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Hello. Good evening. Good morning. Good afternoon. Wherever you are in the world. Thank you for joining the Black Belt Academy. When I say wherever you are in the world. This evening, we got people from 13 different countries. Notwithstanding our producer Gabriel who's in Lithuania, but people are registered from Egypt, Colombia, Libya, Georgia, Guatemala, Sudan, Yemen, Mexico, Indonesia, Myanmar and U United Arab Emirates. Thank you very much indeed for joining the Black Belt Academy. And thank you to the 4237 followers on Facebook in the 682 on and wrote a very profound text, arm battle and swordsmanship. But as you would have gathered the metaphor of warrior and surgeon and the way of the surgeon is very much like the way of martial arts. So the piece I'm referring to this evening in the practice of every way of life and every kind of work, there's a state of mind called that of the Deviant. If you strive diligently on your chosen path, day after day, if your heart is not in accord with it, then even if you think you're on a good path from the point of view of the straight and true. This is not a genuine path. If you do not pursue a genuine path towards consummation, then a little bit of crookedness in the mind would later turn into a major warp reflect on this. And as I looked at that paragraph, I reflect on all the images I've shared with my fellow sense, Chris Caddy on how to hold the forceps. Now, when looking at these pictures, I see people hold the forceps like barbecue tongs overhand like that sometimes holding it as a pair of as the scissors and very frequently, I see that a pinch. So there is a whole variety of ways of holding the forcep, but there's a one way deviate from that. You'll find that the smallest error ends up in a really crooked path. So the way we, I recommend that we hold the forceps is really to use the unique muscles of the hand. And I would commend you all on your answers to the questions this evening. They are detailed and thorough and are glad in my heart. The number of muscles in the hand, you got three thinner, the abductor of per flexipes, three hyperthenar. But on top of that, you got a small quadrangular muscle that arises from the flexor retinaculum and goes into the palmar up neurosis. And this is the palmaris brevis that actually tightened the skin and therefore the grip on the ulnar side of the hand. You have four dorsal interossea, three palma OSI and to remember what they think of dab abduct, pad abduct. And then of course, you got my favorite muscles which you describe very well. The lumbrical arise from the tendons of the flexor pollicis, flexo Dior and profundus and on the radio side, and they extend across the finger into the extensor retinaculum and they do that, they flex the metacarpal pharyngeal joint and they extend the interphalangeal joints. And you taught me something this evening as well that these are the only extensor muscles of the upper limb that are not supplied by the radial nerve. Thank you for that. So I count 18 muscles but there is the pros profundus that is counted in the hand muscle that raises from the lateral border of the radius and enters the palmar up neurosis. It's rare, but again, improves the grip. And what's unique about our hand is our ability to put them together, the master upside down. And as you say, pros supernate at about 270 degrees, which we have focused on the stitching. But it's these lumbrical that I think are underappreciated by the surgeon because if you look by extending the pharyngeal giant and your policies, palp of the fingers and thumb together, you know that maximum remembering that you get more sensory input from the palp finger than you do from your eyes so that you do feel your way around and the force should be an extension of young and therefore of feel. And I'm gonna bring you over to the top to demonstrate this. So resting the forceps in the first interosseal space, extending interphalangeal, bring your fingers and pulps and caress the forceps. You cannot bring enormous amount of tension or grip do this and I'll show you how and why. So I've got here both hands a bit of play and I am going to use my lumbrical with my left hand and flex the D IP joints with my right and flexing the D IP joints with my right hand. I'm using flexor digitorum profundus and flexor pollicis Longus, these flex the distal interphalangeal joints. They are the biggest muscles in the third compartment of the forearm. Literally, you can hang your body weight by the fingertips and that's what cave people do not cave climbers, uh wall climbers, do what I I'm trying to do is squeeze the green really hard, but I can't squeeze it any more than that. No matter how hard I try do it from that side. You can see I've actually gone through with my pinch and no matter how hard I try, I barely in the plato the green, I cannot squeeze it. I cannot apply pressure. And is that keeping your distal and proximal interphalangeal joints straight that will ensure that you're going to use the lightness of touch and intrinsic muscles of the hand. I'm still squeezing it hard and I can barely bring the palps of my fingers together. And that is really trying hard, but I haven't gone through and why this is important. If we focus down and what are forceps is going to do to the tissue, it's going to crush the tissue. And if, if we take pressure or force over the area and average print pressure is 25 newtons and the area of the forceps, I've as five millimeters squared, you have 25 newtons of five millimeters squared, which equates to five times 10 to the six newtons per meter squared. In other words, 1785 psi and when you think of your pressure in the car hire is 30 to 35 that's an enormous amount but the damage it is doing is considerable. Now, although I'm holding a pair of forceps, two forceps here, we'll look in more detail. I'm just reflecting the skin edge and I want you to take a good look at this banana skin and that skin edge as I reflected, you can see that the bruising is full