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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 Reagan. I'm a cardiac surgeon in Yorkshire in the United Kingdom. The past director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. If this is your first time to the Black Belt Academy, thank you and welcome. If you are one of the 3297 followers on Facebook or 585 on Instagram, thank you very much indeed for your support is much appreciated and I hope this is making sense to you this evening. We're going to be talking about the finest cut and yes, this is my katana. It is a live bleed and the timer itself must be one of the finest weapons that has ever made. It's been use has been described for 600 years and every movement is prescribed and described to every angle and flow. The HIPPA Gary is a bit like electrons flying around an atom, describing the vertical, horizontal and diagonal strokes required when wielding this weapon, all these movements to be fluid and continuous without hesitation and usually within a heartbeat, the katana itself is dedicated to slicing rather than stabbing. And the five body katana is exactly what means a blade sharp enough to cut through five bodies in one cut. I reflect on my training as a surgeon and the hesitancy that I have seen amongst trainees using something very sharp and relate to a short story in drawn the samurai sword, the Japanese art of swordsmanship. One day I asked the sword mast, er how can I cut with a sword if I do not do it, it cuts. He replied, I've heard you say that several times but so let me put it another way. How can I wait for the cut to happen if I'm no longer there? He replied that awaits at the highest tension. So let's stop talking about it and go on practicing. He concluded then one day after drawing the sword, the masters made a deep bow and broke off the lesson just then it cut. I stared at him the wounded and when at last understood what he meant, could not suppress a sudden group of delight. The masters told me you made this time absolutely without purpose in the highest tension so that when the cut fell from you like a ripe fruit. Now go on practicing as if nothing had happened. I'm afraid I do not understand anything more at all? Even the simplest things have gotten a model. Is it I who cuts with a sword or is it the sword that draws me into the state of highest tension? Do I cut the goal or does the goal cut me? Is it spiritual when seen by the eyes of the spirit or both or neither sword goal, ego or melt into one another so that I can no longer separate them. And even the need to separate has gone for as I take the sword and cut, everything becomes so clear and straightforward and ridiculously simple. Now at last, the masters broke in the sword edge has cut through you faith. When using the knife, it is decisions before incisions. And there is a purpose and mindset that goes through the privilege of making an incision. That's your indelible in signature on that person for life. And this is where I do like the martial arts because sheen or cook are you is the spirit of Japan. And there's a beauty in the martial arts without gene, they're just movements, hollow movements, mindless movements, meaningless movements. The mind has to be present before it can be controlled. And we've gone through this before Sh Ocean is open to experience. Issue is focused motion, lack of self consciousness, foodish in drive, persistence, motivation, determination, and sunshine finished business. These direct and guide the movements of the body and the blade. The hesitation that I see with a large blade is because we have not really imparted. The essence of using the knife. Sharp dissection is clean that section. And if you feel your dissection is looking a little bit ragged or difficult change, the blade, you need a sharp knife. So blades have been used since the stone age as flint tools and even blades used scalp als in Mesopotamia and in Egypt, Hippocrates used a mccary in which is a type of blade with a handle. And it was the Romans who came up with a scalpel iss the scalpel. We've been using sharp objects in medicine to release the evil vapors and my asthma's in lancing boils and infections and removing dangerous useless limbs. It was only with the understanding of mythology. Did blades become more popular? And Bardem Parker in 1915, patented the first scalpel. But as in 19 thirties, that's one more turn and fair weather. A company in Sheffield who are making razor blades decided to enter the scalpel business. They are based in Yorkshire in the UK at the heart of the metal industry. And Morton himself was a metallurgist in 1962. They got involved with the British nuclear industry and established their first Cobalt 19 Sterilization Unit. And now one of the world leaders in sterilization, they are now producing 70 different blades with 30 different handles. 1.7 million blades a day, go to 100 different companies in countries around the world. Swan Morton have become synonymous with a scalpel blade. But what I like about Swan and Morton was Swann's philosophy on business and this is where I'm going to put my MBA hat on. He said, claims of the workers producing the goods come first because the goods are just a byproduct of human endeavor and the humans on which the work is based. The second thing was if industry cannot pay the worker or making profit for the owners, then they need a new policy. And if the management cannot deliver a new policy, they need a new management. And the last, if they cannot do the above, the worker has the right to insist on all three being implied all the time. So 50% of Swan Morton is actually owned by the workers and 50% in a charitable trust. What I love about this example is this company has put the worker first and those of you who have followed the faculty of surgical trainers. I interviewed Bob Chapman head very well, Miller who talked about everybody matters. Well, let's get on to understand how to use the blade. And as with everything we do in surgery safety is of paramount