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Summary

This on-demand teaching session will provide medical professionals with the knowledge and skills to use scissors for surgical procedures. Led by retired cardiac surgeon David O’Regan, the session will explore examples of scissor models, such as Mado scissors and Chinese paper cutting. Participants will learn how to hold scissors to ensure accuracy, precision and safety, and will also put these skills into action by practicing with paper and sausages. Join us to experience a unique and engaging educational session and equip yourself with the surgical skills you need.

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Description

The McIndoe scissors are perfectly designed for dissection. BBASS emphasises the correct hold to maximise the feel and use of he scissors. They are the 'Swiss Army Knife' of the instrument tray as they can be used for cutting, dissecting and separating tissues. BBASS offers unique low fidelity models that can be used to 'home' your surgical skills.

Learning objectives

Learning Objectives:

  1. Understand the history and design of the MacDo Scissors and their importance in surgery
  2. Develop proficiency and precision in using scissors to cut surfaces of various shapes and textures
  3. Acquire techniques for safely cutting tissue layers to avoid damaging the underlying layers
  4. Become knowledgeable on the principles of blunt dissection to remove tissue
  5. Understand the importance of feedback in developing surgical skills, and practice paper cutting and dissecting sausages to aid one's understanding of scissors technique.
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Computer generated transcript

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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 o'regan. I'm a retired cardiac surgeon living in Yorkshire in the United Kingdom. I'm the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College in London. If this is your first time joining the Black Belt Academy, thank you very much. Indeed. To everybody watching. If you have any questions, please put them in the chat room, the producer re this evening for med, all will ask the questions and I'm happy to be interrupted at any stage. I'd like to thank the 4231 followers on Facebook and the 643 followers on Instagram. Tonight, we're gonna be talking about scissors and on the menu because we are homing surgical skills. I have a tangerine, an orange smoked mackerel and a raw pork sausage. And I hope with these three models to demonstrate the essence of scissors and dissection and separation of tissues. A visiting student from China gave me these beautiful Chinese sensors. They're rather big handles and loops that your fingers go through but awfully sharp. And you can feel the blades as they move together. But this was part of the Chinese art of cutting paper that beat that hand cut paper. And you and I throughout our kindergarten and nursery school, we're encouraged to cut paper with a pair of scissors because that was part of your coordination. One of my favorite instruments in surgery is this. They Mado scissors. And I did ask in your homework, who was Mac and Dough? And we had a correct answer. Mado was born in New Zealand in 1900 went to Otago boys school and then on to Otago University to study medicine. He was the first person in New Zealand to get a fellowship to the Mayo Clinic in America. Having gone to, to hospital in New Zealand. That is by the way where my colleague Dave mccormack works in his fourth time in karate and in the southern hemisphere, his attention has been distracted by management. What's interesting about mcindoe? He got this fellowship and the instruction was only for single men, but he had been married six months previously and he didn't tell them. And it was only after 12 months having traveled to America by himself that his wife joined him on the fellowship. I like this. He didn't break the rules. He bent the rule because the rule was stupid. He was then spotted by another one of my favorite surgeons, Lloyd Barclay Moynihan, whose bus is is at the top of the stairs, at least General and family. And Lloyd Barclay Monaghan invited him to come over to the UK and his cousin Harro Gilles, who is an O laryngologist at Barts Hospital specializing in cheek fractures, took him on for surgery. He then became a fellow of the Royal College of Surgeons and was appointed as a consultant at the London School of Hygiene and Tropical Medicine. Before becoming consultant at East Granted just before the war. And this is where he made his name in the reconstruction of disfigured and burned World War two fighter pilots. So the next interesting point is that he noted the pilots who came down in the sea survived better and did better on the grafts than those who came down on land or on water. And from that decided to, to prepare his skin grafts with saline, which improved the efficacy and the take up rate. What was interesting on the third point is not just his curious mind but the fact that he looked after the whole of the patient, he disposed of the convalescent uniforms and I'm sure you will be aware of these dignity gowns that we have in our hospitals and in the UK, they're open at the back. And so somebody walking down a corridor would think they're covered, but the posterior and air is exposed dignity, not, but what was also important. He encouraged the locals to invite these disfigured, burnt soldiers to their homes, to entertain them. And you also only employed good looking nurses who would not turn away from somebody who was severely disfigured. Apparently a lot of hanky Panky went on at East Granted Hospital and many of the soldiers actually married the nurses. He went on to be knighted for his