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Hello, good evening. Good day. Good morning. Good afternoon, 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 in Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trainers for the Royal College of Centers of Edinburgh and a professor at London. I'd like to thank you the followers 4229 on Facebook and 629 on Instagram. If you are returning, thank you very much for your support and if this is the first time, welcome and you are starting at the beginning of our Stitching series that I hope will make sense to you every time you go into theater from now on because there are certain elements of this that are ta it to the expert surgeon, but nobody is pointing it out. And if you look at the pictures and the way people are operating, we are not practicing as we ought. I tweeted this evening, a picture of a driving range and behind me, half a kilometer is the driving range of running park and that's where we're broadcasting from in Yorkshire in the United Kingdom. Now, there are lots and lots and lots of videos on how to swinging a golf club and getting the perfect swing to hit the ball and you get the perfect swing, you can close your eyes and the ball will go in the direction you've allowing yourself up and you'll see the expert golfer. And I hope during the course of the series to join a golf pro at the academy and we can have a live lesson. I've been hitting a few balls, the expert golfer put sticks down on the ground and the lines, their feet, their shoulders, their pelvis. And I've been watching them train looking at the club angle, the club speed and literally have a hula hoop around them to demonstrate the swing of the club. And part of that is to get the club to hit the ball on the sweet spot. So if you look at my club here and I'm not very good at golf and I've been hitting recently, you see there's a lot of activity on the outside of the club and that explains why my shots are flying off in all sorts of directions because I'm not hitting the sweet spot. Stitching is a bit like this as well. There is a sweet spot on your needle holder and your needle has to go. Did you on a circle? And I'll show you why and explain some angles as we go through it. So I'm gonna take you over to the top camera and simply explain that all needles are made on a circle. So no matter how big it is or how small, if it's three eights, five eights, they're all made in a circle. In other words, on a perfect circumference. So if we were to take a tangential slice through the tissue at any point in that circle, we would expect the needle is made a hole in the tissue and the thread following the needle sits comfortably within that circle. If there's any deviation at all in golf, the golf ball goes off right and left. I haven't quite explained that to myself yet, but I'm practicing what you find a tang, gentle slice will end up as an ellipse and the thread will sit in the middle that's representing the blue of Prolene. And there's a gap between the thread and the hole or tunnel made by your needle. And that is sweating of an anastomosis and cardiac surgery or even spurting for that matter or a microabscess in a bowel anastomosis as well. It causes problems and trouble. And the whole idea behind stitching is each and every time your needle passes through the tissue, you need to circumscribe a perfect circle no matter what the tangent is. So, how do we do that? And what does that mean? Well, let's come back and just explain some basic principles to you first of all, the rotation of the forearm is folding of the radius of the ulna in pronation, supination. And as explained before that rotation can occur, no matter what angle your shoulder is. And you know that because you've picked up a screwdriver and you can use the screwdriver at the bottom, bottom of bottom, the car boot. One of my trainees actually put an BMW M five engine into a small M BMW and reached the front page of Motorsport for doing an amazing feat and squeezing this big engine into a smaller car. But the rotation is important and it would not help to put a screw in to rotate it and have your screwdriver come out of the hole each time when you apply, you are keeping the tip of the screwdriver straight and you're supinating while we at it. Anybody in the chat room would like to tell me the most powerful supinator of the arm. Anybody? Well, think about it. It is the biceps. It's a brachioradialis extension of the bicep and ation. And that is why the majority of screws are made clockwise because to get it in, you need the power or the biceps, but we're not doing that in surgery because we are using the lumbrical. But what it does mean is that we need to actually hold the needle holder along that line of access, the line of axis as you can see, extends between the middle finger and the index finger and the common flexor origin. So, if I'm actually holding my needle holder as I would hold a screwdriver, not too dissimilar, you can see I can rotate it round and to demonstrate the benefit of what I call palming the needle holder. If you look at my pronation there all the way to super nation, I've almost got 270 degrees. Yeah, almost got 270 degrees. Whereas if I put my fingers in the rings, one, my a