importance. So let's come over and have a look how we mount the blade and discuss how to pass it safely and use it safely as well. The blades come in foil packets, uh easily opened like so the sharp end of the blade understandably must not be touched. And the blade is best picked up firmly in a hemostat on the blunt edge. You'll see this peculiar shape and that matches the shape of the scalpel handle. And here's one from swan and mortar nine AM extremely grateful to them for selling me blades and handles. This shape is ergonomically designed and there's a patent on that particular shape you see on the other side of the handle, they conveniently got a rule to measure in centimeters. The most important part of mounting the blade is understanding, I've come out too quick moving. It is understanding that there's a groove in the handle and you can probably just run your fingernail in that groove and it's in that groove that the blade is going to sit. You see my fingernail running around there. So what we need to do is insinuate the blade into the large end handle into the large end of that hollow. Thank you out again, Gabrielle. If I go out of focus, could you remind me, please will do slip it in over the top. Such a that groove is parallel to there and it slides home with a click. There you go parallel. It's a one handed movement with a blade at all times pointing in to the table such that it doesn't fly off or cause damage to take the blade off. Something lift the end up, slide it too long, get a firm grip of the blade and withdraw the handle, do that again, slide it on and take it off. Now, Swan Morton have come up with the new Keen blade's which are retractable and easily disposed of and easily taken off to avoid any injury. So how do we hold the blade? Well, how we hold the plate determines its use? And I often think of my days with Mr William Water Frederick Southward, who's my teacher when I first started surgery in 1987. And he said, Mr Regan, you hold the blade like a knife. The handle of the blade is actually buried within the palm. And the 90 degree sagittal plane is maintained between the thumb and the middle finger with the index finger extended down the blade to give you that direction, appropriate sector of feedback and does not feel and feedback that determines the depth and appreciation of the tissues. All the time. The blade itself needs to be 90 degrees to the skin. It needs to be 90 degrees to the skin. Because if you look at the sponge, if it's not 90 degrees, and I've colored the edge, you can see the example of bacon slicing through there. But here we've got a fine cut and you can see there's no blue on the edges as compared to them. So your wound healing and the scarring of the tissues starts with your ability to maintain the blade in the sagittal 90 degree plane to the tissues at all. Time you'll find though with long incisions, what happens is there's a tendency to twist around the waist. And certainly when cardiac surgery with the 22 centimeter incision, if you do not abduct your arm and conscious about keeping straight all the way down, you will end up with a curve. So the incision of the skin needs to be supported all the way down in a deliberate cut, supporting the skin as you go as a purposeful deliberate cut all the way down incision. Now, each layer you go through, you may have a skin incision this long. But what you need to do is undermine the edges as you go down. Such that the deeper tissues, the incision is longer, the skin can move across the top of the deeper tissues. But as the deeper tissues that need to be opened, such that gives you access underneath. Otherwise you end up going down a deep dark hole all the time. And that is important to avoid by doing it the other way everting it. So the deeper tissues have longer incisions, you end up with better access. So balanced, certainly between the thumb and the ring finger, index finger down the blade, the handle there and it's really the weight of your forearm. So how do we actually test the field? Well, you just have to practice it just as the mast, er said it cuts but only with practice, will you begin to feel it cuts? And you need to understand the weight your forearm. So I have here some slices of cheddar cheese, lesser cheese, treader cheese, lesser cheese, and a slice of bread. Because to be honest, we're making sandwiches every day and we take a knife and cut the sandwich in half. But I thought, let's see if we can make incisions and practice the depth of the incision through each layer to feel it go through the tissues and see if you made any cut underneath. You can do this with anything. This is Red Leicester supporting the tissue. I'm feeling it go through the tissue. We're doing it live. So I can't actually fake this. Have I made any cut underneath go down so you can have a closer look, no cut at all. Let's try that again. Let's see if I can go through both layers this time and feel my way through both layers without cutting the bread underneath. And I would like to see examples from you in photographs of your practice at home. So I'm feeling it all the way through the tissue, both layers of cheese and this is what I call sustainable surgery in practice because if I don't put this in a sandwich tomorrow, I've got to hungry dogs who would love a snack. So I can see that ah I'll go down. I have actually gone through slightly the deeper layers, just a touch, but I've cut through the deeper layers and that's one of the challenges, we'll try that again. That's one of the challenges when going through solid tissue, too soft tissue to avoid cutting something underneath. And that is only done by feel, certainly doing it one day at a time, proved relatively easy. There you go. I haven't cut the cheese now to go through a solid bit of cheese and feel it through. And there you go. I have not cut that at all. What else can I use? Well, we offer news, sliced meat. This is sliced beef, got these packets from Tesco's is two for the price of one. So I thought ah fabulous low fidelity