey, to get our sutures, 12 o'clock, six o'clock, three o'clock, nine o'clock. And when orientating tubes, the principle is always to stitch towards yourself. So therefore when starting to stitch a tube, a bowel or a vessel, you start at the furthest point away from you represented by this red need. That's at four o'clock to hold my plate up again and hold the 12 o'clock at the top. The furthest point away from me is here there at four o'clock. And that's where I'd start because I could come towards myself from that point over the top, towards myself there. And why it is always towards yourself is because you're not tripping over the sutures. So if that is 12, ok. And let me just get my little bits of tissue if that is 12 at the top and you're not stitching it to something. I think that's 12, 12, 12, 66. And you're coming in at four o'clock which is the furthest point away from you. We need to bring it down into something where we got a mirror image. So six goes to 6, 12 goes to 12 and we start at that point. So if I brought this up a 3d fashion, so I brought it up in a 3d fashion, you'd have that red to red, green, to green, black to black, white, to yellow and then blue as we go round, let me just move this white and put the blue hat pin in. There you go. And that's what we're doing. And really what I'm doing here is from inside out, OK, inside out. Now, whether it's inside out or outside in, it depends on whether you're stitching bowel or stitching blood vessels. Basically, the rule is is that you want the intima to be touching or the mucosa to be touching without any damage whatsoever. So if, if those together you see red to red, green, to green, yellow, black to black, white, to white and continue in a 3d perspective with 12 on the top. If you're looking at a circle, just think how your lips is the same thing. And the lips, fusiform shape I should say is what we see in vascular surgery and the same thing applies. But these points we call them cues and toes and alignment as I showed previously is trifurcation at the top for heel and toe, but the heel and tear the needle is parallel to the two rears of the vessel. And you see the, the back is straight down the vessel and those are either side of it as well. So the circle round and round, whether it's the shape, oval, fusiform is all the same and the principles are the same. Now, what happens if they're two different shapes? You're stitching one thing of that size to something of that size or something of that size. OK. You will see that the 12 o'clock is the same, the three o'clock is the same, the six o'clock is the same and the nine o'clock is the same as are each and every time the clock. So if you're stitching things of different size, it's important to bear in mind that your spacing is still 12 around the clock on the big one, but likewise 12 around something smaller. So hence, it's a bit like gearing, all these gears are being meshed together and brought in to ensure that you got even perfectly circumscribed stitches. Thing is with each and every one of these stitches. You need to be saying to yourself, 123 from the position, place point rotate when it comes to stitching and you vocalize that to your itself each and every time. So what I like about this, this model I've got here is mimicking the back a vascular anastomosis. And I've just noticed that I'm on the wrong side to deliver this, but I will demonstrate why this is a useful model. I'll tell you what I'll get my of this will count. And these are baby socks. The baby socks are quite useful. We'll see why immediately. So as over the line, the baby's socks up there, the four o'clock is here away from me there, four o'clock, 12 o'clock at the top. And as often happens, the intima is separated from the avent tissue, especially in dissections. But what's nice about using the soap is you will see that the sock has a weave go in the sock has a weave. This, we've enables you to lie and concentrate on the place in. You'll remember from your stitching of the button. And as demonstrated earlier in the series that to try and get a needle anything but 90 degrees through the tissue because effort and therefore the simple mock sock model rein forces there you go. Rotation of the needle. Usually with the a monofilament, I prefer to have an assistant to follow. And this way it makes it a little awkward. I'm just picking up the tissue there. And because it's a different physician, your rate entry and exit has to be 90 degrees across both. Since they're not sitting together, it's got to be done independently to do it to one girl is not going to take the layers together properly. So the important thing is see, I was trying to do a stitch and my needle wasn't actually properly corrected. And I noticed that as I was going in and talking to you, but you stop yourself before you do it and put, putting torque on the tissue, don't be tempted to push that through to get the other layer because a thin intima in dissection will tear can give you a problem. So therefore, it's got to be done to the sock is not holding the needle for me. And therefore I'm having to pick it up with the forceps. Remember the tissues usually hold the needle for you and therefore picking up the forceps is not necessarily all the time. But each of these layers needs to be approached with the same point place, rotate as we've been doing with a banana to date and a single layer here, we've effectively in our so model got four layers involved. Each needs to be addressed in the same way. And there is it good way to practice your skills on a sock. What it's doing for each time is reinforcing to you your placement. You can look at the echo distance along there four millimeters apart, which is one we and look at your placement and ensure that you're going through, the material will not accept me going through at a funny angle. And therefore I have to be deliberate and how I placed the sutures. OK. They said doing this without an assistant is, is the the awkward side. But and there you go, that's why I sort of could cause I've just crossed the suture and demonstrated exactly why you need an system through the tissue and through