pronation is limited is not to nine degrees and my super nation is limited as well. And I just got over a but what's happening is the end of my needle holder is moving round and round. Now this is why four surgeons and I was encouraged to practice when I first started my surgery on the bath rotation in 1987 to palm the needle holder. So place it along that line of axis of pronation and Super Nation in the palm of your hand, fold your ring and fifth finger over one of the rings, extend your index finger and down and use the abductor pollicis to tail on and off. And I asked my trainees in the cord, give them an instrument, ask them to practice this. And if they say, how are you today? The repli wanted a nice cheery. Doing fine. There you go. And that takes a wee bit of practice. It took me 3 to 4 weeks as a trainee to do that. But I do recommend we get a needle holder and we start practicing as you build up the strength. You can use a tubing clamp or more rigid instrument. But what you've got now is a needle holder perfectly aligned on that rotation. So your needle continues on a perfect cycle. Now, there's some mathematics in all of this and I will explain the mathematics to you now with a few slides because it all comes back down again to the posture. We have explained that we are standing upright, maintaining your lumbar and cervical lordosis. And actually what I do when practicing needle skills, ask people to put their hand in the lumbar lordosis to ensure they're standing upright as we explained before the muscular surgeons. This is about 27% over a lifetime. So posture is important. The other thing is is that as soon as the elbows leave the side or the shoulders go up, you start using the major muscles of the scapula and the upper arm and the neck in the form of trapezius and deltoids and pectorals. And that Testim dose and you're holding your arms up. When you're doing that, you're increasing the amount of energy, increasing fatigue and increasing your risk of musculoskeletal degeneration. But I think it's more important that keeping your elbows by your side, slightly extended hands, palmer fleed in what, in a poppet position. And I call it Thunderbirds, you have neutralized all the major muscles of the upper limb, including those flexor digitorum profundus, and flexor pollicis Longus that actually flex the D IP joints because as we explained before we want to feel and it's the lumbrical that are working. So this is the com at the frog bit. OK. And this works again, no matter the position of the upper arm and we need to feel. So, coming back then to what this actually means because they are natural angles and I will just share with you a couple of slides. Now as they're uploading, we know that 90 degrees is the perfect angle. It is fourth part of a circle and that 90 degrees is fantastic because if you have you lost the picture, I'm not sure if you like. Can you see the picture? I'm good. Can you see it can be. Yeah, it's working for me. You've lost and you've got the audio as well. So I'm not sure what's happened. Now, Mr Caddy has lost picture and sound. Gabrielle. Can you confirm you got picture and sound? Yes, I do have everything. I've sent him a message maybe. Thank you very much. Indeed. So if you look around you wherever you are in the world, just take a look around the room and look at the window, look at the door, look at the floor, look at the corner, we surrounded by 90 degrees. And what's interesting is that they did a study looking at 90 degrees and asked trainees to pick out the 90 degrees in a pack of 20. And I had 2 90 degrees from 86 to 94 and 93% of trainees picked out 90 degrees. Both of them reliably and with accuracy. When I divided that by 2 to 45 degrees, they couldn't and why this is important, this 90 degrees is the super nation and pronation comes in. You need to place the needle 90 degrees across what you want to stitch. Then you got to rotate it back and place it orientated. So 90 degrees into what you want to stitch, then you simply rotate. Now, if the elbow, the larger circle and the wrist, the smaller circle are in the same line, the rotation is relatively straightforward because you are sit, if you are sitting down the wrists and the elbow at the same level and the placement of the needle will be 90 degrees on the end of the needle holder. However, most surgeons operate and as I explained, standing up, moving from wrist and elbow at the same level to now displacement of the wrist from the horizontal. And if you displace the wrist from the horizontal, you need to open up the angle of the needle. And what this means. If you look at it and you understand parallel lines, you can see that 90 degrees in green, the angle from the horizontal to the forearm by the dotted line is equal to the angle that you need to open the needle out at the bottom because that blue 90 degrees is the same for what you've done is just added that green angle and you need to open it out. The other important thing is is to ensure that to a needle is on the tip of your needle holder in the sweet spot because the rotation of the needle is compromised if it's held further back in the jaws. And we're going to be explaining this and exploring this with computer modeling, the