practice for the Black Belt Academy this evening as I walked around Tesco's. So again, let's see if we can cut through. And really what I should do is I should change the blade because now it has actually become blunt. So I'll go to the 10 blade and point out as our swapped over the cutting edge of the blade is the curved edge. You never use the point. It's the curved edge. I'm going to use curve ditch and see how this goes through tissue and feel my way through these thin layers. Oh Look at that slight score ng of the meter beneath, but I haven't cut all the way through it. But what this is actually reinforcing to me is learning and practicing a lightness of touch. Let the blade do the work as the masters said it cuts. So doing it live for the first time for you. Here, there you go underneath. I have improved on that layer. You can see just a very slight mark there. Let's see if I can now cut that further. We're not cutting the bread underneath. I actually had two layers there. No, my dogs are going to love this, but I also going to enjoy a beef and mustard salvage tomorrow. There you go. Roof cut. There's a slight scratch on the surface there, but I think I will show you. So you know that I'm not cheating on. This is a slight scratch on that surface, but I have not gone all the way through. So they're very easy things you can do to see and practice your knife skills. There are different types of things going through the supermarket and this was part of my two for 3 lbs, 50 of Tesco's maybe I should get test goes to sponsors this event as I share their food products. Let's try with a bit of corn beef. Now, this is even softer than the previous tissue and I need to David. I think we need you to zoom out a little bit zoom up. Thank you very much. Indeed. Thank you for that. So, let's come down here, I'm going to get another blade and see on something much softer what it feels like. You can see that this is quite crumbly, but I've cut through that and there's no mark whatsoever underneath. Simple foodstuffs in the fridge will give you that practice and have to feel back. But one of the things that you can do is a simple, but I just is try some fruit and the fruit one is quite good is, can you feel the blade go through just the skin without cutting the flesh underneath? You'll see that if I could cut obliquely. That is what happens with a bacon slice. Yeah. And that's what you effectively do with it skin. But it was this exercise running the blade down. I want you then to squeeze it. No cheating. Squeeze. Have there been any drops underneath in that dish? If not, it means I haven't cut the flesh underneath because I'm feeling the blade through the tissue. This skin is also very good for practicing keeping a blade in a good sagittal plane because if you take it off the central plain, you'll end up with it tearing. But look at the edge and have you cut 90 degrees through the edge and is it clean all the way around holding the knife like this? Taking it round a grapefruit or an orange? You can in practice keeping the sagittal plane to ensure that you get a nice clean edge. But what happens if you've been asked to exercise a bit of tissue and the excision is a mole or something on the skin and this is where you now need to hold the blade like a pen. And I'm grateful to my fellow Sensei Chris Caddie for sending me this barren blade holder. And this is literally can be moved enrolled like a pen in doing this incision. What I intend to do is a fusiform excision. Imagine I'm drawing an eye of the tissue and the lesion and needs belong such the two edges come back together. So again, to practice the fusiform incision and perfectly perpendicular, I'm going to use my 15 blade and practice maintaining and 90 degrees throughout the curve. You notice that I've also got my fifth finger acting as a stabilizer as I'm controlling that. Let's have a look, shall we? There you go. And I can go round and see in my fusiform excision have I got perfectly perpendicular to the skin edges and I haven't cut the flesh underneath a lovely way to practice excision using simple model and low fidelity reinforcing the perpendicular sagittal plane to the tissue throughout the curve. Before we go on, I just want to actually introduce this blade. This is the 11 blade and the 11 blade you can see is a straight blade and really be using it as a functional starving instrument. But to control the depth, I have got it pressed against my finger and my finger is going to control the depth of my stab. So if I wanted a few millimeters, I've got it against my finger, I can control the stab. Of course, if I haven't got my finger, that what happens is I can go into deep. So when using an 11 blade again, I'm holding it lightly, will my thumb and my index finger, but the blade is held against the pulp of my middle finger. And that is enabling me to control the depth. This particular manoeuvre I used when Kanye waiting the aorta and I hold the adventitia with the forceps, insinuate the blade, hold it down. And then I can put the cannula in understanding the use of each blade holding them properly. Appreciating the field will give you that control that you need for dissection and exposures petition because clean dissection, his shot dissection. Another example we can use here is oh banana. Can we take the knife to the banana and feel it all the way through without cutting the banana underneath? Let's have a look, shall we? Who part of it? I was able to, but part of it ended up too deep. I'm not going to make an excuse at all, but maybe I should have actually changed the blade. My point being all of these are giving me that hectic feedback on the tissue, which now brings me to another important element of dissection. And this is a dissection of tissue planes and we're going to use a broad blade life. And I used the 22 blade. It reminds me of Mr Southwood was able to do a gastrectomy in 20 minutes and he was a Zaro when operating in the abdomen and dividing adhesions. Remember, adhesions are usually stronger than the tissues