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Hello, good evening. Good day. 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 heart surgeon in Yorkshire, the immediate pa past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. Tonight, we are making history in so far as that there are 100 and 42 people registered for this evening from 36 countries. So for many of you, this is your first time and you're most welcome and thank you for joining and you're joining at a very appropriate time in the cycle of the Black Belt Academy lectures because we're starting at the beginning. If you are returning. Thank you for your support. Do keep sending me examples and pictures of your practice. We will be running a competition in the coming months for the best examples. Tonight, we're talking about making a stand and in every sport coaches focus on posture and posture. I have deemed the most important element in teaching surgery in my described matrix that we have published posture is the first and foremost of all of them. But we 10 to forget this in surgery. I am standing in a Zen Kash stance doing an Ozu with a front punch. This is part of the first red belt in karate cause the first cause or the great ultimate. What was interesting in karate? Every single move is described and prescribed with exact foot positions and weight distribution between the front and back legs. The Zen Kusi Dashi is standing with your feet one in front of the other at an angle of 45 degrees with 60% of the weight on the front foot with a knee bent. So it's partially covering the top of the right foot. The back leg is locked out such that if I am pushed backwards, the back leg acts as a stay, the front leg is bent and that is protecting the groin area. My hips are forward, maintaining the lumbar lordosis and my strike with my fist is to the Celera and we do this again and again and again from white belt all the way through to advanced times. The interesting thing is that when you look at every sport, there is a description starting with posture, whether you're weightlifting, artery hurdles running, it all starts with posture and understanding the importance of that. Continuing the theme from last week of decisions before incisions. I'd like to make a comment, what matters in life is to take a stand and there will be situations in life and surgery, in particular where we must take a stand because there's value in taking your stand whether or not anybody notices or whether or not it is risky because doing the right thing is more important than doing the thing, right? And this translates into an excellent surgeon, knows when not to operate, you understand, when to stop hold and pause. But part of the philosophy of delivering health care and being in a health service is that service principle, the customer is always right. Your patient is right. It is what matters to them and many of them will come to you in a helpless or uncertain state. I'm afraid to speak up. We are in a privileged position to be their advocates and I employ you to do what is right for your patient no matter what. So from a evolutionary point of view, homo erectus and evidence of homo erectus only appears in fossils of 6 million years ago where they note that the angle of the hip to the femur changed and the surface area of the knee joint increased by 4 million years ago. The apes that were the predecessors of Ham Rectus, most of them were standing. And at 2.5 million years ago, we start finding a curvature of the spine with a lumbar lordosis and a cervical lordosis. At about 1.89 million years ago, the femur starts extending and the spine connects not at the back of the skull, but now underneath the skull and the head is balanced on seven vertebrae supported by 20 muscles. An evolutionary benefit for this was very simple. Although we were smaller compared to a lot of other mammals standing made us larger and more intimidating. It enabled us to forage for fruit in higher branches. But more importantly, it freed up the hands so we could feed ourselves, used tools and care for our young. And the human hand further evolved to enable us to pronate, supernate, put your hands together up and down and oppose your fingers. And that's what makes it unique. And when you think about it, surgery therefore, is at the ultimate of the evolution of movement and standing and using your hands to their best effect. But what we don't explain in surgery is how to achieve that. And what is worrying as you've answered that 97 of you actually have neck pain. And in fact, I've put a paper in the chat room that suggests that 96% of people have work related musculoskeletal disorders. 