services in 1947. And he established the Royal College of Plastic Surgeons. It doesn't end there because in 1957 with two of his pupils, he bought a farm at the base of Kilimanjaro in Africa. And he established the African Medical Research Foundation. His ashes unturned at the raf church in Saint Clemens Danes in London and he is the only civilian to be buried there. So knowing the story of Archibald Mac, do we need to appreciate the design of his scissors? Why are they so beautiful? You'll note that there's a curve at the end and that curve should be with the curve of the wrist. So when you're looking at the scissor is down the plane of dissection, you can see the belly and you can see the tips the way to hold it as previously discussed when all the Black Belt Academy is through the pulps of the fingers. Cause that is where you get the feel and it's the s of the fingers that are applied to the scissors So I do not have the distal inter pharyngeal joints through the rings. I've applied the palps of my fingers obliquely through the rings and extended my index finger down to give me direction and proprioception. As I cut, as our colleague, Linda Deco had pointed out, I have learned to hold the scissors on my ring finger and that enables me to power my scissors and release these three fingers and I'll show you later to tie a knot and bring my scissors back into play. The fact is is that the scissors are beautiful for dissecting irregular surfaces, soft tissue, hard tissue. But you can only do that if they're held properly and with the curve of the scissors, your wrists and on the tips of the fingers. So one of the first exercises, although we're talking about separating, one of the first exercises we encourage with the black economy is go back to that Chinese art of paper cutting. And I'd like to take you over to the table now and show you a couple of models that you can practice at home yourself. Here we go. So what I have got here is black circles printed on paper. And the idea is holding the paper with some forceps is to cut round these circles as accurately as you possibly can now move and underneath. And I was, and when you open the scissors to open them no more than is required to do the job because it is a little ne ne and it does require patience and it does require accuracy. And at no stage during the Black Belt Academy, do I talk about speed? Because speed comes with practice. But really what we want is accuracy and precision. Now I did this earlier and if we focus down, I did some bits that were accurate and some bits not. And you can see that if I put it on a contrast background, the bit that I've just cut there, there is no black whatsoever. As a cut around here, you can see the rim of black and some dog ears that I've deliberately left there because it shows you and gives you feedback on the accuracy of your cutting. So simple paper exercise. Yeah. And uh is a difference between accurate cutting here and not an accurate cutting there and alternating that with a black background. I can then take this off and put it on a black background and see if I've got any white left. So this is the basis of the one of the scissor skills that we are going to put on the app on the Black Belt Academy of Surgical Skills. So I can now put that on literally black and white. Do I have any black there? Yes, I did to show you the difference. But around on this side, no. Do I have any white on this? Yes, you can see little flecks of white. You can do the same exercise using bars, printed on paper. And I'd like to think, yeah, even though I've got a kind of scissors, I should be able to cut in a straight line. These exercises are not meant to be easy. They are meant to challenge you and test your skills. So there you go. You can have a look at that. We got white along there that bit. The first half, no white and the opposite is true. If I put that on a white background, the contrast shows you your degree of accuracy. So a simple paper cutting exercise will help you think about it precision in cutting. As I said, these are not supposed to be easy at all. No. So this time, I've got no black left on there. However, if I put it on the white surface, I've got a rim of white. So all these are giving you immediate feedback as to the accuracy of your cutting and your stitching. And the precision is achieved by opening the scissors no more than necessary to do the job. My fingers extended down and I'm literally nibbling as I go. And that nibbling is really what you're using to develop tissue planes and separate things. So my first example of tissue planes is the pork sausage. Now, I like the pork sausage because you've got a skin over it and the skin is not too dissimilar to the fascial layers that you would get over vessels the scissors are kind of useful to insinuate into a layer. And you can see there's nothing between the scissor and the skin. So this is a useful tool to determine if there are any vessels or neurovascular bundles crossing the fascia layer that you are developing. So, having developed the plane again, using that scissor nibbling technique, we are separating the fascia of the sausage. And if it like cutting Christmas wrapping paper or birthday wrapping paper, if you're in a good plane, I can leave the cyst as partially open and slide them up to develop the plane further, not forcing my way, but letting the scissors do the work. Pausing now and again, two did develop the plane there. I can see masses under underneath and I've got a clear view of the tips. So I haven't got part of that skin off. I can use the scissors as well to gently stroke the tissue off. If I'm in a good plane and use the scissors in this regard for blunt dissection and the use of the sausage, it is fabulous because you need to preserve the sausage underneath