themselves and their best cut either with scissors or a knife. But Mr Southward was brilliant with a knife. So glad more Zan in Romania extols this model, it's a piece of fish and we're going to mimic the skills are often used a master chef by removing the skin to do this. We're now going to change the group from sitting the handle in the hand and I'm going to now move it out into my fingers across really probably the second felon. Geez. I'm holding it lightly and I'm going to be using it as if I'm using a brush and brushing a surface and I get a brush, my knife just as I'm brushing the brush here against what I'm removing to develop tissue plane and dissection. So here I started earlier is some skin and a bit of salmon. And the idea is that I got to tease this off without cutting the flesh and actually leaving most the salmon on it. And I think I'm going to probably have to get a new knife. You'll be surprised with dissection how quickly you go through blades and dissecting. You see, I'm just brushing this against the surface here, sweeping across the broad area and developing the plane. I'm not taking the knife into the junction between the skin and the flesh because that will start cutting the skin but also start cutting the flesh. So I'm just brushing it against the surface hair. These models that I'm introducing on a Black Belt Academy can easily be adapted wherever you are in the world and you can use any type of fish or you can even take the skin off the chicken. Don't worry, this is not plastic is not going to add to the environmental burden of that surgery of surgery because all of this is either going into our cooking or I've got two dogs who have loved this as well. But I hope we can see with a bit of patience, diligence, uh swapped to a 10 blade, I think because this is sharp. Er, but I can do the same. See, there you go 10 blade sharp. Er and I'm now making a lot more progress, take it down so you can believe, see exactly where I am okay and the effect, it's interesting that knife in this situation, you don't run the risk of cutting the tissues at all and the fish itself, it's very delicate and you run the risk of cutting it if you do not use the plain properly. But when you get practiced and you used to doing this over wide surface, it can be a little bit bowler with these drugs when you got the field and literally sweep it across the broad surface as I'm doing here, as I said to colleagues beforehand with the black about academy. All these have done live because you need to understand that even at my stage, I'm learning and practicing and to try to mass in the out as well. For those of you who are observant, you see that my belt is now good a white stripe below three red stripes because I went for my first tag towards my fourth man 10 days ago someday. And the tag is to indicate the next step in my journey towards fourth time, which I can only take four years after my third, which was in September of last year. So my fourth time I can only take in 2026. I won't be learning anything new or anything different because I knew inverted commerce, the 16 Carter's and 10 of them backwards. But what I'm going to be doing with my martial arts is refining the movements and refining the skill and refining the execution. And that's the thing about martial arts and a philosophy that I want to impart upon you. Mastery is a journey is not an endpoint and we're all on that journey no matter where you are and we can always do better and become better in our skills in the truest sense of the word technical skills, but also mindful of the sheens the conqueror has described and brush edo away of the Nationals Warrior. So as a test of skill on this, what we want to see is that the skin comes off cleanly and white with no salmon on it. And I have not disturbed the salmon underneath, clean and white. You note that I'm not teaching speed at all in these lessons. What I'm wanting to try and part upon you is that it's attending to the basics and mastery of the basics all the time because mastery comes by that strict attention to detail and the very simple basics of how you hold the instruments, how you use the instruments and literally feel the instruments with time and with practice, the rest will come and you will see the difference in the outcomes of your patient's with less bleeding, less maceration of the tissue, less wind infection and satisfaction. Because that scar is the signature that you leave on the patient. You may not ever remember them. But then we look at this car and remember you for the rest of your life. So when it comes to the incision, think how you do it supporting the tissues, 90 degrees to it. A king section is sharp dissection and that's where your wound healing begins. Thank you very much indeed, for joining the Black Part Academy of Surgical Skills, Gabrielle. Do we have any questions? Not at the moment, no questions. Well, we did note that in the answers that you offered beforehand, I hope you now understand how to hold the knife. I hope you understand knife safety and mounting it just one other thing with passing the blade and passing the blade, a pass it to you handled first blade down, lay down, handle fast. But in theater this day and age, I believe all blades should be passed in the kidney dish from the scrub nurse, kidney dish to you to kidney dish to the scrub nurse. If you do have to pass it by hand, laid down, handled fast and don't carefully carelessly, pass it off to the left without making sure the person is picking it up properly. Thank you very much. Indeed. Please join us next week. We're, I'm delighted that we're going to be joined by Phil Beman. Fill started his career as an R A F tornado pilot. He's been on 32 sorties in various wars and trained the red arrows. We'll be talking about the theater of operations and operations in theater and the skills shared between a surgeon and a top gun pilot. Join me next week. Thank you very much. Indeed. And do invite your colleagues to follow. Thank you Gabriel for your support and production.