thickness all the way through and that's with two forceps, these little jagged teeth in these Adson tooth forceps, you got a little ra tooth there interdigitating with two teeth there and you can see the teeth looks on a banana and all too often. I see these teeth marks on the skin and scratch marks, but not only that you are causing full thickness damage. We know there's histological damage of the bowel mucosa and of the endothelium within due justice use of the forceps on the opposite side. You've got non tips, non tooth forceps. Again, they're fine teeth either side. And these are my favorite forceps. They're called the Bakey Forceps. And we'll talk about Bakey in a moment, excuse me. But again, even these forceps have caused damage and they have scratched the skin. never ever ever grabbed the skin with forceps. In fact, a skin hawk is preferred by all plastic surgeons but also never grab the bowel or the adventitia because you see now the damage is done. That's a bit of banana which I earlier grabbed non tooth and two forceps, non tooth and two forceps. But look at it from underneath, look at that damage on to and look at it underneath. It is considerable and therefore beware that your can cause. So now these Tobey forceps, I've got a of 21 side interdigitating with a double ride and they called crushing or forceps. But I think after you've seen that banana, it's not. And I'm pleased that you all know that was of September 19 0, and died on the 11th of July 2008. And he worked at the Texas Medical Center. He was the father, as you say, of cardiovascular surgery, invented the Dacron grafts to repair aortic dissections. And the classification is a classification of aortic dissection. But he was in invent roller pump and artificial heart but he fell out with one of his trainees. Dubay fell out with Denton Cooley, took an artificial heart of his and put it in a patient and they never spoke to each other again. Dubay got the presidential Medal of Freedom, the National Medal of Science and the congressional gold medal. He's actually buried in Arlington Cemetery. He stopped operating at the age of 80 having done 60,000 operations, he actually died of a dissection, not of the dissection. Initially, he refused treatment, then was persuaded under duress to have an operation. And he's the oldest survivor of aortic dissection at the age of 98. And they used the Dacron graft. So when you're actually holding the forceps, and I'm pleased to see and read that, you know, who d and cool that you now will afford respect to the instrument for the surgeon after whom it's named, but also how to hold properly. And the thing about holding it between the extended finger and thumb is that your wrist movement and your arm movement can get work in any position, allow you to do this too often. I see it flexing out. And as soon as you do that, you start flexing the proximal and distal interphalangeal joints, increasing the pressure on the end of the forceps and sometimes it even deviates to be held like a pen. What's interesting when looking at the photographs of basic surgical skills courses. The number of people that are holding the forceps incorrectly, it doesn't appear that we're teaching how to hold force properly. And I reflect on the OS had scores for surgeons and not many and not one I've seen includes how to hold the instrument properly. So the forceps are not only for stabilizing tissue and retracting tissue, they should not be used to deliver a needle. Now, I was going to demonstrate this to you. I've got two needles, same size, same shape in a bit of playdough, same size shape, same shape. And I've haven't tried the e because I wanted to keep the shape of the playdoh on this one. I am going to continue the rotation of the needle note, the needle is held by the tissue. I'm gonna deliberate it out and take the needle out on this side. I'm gonna do what a lot of people do when stitching, they put the needle through, they grab it with a pair of forceps, they pull it through. And if we focus down on the exit wounds, so to speak, you will see that on one side, the needles come out with a clear punctum, play a hole on the other side. It is skidded and actually torn. It has torn a player. No, if you're doing that with tissues, this is this kid and I'm looking at a there as well. So delivering your needle with the forceps is a bad habit. And I hope this model is demonstrated that the rotation of the needle through the tissue is compromised. Compare that with a clean hole, the other side and what you can't see clearly. And I'm trying to actually get it closer and closer. Yeah, there you go is the damage that is caused. Yeah. Yeah, I'll take the light down. So please, there you go. Less light can see there, there is a tear. So please do not ever deliver your needle using the forceps. Forceps. Is there to stabilize the needle if necessary. If the needle is not being held by the tissue. The second thing I found is that people are stitching and this is going back to the stitching was we've had. The problem is in holding and retracting and focusing on your stitching. People allow their forceps to drift and drag and I'll come back out. So what I've done here is put some staples around the banana mettle that we have previously described as I focus. Oh, delivery needle. I must also make sure that I'm holding the staple lightly and not pulling it out. The problem is when people are focusing on the needle itself, they are forgetting the damage that has been done by the forceps. In this model. You have to use your hands independently and beware that your forceps may well be causing. Am because if I'm not careful, I'm going to be pulling the staple out, try yourself at home I'm trying to get the right lighting on there. And these only lightly put it in the banana. So your forceps should complement the action of your stitching hand or dissecting hand with careful and all the time. I'm holding you with extension, using those lumps, making sure that both joints are extended. The number of photographs that Sansei Kri and I have