bioengineering department at Imperial College. So we'll come back to this. And what does this mean? Now, there are a couple of things that are useful to remember then in picking up the needle and we'll explain that as we look closely at the needle itself. So the working part of the needle, let's get it in the midline. The working part of the needle is focus. The working part of the needle is this middle bit the shaft. And what's interesting, the shaft itself is not completely round, it is cuboidal. And I'll explain to you the benefit of that in the moment at this end is the sage which is usually the thickest part of the needle where the thread goes through econ have just brought out a new needle where this is now the thinnest part. And at this end is the point with various types of cutting edges round edges and bevels depending on what you are doing with a needle. But the important thing is is that we got to hold the needle just beyond the halfway, just beyond the halfway and it's got to be held at the tip. And you see that angle from the horizontal, that is the angle I'm standing at an ironing board and that's what we're practicing. That is the angle that my forearm is making from the horizontal because my wrist is lower than the elbow. Now, when practicing, I need to ensure 90 degrees each and every time. And this is your perfect alignment of your needle is 90 degrees across what you want to stitch. Now, I've often been asked is how far along the needle holder do you actually hold it well? If you go too far, you will not be able to pronate to point the tip into the table. And what I believe is that the rotation and how far you, you turn, the needle is really dependent on your ability to pronate such that it's pointing 90 degrees into what you want to stitch. So there for me is probably a little too far and no, just a fraction. I'm pointing to what I want a stitch. And this then becomes the very essence of stitching most of the time we are operating at depth. And what we have here is a microwave potato sitting in a pudding basin and that microwave potato is extremely hot when you take it out of the microwave. So do be careful. We do have to put in safety warnings on these because we don't want people running into trouble just trying to move this a little bit. And what I've done is put a couple of lines across potato if I went down to try and stitch this with a needle mounted at 90 degrees. And I can always know the sweet spot because I'm feeling the shaft and the tip of the needle holder on the palp of my finger. And I'm not going to cut myself doing that or you can take it out to pack it that way. But if I take it down at nine degrees, you can see the sagittal plane is completely lost. Mhm And the thing about 90 degrees, it is 90 degrees in every orthogonal plane. And therefore, if I angle it out, you can see now that is aligned and there's an audio sound with this. If I might demonstrate to you, they listen to this compared to essentially the belly of the needle is pressing down on the tissue. And as we'll explain later on, in our further series of stitching, that ability pushes the posterior wall of a vessel way if you're stitching it. So we have the first question. Um How long do you microwave the potato for? I got it in there for 3.5 minutes and then another minute on top. So 4.5 in total. Well, really what you want is a soft potato and soft skin because it's the soft skin that is going to tell you whether you are rotating the needle cleanly or not. Imagine a diver going into a pool. The perfect dive hits the water with no splash. And these or I call are my splash models. They tell you when it's not quite right. So 90 degrees aligned with my red line across what I want to stitch the blue line, I now rotate it back pointed 90 degrees into the tissue. And I ly rotate this needle through and all being well, it comes out on the line opposite. But note that the tissue is holding the needle. I do not need forceps to grab that and grabbing it with the forceps. I'm going to ruin the rotation and now deliver it iterative from this. Just be on the halfway and gently pick up the needle goes coal and I'm gently picking it up. I should be able to pick it up in the right position. I have not. And this is where the problem of stitching occurs because if you do not pick it up in the right position, each and every time you can see. Now my next attempt at putting the needle through the tissue is compromised both in this orthogonal plane. But now I can't rotate back to point into the tissue as well. So the one correct movement leads to another correct movement and it's all about this alignment each and every time to pick it up. Just be on the hallway. Oopsy. And I haven't got it quite right yet. So just the needle again and you have to be disciplined with yourself, with this alignment and needle adjustment each and every second time, don't assume just because you've picked up the needle that it is going to be perfectly aligned better. But I have to adjust that. The great thing about the potato being in hemisphere, you now got the opportunity to explore the alignment, whether it is away from you, like him to your left, to your right or towards you. And what you need to do is get your needle aligned and