and leave nothing on the skin. So there you go. The scissors. Now, are you being used to tease the skin off? Now, that was a regular pork sausage that I bought at Morrison's today. You can get sausages with thinner skin. Tu Piatti. So you look at what sausage is available in your supermarket and give it a go yourself. But the simply open thing, the scissors is enable me to develop the plane slide, my scissors along underneath, clearly seeing if there is any space. So my next bit is going to be a challenge. And that's the thing about the Black Belt Academy is I'm introducing low fidelity models all the time that are going to give me feedback on what I'm doing and develop my skills as a surgeon. So you'll see here on the smoked brit of mackerel, it's very soft tissue and smoked it may be, but there's still a tissue plane between all the layers. And the idea is to try and develop this tissue plane carefully without macerating the tissue either side. So I'm gonna use the combination of blunt dissection, hand shaft dissection, nibble the tissue. I'm gonna use eye open to separate I removed to close, open to separate I removed to close, you never close. And this is the other principle of using the scissors, you never close the scissors if you can't see the tips. So you open gently to separate the tissues, you don't open it hard because it'll force it open and macerate the tissues and all these models. And I haven't used this model before. And this is the first. So surgical dissection on a smoked mackerel, just putting a plug in for sustainability. This is organic. It gives you a real feel of what is going on. But the smoked mackerel will be fabulous with, for the dogs on their biscuits for breakfast. So there's no waste to. The Black Belt Academy is conscious about sustainability, plastic suture pads, plastic material and waste. So there's a, a very difficult tissue plane here that I'm teasing out. I'm trying to separate in different layers and I'm using that with a little bit of sharp dissection and a little bit, a blunt dissection and it's easing. It's a gentle easing because if I put my scissors in and look to that la, I tear the tissue, that's not what I want to do. I want to actually develop the planes themselves. Oh And as I open it up, there's a plane and I'm using my forcep to hold that plane open and I'm gonna develop that plane a bit further. Oh, there we go. There we go. Yes, I'm fileting the fish. But I'm using my scissors to separate the tissue plane gently and I'm not forcing it if I was forcing it the straight, get on the other side. This is a boneless fat bit of mackerel and I can use this again to develop the plane. There you go, starting to fall apart there. But same principle of a combination of using your scissors as a blunt dissection tool as well as a sharp dissection too. And the sharp dissection tool as you've seen is taking the scissors if it's a fascial laa and separating it in that sort of action. But the whole of this is to give you a feel. No, because the mackerel is so soft and smoked and cooked, you very quickly feel your way through this tissue because if you're hard and brutal, the legs would not separate. You could do this on cooked fish, uncooked fish, whatever is your fancy. And I'm gonna use again, insinuate my scissors into this leg here and I'm opening it in the line of the plane just to try and tease the la. So I'm not going across it because that rips. I'm going along the line. I didn't say it was gonna be easy. But the whole thing about models and home practice is to choose something that is real that is going to give you feedback if you are really clumsy. And I hope by the end of this, it's not going to look like a macerated mess. I think that's one of the more difficult models that I've actually used to date on the Black Belt Academy. Something simpler but also equally difficult. Yes, this des clementine in a lot of infected cases, there is a thick fibrous layer over the tissue, not too dissimilar to the skin of the clementine. So again, the principle, I'm developing the layer opening my scissors up in the tissue and I'm taking them out, the scissors are used if you've got an irregular dissecting surface or very hard tissue and you're working in a small area. This is again, teaching you that lightness of touch, but also gaining confidence in opening up scissors in tissue planes. And the idea is to do it without damaging the segment underneath. I remember taking pericardectomy, painstaking hours of dissection, literally nibble, nibble, nibble. And if you're in the wrong plane, you end up taking off the vessels of the heart and the epicardium. So being confident, dissecting tissues like this is of vital importance. And again, this is not easy here. Are there any questions from the audience? Please ask questions, feel free. I'd like to thank Rink on the call this evening, Riu set up a Google Drive and has actually copied me in and I'm watching her, her home practice and I'm seriously, I'm seriously impressed. Um There aren't any questions as of yet, but I do encourage and I have put it in the chat as well. I do encourage the audience to ask any questions at all. Um If they come to mind. Thank you very much, Lea. And if wrinkles on the this evening, I really enjoy watching your videos and watching the practice. So if you would like to do the same, I'm very happy to look at your practice at home and I'll be very interested to see models. We're going to run a competition in the next couple of months. But I'm looking for the most innovative and creative model for home practice and those who send me a good model, we'll get their own set of Black Be Academy Instruments. So, having dissected off the skin there, the next challenge for me in this dissection is to take out a segment and am