72% in the back, 53% in the neck and 46% in the shoulders. And this is higher in plastic surgery and neurosurgery and cardiac surgery. But 27% of surgeons will have severe musculoskeletal degeneration. By the end of their careers, I had fusion ac 56 for years of inclining my head forward and Tim Jones did a Mark Jones did a very good study that demonstrated 75% of cardiac surgeons in the UK had degeneration of the cervical spine. But nobody in my career taught me about the importance of posture and the importance of table height. Of course, the musculoskeletal degeneration is related to your weight, lack of experience wearing lead aprons and interestingly, women tend to be more aggressive than men. And it's suggested in that paper that is because the table height is perhaps too high and that they're raising their arms and therefore incurring a problem. What we have to remember is when we're standing upright, I bring in this pro is that there should be a direct line between the crown and the head, the yellow, the shoulder, the elbow, the hips, and just in front of the ankles. And if standing up against the wall with your feet, two inches from the wall, you should be able to touch the wall with your buttocks, your shoulder blades and the back of your head and easily be able to put your hand into the lumbar lordosis. In many of the basic skills programs that I teach, I'm encouraging people to practice their dominant hand skills with a non dominant hand in the lumber, lower doses trying to reinforce this correction of posture. The problem is you see is that when we start moving our chin forward from the midline, instead of being balanced on the top of the seven vertebrae for every 2.5 centimeters forward. You are adding 4.8 kg of weight to your head. So by the time your head's protruded forward, you've got 19 kg of weight. This is how much extra weight that your cervical spine is actually having to support. And what happens in this situation is that your chin goes forward, the sterno cleidomastoid shorten and tighten the shoulders round the pectoralis, major muscles shorten. You lose the cervical lordosis. You start hunching over with anterior pelvic tilt, shortening of hamstrings. And you can recognize the rolling of the shoulders over. If you look in the mirror and not standing correctly, your knuckles should be pointing out laterally, but with folded shoulders, the knuckles are pointing anteriorly almost in an apelike form going backwards. So the problem is with standing for long periods. Not only does it increase your heart rate increases, fatigue, predisposes you to varicose veins, the pooling and edema in your lower legs increases the oxidative stress on the body. But also you end up with degeneration of your muscles and fasciitis particularly in the feet. So to stand, one should be standing one's feet slightly apart with the knees between the 2nd and 3rd toes. Ideally, 1 ft should be slightly forward and you should be balanced on the balls of your feet. Do not lock your knees out in locking your knees out. You're immediately increasing the pa pain of your knees around the joints and the back, keep your lumbar lordosis. And that's why when we're practicing our basic surgical skills in the Blackboard Academy, I want your hand behind your back. When you feel that you are getting tight, put your instruments down, shrug your shoulders and let them drop. Be careful of leaning forward in that roundness. When you feel that happening, simply pinch your shoulders backwards to stretch and bring your chin back in. And one way of practicing that or releasing yourself between cases is to put your shoulders in the back of your head against the wall and gently walk forward. But keeping your chin in mind, you, you've gotta do all these exercises with care, mindful of any degeneration. But the interesting thing is that almost a third of you do no exercise at all and operating is actually physically very strenuous. In fact, we spend as in the paper, I've shown you 100 and 30% longer on our feet in any other physician in the hospital and that takes its toll. We need to work on exercise. You don't need to go to the gym to work out weights, but you need to work on core exercises and simple exercises like standing with your back against the wall in a seated position or on a plank, high plank with your back, straight, neck, straight and bottom down on your hands, on a low plank on your elbows for a few minutes a minute is good. A few minutes is very good and longer than that becomes exceptional. But that is keeping your core. What is interesting that Miyamura Masashi actually talked about the physical bearing in martial arts. As for physical appearance, your face should not be tilted downwards, your gaze should be steady, the back should be straight with strength focused at the nape of the neck, feeling the whole body from the shoulders down as one lower the shoulders, keep the spine straight and do not let the buttocks stick out, concentrate the power in the legs from the knees down to the tips of the feet. And this is with a slight flexion of your knees, tense the abdomen. So the waist does not bend. There is a teaching called tightening the wedge, which means the abdomen is braced by the scabbard of the short sword in such a manner. The belt does not loosen. Generally speaking, he says it's essential to make your ordinary bearing, the bearing you use in martial arts and make the bearing you use in martial arts, your ordinary bearing. This should be given careful consideration. And I think if you replace all the words of martial arts with that of the art of surgery, now we're beginning to understand. So what common thing do you think you do every day? And naturally, without thinking about adjusting the height of the table, put it in the chat room and Gabrielle will call out your answers. And those of you watched before will know the answers, but you don't know the answers. Please take a guess any answers. Gabrielle. Not yet. Well, let me give you a clue. The iron, your iron you pick up and naturally adjust the ironing board, not to iron up here, not to iron down there, but to iron at a functional height that is comfortable for you. And that is the