then work out how best to place your upper arm in these awkward angles in this position. Here, I have abducted it. Yeah. With my elbow out of the air, you'll find that the displacement from my wrist to my elbow is less and therefore the angle is less. But again, I'm practicing the needle in and needle out gently. Pick it up, check the alignment again, come out gently, pick it up, check the alignment again and you note it as I picked it up there, I gave it a slight nudge to get me into the right position. This angle here is the most difficult I find and this is the angle of sorrow in cardiac surgery because that is the bottom of your aortotomy for the aortic valve replacement. And what you've got there is the aorta, the superior vena cava left atrium at the bottom there and the sinoatrial node there, you ain't got much space and you need to actually get your needle in two and out that angle without tearing it because your daughter is totally an athlete and forgiving as that potato is there. And yes, the aorta can be that fragile and that difficult. So once you've worked out your body position, let us just consider for a moment, how are we going to use this needle? And I'm just gonna pick up this smaller one. I'm holding it just beyond the halfway at the shaft. 90 degrees. Now, the next thing to do with your needle and because it's cube, oil is slightly undue the ratchet to still holding it on the trigger, but I haven't got the ratchet. Yeah, and simply practice flipping or etting your needle over the top forehand and backhand. And you'll see doing that, the cuboidal nature of the shaft becomes apparent and you'll get the feel of the needle flipping, forehand and backhand, forehand, back hand, forehand, black hand and note the angle is much the same as you it over the top. And this has the advantage of controlling your needle within the operative field not taking it out. Uh and maintaining that rotation. The forehand and backhand flip will become apparent in two weeks time as we continued the discussion about going round and round. But practice with the needle rolling it over and appreciating that cuboidal nature. If you want to mount the needle backhand, simply turn it upside down on the palp of your finger, apply the needle, hold it and you've got a backhand if you want beforehand, apply the needle that way. Although I'm holding the needle, I'm not holding the point. I'm hold feeling the shaft and I'm not gonna to needle, stick myself with that. So practice alignment. So let us assume that we have got here a linear wound. OK. And I've marked out one centimeter intervals on this to practice my stitching each and every time I take a stitch, I need to actually align my needle 90 degrees across what I want to stitch. I need to rotate it back and rotated forward and it should come out on the same line, deliver it to halfway, pick it up, check till I've got the alignment again. This is akin to the golfer, putting there's sticks on the ground and you can do this yourself at home with a banana and practice your alignment. And I do recommend you draw lines because when you first start, you will not get it 90 degrees. And what I find is people are so focused on doing it quickly that they do not align further up the incision. And what you find. And I'll demonstrate here is that you lose, the alignment is not at the tip. And now I'm having to contort my body into all sorts of positions and try and force it through and I'm missing the target because I did not set up properly. And the one thing about golf, it all works perfectly if you've set up properly. Now, this is all very well with a linear incision and practicing your alignment. But what happens if it is not linear and we'll flip the banana over and take a look as I'm doing that, I can score myself and see where I've hit the line opposite. Well, what if it's a curved incision? The difference between the alignment of the needle holder here and the alignment of the needle here is an angle of 60 degrees and that 60 degree angle is important to appreciate as you are stitching because to achieve that, you'll find that you need to now change the weight distribution uh from one leg to another. And at the present moment, I'm predominantly on my right leg, pick a needle up. But each time going through this place, point, rotate discipline as I've come to the halfway mark, I am now balanced on my right foot and my left foot. And as I continue down the stitching, I'm finding I am now standing more on my left foot for this alignment and simply changing the weight distribution from your right leg to your left leg, changes the tilt of the pelvis and tilt to the shoulders. And this has a profound effect on the final angle and alignment of the needle. The great thing about the banana is if I turn it back over, if we focus back down on there, you can see the exit wounds, so to speak, on the banana and you can on a score and we'll be putting this on an app 10 lines. How close did you get to the opposite line? You can see there missed, missed. Perfect. Perfect, perfect missed. Ok, perfect. OK. So you can actually score yourself and practice till you can't get it wrong. So the message is with repeated stitching, do not focus on the action. The sly or the needle