I Abel to dissect out a segment and a bit like that little bit of macro? You see, we've got segments here as you have segments in the lung, you have segments in the liver segments in the kidneys and let's increase the lighting for you go. I hope not make sure we don't focus. So my scissors, I'm opening them up in the plane. If I open them up across, I run the risk of damaging the segment. So I've got to be careful both ways. Use a combination and I'm easing the segment out or trying to ease the segment out without damaging the clementine a side. So it's again a combination, lovely stroking using the blunt end of the scissors. You can imagine there's no point trying to use these because those are really sharp and gonna cause serious damage. What I like about this is there's a nice nose and a blunt end that's enabling me to develop this plane have. Who said that surgery at home can be boring. I do find myself as I'm concentrating here going silent as I'm focusing to talking and operating. There's also a challenge, but I hope you agree that we are making progress here and at the bottom end, I've got a little bit of bleeding. Yeah, we haven't called it bleeding. I haven't got bleeding there. I've got tangerine juice so I need to create a bit more space in my dissection two. Make sure that the segment is dissected. Free. Think about dissection. You don't work down one particular space. You are actually working over a whole area. So if you find yourself having difficulty in one area, move to another and continue the dissection and work around it and come back to it. Yeah, I've got a little bit of a little bit of sharp dissection to get that last little bit or fashion layer off. And now you have it surgery on a tangerine. Now, tangerine segments come out inverted commas relatively easily. So let's make it a wee bit more difficult and bring in and grapefruit. Now, the nelson scissors is significantly bigger and longer and it is something that I reach for. Yeah, when I am taking off pericardium or pericardectomy or in the lungs. And I'd like to thank bra for actually giving me these Nelson scissors for them. Yes. So sorry to interrupt you. Nicole asks in your opinion, what is the most useful instrument in surgery? Oh, well, it's a, they call it a combination of both the knife and the scissors but, and you got to know when to use them. Ok. But I, I personally, if you want me to name one, I like the Makindo scissors because of the story that goes with it. And the man behind it. It, and he epitomized what I believe are some of the greatest attributes required for a surgeon, an inquiring mind, a determination and a perseverance. But also he is extremely humble. And for me, what makes him wonderful and I'm sure it's only because it's recorded, he had the patient's interest at his heart and treated them as whole people and holistically. And for me that is why I think he is one of the best surgeons ever. Now, I'm not saying others don't, but this is recorded and what he did and that's history. So again, skin on the orange is a lot thicker and is stuck to the segments and it's a lot more challenging to get off. But I can assure you this is just like all the pericardectomy and cortex on the lung. Because if you imagine if this was a lung and I'm doing this and taking this thick cortex off, I'll know if I hit the lung because I'd see an air leak and it would bubble. In this case. What I see is orange juice, but the skill is just the same, not just the curve of the scissors is enable me to go around the curve of the orange and therefore on curve surfaces, the scissors proves fabulous if you got a flat surface as previously shown and we will be talking about in a couple of weeks is the use of the knife. The knife is useful in that circumstance, I can find myself spending hours you see down the side here, the skin of the orange is being pulled with the skin of the the or skin and it's just pulling off the surface there. So I need to be careful and stop myself doing that by nibbling the skin off the orange surface and leaving it on the segment itself. I just, I'm taking my scissors and I'm cutting in to the skin and not cutting now to demonstrate, holding the scissors the other way around from doing that. You can see that I am going to the nibbling against the orange skin, but the blades are opening and closing against the orange segment itself. And if I'm focusing on the points, I'm not looking at the blades which will be cutting the orange. And that is why you got to hold it with a curve of the wrist. The other way of holding sss is upside down in the ent version. So imagine I've inverted it. There you go. You're looking down my wrist, but I can move my wrist like that. And as I'm, I can see the point and I can see the belly and this enables me to dissect in depth. So if I'm find myself with my elbow and my a in the air as I was there and having difficulty, I've turned the scissors upside down again. The principle is I'm holding it between my index finger, my thumb stabilized with my middle finger and ring finger, but my fifth finger is extended down to give me that direction. And stability ent surgeons working down small holes, often use the scissors in this way and it gives you an extra dimension. So imagine if I was working down the center of this, if I put my hand over the top, you can't see it. I can't see it. But if I hold it upside down, you can see it and I can see it as well. And same again, I can dissect out these segments. And I want to be able to do that without breaking the orange skin and sometimes it's extremely difficult. And that's why we have these models. And the important thing is it's giving you the feel because I don't believe that any plastic N is giving you the feel on the tissue. Again, I'm using a combination of