key, It is comfortable and functional for you. So, although a lot of you attempted to answer, what height is a table, think of the operating table as an ironing board. When you're ironing at home, you would not operate up there or you're not operate down there, but it'll be at a functional height. And I'll go on to explain why this is important. Does anybody know why the countertop is the height? It is put it in the chat room? Any answers Gabriel? So we have one just given from before for your previous question, 3.5 ft and then surrender saying I assume to the second question driving. So can't interact, right? So the height of the table of a count kitchen countertop is to match the median height of the population to optimize the function of the upper limb. So to understand the function of the upper limb and why this is important, we need to understand a little bit of the anatomy. I'd like you to shrug your shoulders and just drop it down for you uh ease of use and ergonomics exactly ease of use and ergonomics. So if you shrug your shoulders and just let your scapular drop and shoulders drop. Now, there's one very important thing here is that the upper limb girdle is not really connected to the skeleton. It is quite free. The only connection to the skeleton is through the acromioclavicular joint to the stomach part, the clavicular sternal joint as well, both of which are sinovial joints. The upper limb is suspended on this arm and the upper limb is joined to the glenoid humoral joint of the scapula. And the scapula is actually held to the body wall in the scapular is held there by the big muscles of trapezius, rhomboides, latissimus dorsi and serratus anterior. But with the smaller muscles on the scapula, the supraspinatus infraspinatus, the teres muscles and the sub suprascapular muscles which form the rotator cuff. This enables you to elevate the shoulders, depress the shoulders, retract them back, pronate them forward and obviously lift them out to the side. So joining me for a moment in a little experiment, I'm gonna continue the rest of my talk for the moment with my hands out to the side. Because as soon as you start fixing the scapula, you start employing those big muscles and my hands now are out to the side. Yes, I can pronate, supernate. I can c conduct this shoulder and flex and extend the arms, but my movement is somewhat limited. And the function of the muscles, particularly of those of the hand are limited as well because the gleno humor joint is a shallow ball and socket joint. And it can only achieve the full circumduction of the shoulder because you get movement of the scapula. As soon as you start doing that, you're employing a lot of trunk muscles, increasing the muscle activity, increasing fatigue and potentially increasing the risks of tremor. The elbows just flex and extend with the difference that the radial head en nals, rotation and pronation and super the wrist is effectively ellipsoid. And that is again giving you some circumduction. Your fingers are all pure synovial joints and hinge joints as well. But as we've been talking and I hope your arms are still in the air. You will begin to feel the strain and stress across your shoulders and upper body at Gnr karate gradings we held in these stress positions during our three hour grading ceremonies as a test of fitness. But surgery should not be a test of fitness. This should be a test of you maximizing the intrinsic muscles of your hand. No, in the thumb, they are the muscles, abductor, flexus and opponents in the palmar hyperemia. Uh eminence, there are three muscles again, abductive flexor and opponents. Then you got two short muscles, the A doctor policies and the PMA Brevis. Then there are two intrinsic layers in the hand. The into our side, the four dorsal, into our side, which abduct and the three palma into a A I which abduct and they supplied by the ulnar nerve which also supplies the hypothenar eminence. But now we come to what I think are the most important muscles of the hand and they are the muscles that do this. Yeah, four. They are the lumbrical, they are eyes from the flexidor Profundus and extend across the finger to the extensor retinaculum of the distal pharyngeal joint. So not only does it flex the carpal metacarpal, the pharyngeal metacarpal joints, but it extends the phalanges. Now, if you think of the evolution of the human hand, what we're able to do now is bring the palps of our fingers together, a thumb, index, middle ring and small finger that is unique. And for the palps of your fingers, you have a bigger sensory input from the palps of your fingers than you do from your eyes. And as Lord Barclay Moynihan said, the surgeon needs to be able to caress the tissues and feel the tissues. And this ability to bring the palps of your fingers together is important for the feel of the tissues through your instruments because the instruments should be extensions of your fingers. So by now, your arms are probably aching and most of you have dropped your arms by your side. We haven't been talking for very long. But in that short period of time, I can feel it across my neck, my deltoids and feel the strain as well. So the functional height that I believe is important for surgeons is show your shoulders, let the upper limb drop and hang by the side. How have the elbows, partially flexed, not extended, partially flexed, such that your wrists, a palma flexed. Now, in this position, you