going through the tissue, focus on the set up each and every time because it's the set up that will save you time and make for smooth operation because smooth operations are fast operations. This is not teaching speed. It's being deliberate and precise, the needle handling all the time and note that I have not got forceps involved in this process at all. And I think this exercise do this a couple of times a week very quickly. You will start training your eye an alignment on the needle as well. So what happens if we get something like this? 90 degrees is 90 degrees to the edge no matter what. And there are two things to know is that the 90 degrees on the wid there is different to the 90 degrees there. And that is important because if I went through here halfway and then start to try and turn it to get through there. Voila, I've torn it out the banana and I've torn it out the skin because I'm trying to force the needle to two incongruent angles that 90 degrees has to be now separated into two specific movements, one side, 90 degrees. And this is important for closing wounds because if you don't adhere to this principle, you will not avert the skin edges and bring them together in perfect diversion and apposition. So the plea is unless the two edges are sitting together, please do it in two and align it each time. Now, the fun thing about this example as well is can you take the needle I/O of the skin alone without actually mushing the banana underneath? And again, this is teaching you feel and pick up and trying to preserve the banana underneath. See you stitching now becomes quite deliberate. The banana is actually very good for scoring the exit wounds and recording rotation. The second um stitching skill is using a boiled egg and it actually cutting it in half. And this time, it's extremely good at determining the point in or the needle into the tissue as you point the needle between the yolk and the white and rotate it out without scrambling the egg or breaking. Demonstrate that next time the thing at the heel and toe. In vascular terms, 90 degrees at the apex of a fusiform incision is parallel to the two edges. And this in vascular surgery is important is that the apical stitch or the toe or heel stitch is the alignment is parallel to the two edges of the vessel rotated back and rotate it out. The belly of the needle can be used to push the posterior wall away, slide it underneath and think about exiting the anterior wall from underneath as well. And I teach that using 70 needles on 1.5 millimeter coronary vessels. Of course, we are all familiar with the ninety-degree principle stitching. Anyway, for those of you who have actually stitched a button on a shirt, the wa and left leave gaps in the tissue. When the cloth, it is easy to put a needle directly through at 90 degrees. But just look at this as I try and put a needle through at an angle. Look at that resistance. It is extremely hard and that is the important element. So to combine the movements of the 90 degrees of place point, rotate, there's one last thing to point out. And I don't expect you to get this immediately because it all requires practice. I'm gonna place my needle 90 degrees across what I want to stitch and I'm going to rotate it back in my simple rotating back, which is a pronation what I'm doing in that pronating to point back, I am taking the ratchet off the needle holder in my pronation. So by the time it gets to the back, I'm holding the needle without the ratchet. And now I am passing the needle into the tissue and continuing the rotation and picking it up. And once your practice is doing that come round and did it backwards again, doing that without tearing the skin of the potato. So now we starting to put all these movements together. And in martial arts, we have techniques and we put these movements together into combinations and the combinations go into carters and the carters then form the basic of defense and fight. But we need to, as John Taylor eloquently explained, that's why the martial art principle of teaching this is true because unless you get the technique right, you cannot put the combination together and therefore the acc at the end is going to be compromised as well. But each and every part of your stitching from now on needs to be deliberate. It needs to be 90 degrees across what you want to stitch 90 degrees into what you want to stitch, rotate it back and let the needle do the whack for you. I despair sometimes watching the trainee closed at an end of an operation and I'm going to make a political point because a lot of consultants are leaving theater to leave the most junior person to bring the tissues together and to close. By that time, everybody is tired, including the scrub nurse, the anesthetist, and they all start tapping the watch and the trainee feels under pressure to do it as quickly as they can. But in doing so, they forget the pick up one just beyond the halfway two, no space between the tip and three angle out. They then forget the place point, rotate and in the anxiety to please everybody in theater in closing the wound, then go 123 and then drag the suture through. And if you can imagine fat being squeezed between your fingers and squeezed out in between, that is what I've