the loops and catch yourself. And that's why you need somebody to be following on a lateral hold and not a full the bowel anastomosis is here. Your mucosa is in pink. Now, what you need to do is we ought to bring it together in your socks to ensure that the mucosa is brought together. And this is inverted, inverted can. Yeah, that's great. Ok. So this is the bowel. It's the mucosa. All right, pink. You need to practice it such that the mucosa comes together and you're inverting on the outside, inverting the sock and you do that by bringing your needle through. But this time delivering the needle from inside, not from the outside and take the suture off just on the one side and demonstrate. So this time, same thing applies rather than inside out, just to say on the vascular anastomosis. You got to be inside out downstream because you do not want to lift the intima of the adventitia. So it doesn't strip away. So the principle is the downstream element should be always inside out in the bowel that doesn't really matter. So what we're going to do here, yes. Come from the outside and the attack your mucosa rather than take stitch all the way through. Some people put a stitch all the way through others tack. Many years since you did general surgery. So yeah, inside 2 L5. So it inside and simply taking the suture through right to the inside inverts. I definitely need assistance in this to demonstrate you prop in that the anastomosis. But even if you don't have consistent, it is useful to practice the skill just with a needle to get you literally your alignment and get your I am I need to the layers and we treat each layer in turn and you get out of focus again. Thank you. So, very simply when we say going round and round, whether it's in a two D pain or 3d playing, we employ the same principles and that is ensure that you pick up the needle, it's perfect every time on the foot you stand on for backhand, stitch for a right handed person, he answers the left foot and simply changing your weight distribution from the right leg to your left leg, tilt the pelvis and then tilting the pelvis will rotate the shoulders as well. And those few degrees of freedom give you that extra maneuverability and axis as you're going round and round is not a deliberate, sometimes it literally is a deliberate step, but other times it's simply shift in weight. Are there any questions from anybody watching Gabriel? Not at the moment, but maybe someone will put the questions. Now, if you have any questions, put them in, no questions in the chart. So it comes back to my karate carter that I did that simple bit. I was standing and then K Dashi which is a 60 40 split having finished in that position. What I needed to do was bring my back foot to my right and let me turn around and finish. And that simple maneuver I fumbled and I lost position on that car too. There's no complacency in these things in a competition, their multiple moves each requiring a deliberate position, a deliberate maneuver. I'm demonstrating that, you know, the technique, I think there are 27 moves in that particular count. And one simple stumble on that rotation cost of place. But that one simple rotation failure to rotate the needle in an an osis wherever you are in the body could mean the difference between success and failure. But you're not going to appreciate that. And two, you start focusing on getting the basics right. That's what we try to do at the Black Academy of Surgical Skills is reinforce the basics and offers you models to practice at home. The thing about a model, but like the salt, it doesn't have to be the real thing. What it needs to be doing is mimicking an element of the technique. And the important thing is the basic the alignment of the needle to the tissue. Please do not ever take the needle to two layers unless they're sitting together and they needles perpendicular across both in all circumstances, whether it's fusiform or a circle. Remember to be 90 degrees across what you want to stitch and the more you draw that in, the more you pick yourself up and poor needle picker, the better you'll become. And that's what practice is all about. And that's why martial arts takes a lifetime to master because even the simple oldest things have another level of known and complication to them that you only appreciate the practice. Thank you for joining the Black Belt Academy. Next week, we're going to be joined by Fellow Sense Chris Dear. He is an emeritus professor of surgery, the past president of the Association of Canadian Surgeons, a senator at the University of Alberta, head of the Division of Bariatric Surgery and now retired and writing books and is kindly written a lot about the instruments that we use and this is now available. Thanks to Gabrielle on the website of the Black Belt Academy, do join us next week, we're going to be talking about show me complications. This is often asked of the surgeon. Do you have complications? And they reply no, I don't or show me a surgeon who doesn't have complications? How do you collect your data? How do you actually deal with complications? How do you live with the complications? We work in a show me environment and I feel if you're not prepared to show me you shouldn't be allowed to operate. And as that philosophy, I inculcated in trainees when they did an operation. It was their responsibility to put it on the pat data system there. And then contemporaneously inaccurately to reflect the excellence of their work. Had they not done that I would not allow them to do the next case because it's important that we demonstrate I work and you're only as good as your last operation. So do join me next week as we chat to Chris Gara and we explore this subject, which is often regarded by many as a taboo. Thank you to all of you wherever you are in the world. I am going to ask mad and ask you the most convenient time to run this considering that this evening we have got people from 17 different countries. Thank you very much. Indeed. Do pass away around and do tell people it's available on catch up as well on the med platform. Thank you Gabrielle for hosting this evening and thank you for joining us.