have neutralized all those major muscles that I've talked about that support the 5 kg head, all the muscles that are supporting the 30 bones in your upper arm. And now we are focusing on and isolating just the muscles of my hand. And this palmar flexion, almost a puppet. And not many of you would relate to Thunderbirds or Marriot puppets. But Thunderbirds is that movement and it's that shoulders down albs by the side and that palm of flexion that is functional height. And actually, if you stand up against the ironing board, you suddenly realize that is the height that you set the ironing board to iron. So the height of the table is dependent on the functional anatomy of your upper limb, which standing correctly, not only reduces fatigue and all the stress of standing maintains your lumbar lordosis maintains your cervical or dosis keeps your chin in and you've got your head inclined with your hands, palma flexed, isolating those muscles. Now, this does become worse when wearing loops or headlights or particularly aprons. And this particularly important in those circumstances that you take regular breaks to stretch, pinch your shoulders together, put your arms against the top of the door frame and lean forward to give yourself a stretch and walk around. Some surgeons like wearing a ma standing on a mat that gives them the ability to stand and flex the knees and alternate the weight between the balls of the feet. And if you think of the soldiers that stand on guard outside Buckingham Palace for hours on end, they are trained to stand, but they are changing the weight on the balls of their feet and they're keeping legs slightly flexed rather than locked out. And what's interesting. And I didn't realize till quite later on in my karate training is that if you want to stand on one leg and maintain your balance, don't try and stand with your leg extended stand with your leg partially flexed and you'll find it a lot easier, particularly if you distribute the weight onto the ball of your feet. So regular exercise is important yoga to maintain that flexibility of your back and neck. And there are plenty of examples online plank and squats, not only increase your core muscles but have recently been shown to reduce your BP. All other muscles and lifting weights do within your capacity, mindful of your own limitations of musculoskeletal injuries. But the position of the head is of critical importance to your future and it needs to be perfectly balanced at the top. What was interesting during my days of horse riding is that simply looking towards the next fence, you are going to jump, that weight shift from timing your head would translate to how you sat in the saddle and was part of the instruction of the horse. So when we are show jumping, we're taught to anticipate the next jump and look towards it as we're going round because the weight of the head carried the weight of the body. Now, when we are operating, we are not standing still all the time because as we will describe in the forthcoming lectures is that posture is important, but the alignments of the needle and angles of the needle, as we will describe in the forthcoming lectures will dictate your posture. So going back to sport, um that's anus that I did is different left leg, right leg. But the principles are the same that my knee was over my front toes, my back leg was locked out and I'm punching to the solar plexus. As you're playing racket sports, you'll find that the backhand shot is off the right leg. If you're right handed, the forehand shot is usually off the left leg. Although the movement and surgery is not as gross as changing leg, simply changing the weight distribution from the right leg to the left leg will tilt the pelvis and then tilting the pelvis will tilt the shoulder girdle. And that degree of movement will give you better position it's interesting in the paper that I put online that it was suggested that women suffer more neck pain than men because they do not adjust the table height. And only 44 of all of you, of 100 and 42 actually adjust the table height. And I'd be interested to know what prevents you from doing that. If the table height is too high and won't go any higher, please ask first, do the varies heights from a couple of inches to a step or higher such that you can bring your upper limb to a perfectly functional position. And it's this position for most surgeons who are standing that will isolate the intrinsic muscles of the hand, enable you to do the most important thing in surgery, which is bring the palps of your fingers together and feel the tissues and feel what you're doing. You probably noticed with your arms fixed out to the side, you had very little range of movement with your elbows by the side shoulders down, you now have got the full benefit, a movement of the lower limb and the muscles of the hand. We have a question from Steven. Um If you know, according to the study, why would women prefer not to adjust stable heights? ID, I do not know that. And I hope I it one I it might be the uh didn't realize the table goes up and down or are afraid to ask particularly if you're in a training position, I think also, and this is particularly difficult if you are training and working with a surgeon with a disparity in height because both the surgeon and the assistant need to be comfortable. So one of the two, the surgeon or the assistant will need to actually stand on the