been observing when closing of sternotomies. So I would much prefer to stand there and talk the training through how to close and respect the tissues because ultimately, this translates into how well it heals. And as I said before, the scar is your indelible signature on the patient. And therefore, it's in all our interests that is done properly and it all comes back to alignment. So, yes, there are many, many programs on how to swing a golf club. And I have just started going to the driving range and trying to learn to align the track man at the driving range can actually track my club speed its angle and track the ball and give me a printout at the end of this showing me the direction deviation and speed of the ball each and every time for each and every club. That is my ambition for teaching skills and angles with a needle. I sincerely hope this makes sense. Do try it at home. Do let me have some feedback. We'll put the feedback questionnaire in the chat room. It's important that you let us know if you have models that you're practicing at home that do some, some things, send me photographs. What I am going to offer is another competition for the most innovative surgical practice model for stitching at home. I'm using a potato and a banana. We've demonstrated some knife skills and scissor skills with peppers and fish and chicken. If you've got a different and novel model, wherever you are in the world describe it, send us a picture. The closing date will be the first of October and the winner and runner up will receive a set of instruments from the Black Belt Academy. Have fun and enjoy this. It doesn't require a lot of hard work, but it does require that you actually spend time thinking about how are you doing here. And what I do encourage people to say when they picking up the needle 123 check, checklist, place point, rotate. If you start vocalizing it as you're doing it as well, that will help in be the instruction in your muscle memory. I'd like you to join us next week. We have a special guest, Paul Barrack and we'll be talking about the blood brain barrier. Are you familiar with that? The rapes, the anesthetist at the top, the surgeon at the bottom. But we'll be talking about human factors and the importance of the partnership and respect between the surgeon and anesthetist working together for the better of the patient. Thank you very much for your attention. Thank you for joining us, David. Do print the word. We have a question from wrinkle. Um It's just linking back to your last um model. Should one start at the two and first interrupted mattress and then the other one win. That is a good question. Thank you for asking that if you've got an I regular wound, it is best to actually close it starting from each end. You do one at each end and maybe approximate in the middle and then work towards the middle on each each side. Do not start on one hand and work one direction. Only the problem there is that you'll find that even with the train die, you are likely to end up with a mismatch on one side in the other. Mattress sutures are useful if you want to actually start everting. But mattress sutures by definition are strangling tissues and I believe they are a shortcut. Two proper evasion through proper rotation and use of the needle. The cleanest and best stitches you can use are actually simple interrupted sutures, the fine sutures with gentle approximation of the tissues. And if you'd like to practice that I suggest you use the banana again, is open it up on the opposite side, remove most of the banana, but leave a little bit at the tip to hold the edges and then try closing the banana skin with simple interrupted sutures. You'll find that it's very easy to cheese wire through the banana. But at least it's gonna teach you lightness of touch and perfect apposition of tissues because it's respect to the tissues that will determine the healing and outcome. In the end. My fellow sense, a Chris Kendy is a plastic surgeon and he does a lot of this work and I might invite him to ask you answer the question about the best suture to use. I think Chris had some issues with internet connection. OK. All right. But he would actually go through a 50 interrupted sutures, proline sutures and you take them out depending on whether it's dorsal surface or ventral surface according to determining the length of time. So usually it's two days longer on a dorsal surface than a ventral surface. Remembering that sutures themselves and the passage of the needle through the tissue is causing damage but also is a potential for infection problems as well. So it's a balance in the end. I hope that makes sense. Nku We have a thank you. Pleasure. Any other questions? Gabrielle? Not at the moment? Super well, thank you very much. Indeed for your attention. I hope this makes sense. Do have a go do practice at home. It can easily be done anywhere, any place and literally 5 to 10 minutes every day, I promise you within a month, you will see a difference. Remember it's technique before power and speed and the same with golf, martial arts or any other sport to be a honest, but we need to actually get the technique right. And that's what we're trying to do in the Black Belt academy. Thank you for your attention.