blunt dissection, a scissor and being used as a probe to separate the lens. But I'm also using the tips to cut. If I come this side, if I went in and went like that, you see the squirt of juice. Yeah, it just macerated the tissue. So the orange and the tangerine give you a wonderful feel for the tissues. So I'd like to see photographs of your practice. What things do you have at home or in your garden or in the supermarket that have layers. The picture I took and advertised was in the kitchen garden here at running park was of an arty choke. I couldn't actually take the arty choke off the garden not allowed, but that had layers. And I wondered what it would be like to dissect an art choke. But you got the picture so I can turn my scissors upside down again and I can work down quite a deep hole where as I got view of the belly and the tips. So coming back to what I said earlier, why I actually hold the scissors on my ring fingers is it enables me to palm it. And then I've got these three fingers free and this was a throwback from my days as a general surgeon and as a cardiac surgeon, I'd say karate empty hand. But you see, I can tie a knot with my is and I'm not going to cut the string with these scissors because it's quite rightly pointed out. Previously, those scissors are not for cutting anything but the finest sutures because it'll ruin the scissors and that would be disrespecting Maor. So I hope I've given you a flavor of how you can practice your scissors skills at home. It doesn't require much. I challenge you to send me photographs of your best pictures. I'm going to put a closing date at the end of October for the best and most innovative models across all aspects of what we've been teaching in the Black Belt Academy. And if you send in your pictures to metal with your name and address. I'm insured that you'll get some instruments. Now for the person in Abu Dhabi who won the competition last time, I promise you, I sent the instruments on two occasions, but they were sent back first because the address was wrong and second then it was not accepted by customs. So I do apologize about that and I'm not sure how to overcome, but I'll try again because if you don't succeed, you try and try again. I hope this exploration of scissors has given you ideas on how to practice. I hope knowing more about Archibald Mao that you will go away now and treat his scissors with the lightness of touch and the respect that he deserves. Be very pleased to take any questions from anybody or any observations and Ria perhaps you could feet that true. Ria wants to become a surgeon too and hasn't watched the Black Belt Academy for a while. So Ria, I'll ask you, what are your thoughts, please? I'm not sure if it was the sorry, it took a while to join. And I, I thought it was amazing. I was very surprised by the fact that you are such simple looking kind of things in terms of like the smoked mackerel and the orange to really practice your fine motor skills. I didn't realize that you could be so resourceful and still practice skills that are incredibly important. Exactly. Exactly. And the point being is you do not need a fancy skills lab. You do need not need animal tissue, either that is going to go off in your fridge and upset your housemates or spouse or partners, whoever simply walking around the supermarket with a little bit of imagination. You can think to yourself. Hm. I wonder and have a go. The thing is about organic material. It gives you that necessary feedback and that feel that I'm anxious to communicate and teach to you. And that feel only comes by practicing on different models and understanding that finer movement of your hands and the pressures. If you think about pivots and forces, if the pivot is there and it's force times distance, that distance and that force shorter distance and the force there is gonna be higher. So your hand has a longer lever to enable you to get in to a deeper cavity. But your hand has got a huge amount of force over that distance that's going to be equal and opposite to the force times distance this side. So that's why you need simple physics to be very gentle because the forces translated by your hand are going to be magnified simply because the pivot is there force times distance, force times distance and they got to be equal. So you can imagine the forces being translated in separating your tissues like that. That's I GC GCS physics for you. And if you can't remember, go back and remember and look at your pivots and moments. Any other questions? Yeah, I think is having you coming back in there aren't any questions as of questions? Ok. Well, I'd like to thank you very much. Indeed, Ria for hosting this evening. I hope I've stimulated your imagination and those who have joined. I'd like to thank you for joining the Black Mountain Academy and following. Please share it with your friends. One of my biggest concerns at the present moment is that surgical trainees are not getting hands on experience, but I hope to demonstrate to you that a lot of hands on can be done at home. And that's why our strap line is Hoing surgical skills. Next week, we're gonna be talking about shark dissection. Uh Then go on the following week, we talk to you about history and examination because it's decisions before incisions. At the end of the month, my two fellow senses, Chris caddy and Tim Terry are going to be talking about reflection, resilience, mentoring and coaching. What's interesting about martial arts? You play football, you play hockey, you play rugby, but you study martial arts in the same way that you study surgery, a mindset, a technical skills and practice are the same and we need to practice. Not until we get it right, but until we can't get it wrong. Thank you. Thank you, Leia. We'll see everybody next week.