stool. Michael worked with me for six months and he was 6 ft four. I was the first surgeon trainer in his whole career to actually stand on a step to allow him to operate at a comfortable and functional height. I think there is perhaps a cultural barrier, a po and literally a power difference, uh which needs to be understood and realized to bring you on a level. So you can see eye to eye. I think if you are in a position where you're very tall and the surgeon is very short and refuses to actually change the height. Do not compromise the welfare of your musculoskeletal system by hunching over craning the neck and bending. If you've looked at the way giraffe drinks at the water pool, they spread their front legs really out wide and they're spreading your legs out wide, you can take your spine down to a height to enable, to do that. Actually in karate, we call this the horse riding stance or Kashi and you're supposed to keep it with your knees at 90 degrees. And the two stances, Shiba with your feet turned out or Kashi with the feet perpendicular and hold that in ratings for up to 10 minutes, challenging to say the least. But it is actually part of fitness flexibility and maintaining that core. And for the 43 of you who do no exercise at all, please start thinking about your exercise. Surgery was described by one of my previous consultants as a blood sport, wrong analogy in many respects. But sport, yes, because we are not learning from the ergonomics of sport. Sabermetrics in Ame America is the video analysis of swinging a baseball club or throwing a ball. And the sabermetrics is the baseball association, video analysis of swinging a club and throwing a ball. What's interesting when going to the local driving range and I don't play golf but II enjoy the parallels of sport and posture. The video analysis is looking at the posture and the swing of the club and shallowing the club through and they've got front facing side facing analysis, Tuva Si, who will be talking to us on the 16th of October. Well, all three of them reached Olympic level in sport, one in archery, one in weightlifting and one in hurdling. What's interesting is to listen to how they were coached in these procedures and it astonishes me that in s we do not focus on these elements. I would like to see a video in theater, not necessarily for the communication analysis, but to look at how you stand and how you move. Certainly for all the practice that we're going to do from now on in the forthcoming lectures for the Black Belt Academy. A lot of it I'm doing with the non dominant hand behind the back, the table that goes up and down at home that will allow you to focus on your posture in correct position is the ironing board. The great thing is you can collapse it and put it away. I've just completed a study which I've submitted to the journal of surgical education where I looked prospectively over a four month period at all. The adverts for basic surgical skills courses. I collected 100 and 10, 109 of those courses were conducted and run with people sitting down, many of whom were sitting down at regular tables on regular chairs. Now, the surgeons that operate, sitting down are usually microvascular surgeons or urogynecological surgeons and, but they are on chairs that go up and down and round and round. What's interesting in this study is that even laparoscopic surgeons are at risk of problems and you think and how you're holding the instruments up at this level and doing this action. It's like working like a tyrannosaurs rex. Ergometry does not come to that movement and setting up a camera and setting up the instruments to enable that circumduction on the wrist and find hand control is especially important. They do it in all sports name a sport where they don't do it. But for some reason, we do not focus on it in surgery and it's important that you at the beginning of your career get this right now because once it's a habit is there for a lifetime. If you pick up a bad habit, now it'll take you a lot longer to unlearn it. So I do recommend that you make a stand and remember doing the right thing is more important than doing the thing, right? Take care of yourself, take care of your patient. I look forward to seeing you in the forthcoming series and hope you sign on next week where we have a very good discussion between Tim Terry and Chris who both sense of the Black Belt Academy and we'll talk about the importance of mentoring and coaching. Thank you for joining us this evening. Please leave your feedback. Delighted to answer any questions if you have any further, Gabriel, not at the moment, but maybe we can give a minute just in case anyone is typing. I'd like to ask the audience. Has anybody taught you this before? Mm Explained the importance of the functional anatomy of the upper limb tau. We have a thank you for Steven and mhm oh My sense, Mr Carry has appeared online. Well, he, he's been there in, in the background the whole way through and II mean, it's, it's just amazing what I've done today. I went, went down to Birmingham, did faculty. I think we, we're still alive. So. Oh, is there any observations? Yes. So we have that, um Steven says that once he heard about the functional anatomy and then we have plenty of thank yous from the audience. My pleasure and I hope to see you next week. Thank you very much. Indeed, mister carry any observations from you about this evening. Um It's, it's a rather strange.