looked at where there's deviation and holding the forceps is quite remarkable. So your accuracy and precision in act in holding the forceps can be practiced simply using some rice to pick up rice. Initially, you can start by putting them in numbered straws. That is relatively easy. You tried doing it. However, with bendy straws at different angles, particularly if the straw is narrow. And as you see there, the diameter of rice is more than the orifice of the straw. So not only do you have to be gentle in picking up rice but also you need to be able to orientate it such you can drop it in easily. We ran this as a competition at the a conference in Liverpool earlier this year and ask people to put eight pieces and four bendy drawers as a competition and people came back again and again and again. And the quickest we had was 15.43 seconds. If you drop the rice, you're out, you'll notice when practicing these exercises that we don't practice be. But what we want to ensure is accuracy and precision. You can change this as a game by calling out different colors and mixing it up a bit like that. Simon says game with four colors and you got to copy the sequence. There are a number of different things that you can use to practice your skills. The one of my favorite again, going to the supermarket and looking what's available is to use seeds. And I've got mustard seeds, fennel seeds, pepper seeds and coriander seeds. They have varying sizes and shapes. I think the mustard seed, these small little ones are the most difficult to pick up. And they're scared across a dish. Pice seeds are larger and irregular and somewhat easier to pick up. Ethanol seeds are slippery and the coriander leads. Likewise, I would like to know from you what models you've got at home and what seeds you are practicing with. I've now got a forcep in both hands and can you both hands to practice the skill at the same time because you need to be adapt and accurate with your forcep skills in both your dominant and non dominant hand. I must say standing here, talk to you doing it and concentrating as well. Is another I mentioned, I've got rice in there and you can put those in draws and you can make this exercise as complicated or as simple as you like simply practicing this for a few minutes every day is going to make a significant difference. To your ability to use your forceps. The other thing to add, I've got forceps in my hand is that I can use this as a fob and I can use forceps to support an instrument. So for those of you who are assisting in theater and asked to cut a suture and are a bit worried that your hand is shaky. Put your forcep in, stabilize your scissors on the forceps, make a cut that is quite as acceptable. Do it slowly and deliberately in a rush, many things have got interesting pips and here we got a red pepper and at the bottom, we've got lots of pips and it's rather fun to take these pips out. And as pointed out previously, they, they're almost the same diameter as the straws. Again, if you're too rough, the straws well be displaced and the seeds themselves will fall off again. This is the next that you can use with both hands. It's particularly difficult with the straws here because you can see yourself the seat is not come closer, the seed, it's always the same diameter as the straw. So getting it in does require accuracy and precision to put it in all of this is improving your fine motor skills. One thing you can do again to help with stabilization is put your baby finger out on the edge of the wound or on the retractor and that can give you that extra little bit of stability in holding the forceps. I was operating recently and I noted that I almost automatically put my finger out to give me an extra bit of control. What do we operate on? It is often gelatinous and wet. And although I've used the tomato previously to demonstrate, peeling the skin of the tomato, I thought this would be a wonderful exercise. Did you look at taking the pips out of the bar itself again, doing it with your right hand and your left hand. So every time I walk around the supermarket now I look at the fresh food and vegetable section with a totally different lens, thinking to myself, ah, maybe there's something there we can use to home our surgical skills. Think about all these models. They are easily accessible organic, the DFO Mimi canine in many respects, human tissue and we are not using plast. This is also sustainable. The Royal College of Surgeons of Edinburgh has got a sustainability policy and I'm delighted that we are leading the way in sustainable good practice is tomato. Well, I should go in a pasta sauce or can go on a sandwich. Nothing will be wasted as the pepper and of course, the seeds with cooking. And I'd like to hear from you what models you've got at home and we are going to have a competition were the most innovative model authors woul get a set of instruments. I must apologize. And we ran this competition previously and one of the winners from United Emirates did not receive this prize. Despite me sending the instruments on three occasions, they were stopped by customs. So we're trying to get around that. And with the competition ask that you perhaps put your work address where it is more to be delivered. Are there any questions from anybody watching? Not at the moment, but we do encourage people to ask questions. So if you got any questions, please ask and you'll see that this tomato with the seeds, they are a little bit more difficult to pick up. But this is not too dissimilar to debriding a wound and taking out bits of dirt. I was looking up what's the difference between tweezers and forceps? And I, I'm still confused myself and maybe somebody else could answer tweezers, I think are shorter. They are finer and they are used literally for picking gripping little objects. So hands the tweezers you trained in home medical kits for removing splinters. I think some of our would use the term tweezer as well, but I'm still confused. So perhaps you could enlighten me, the forceps can also be used to probe and explore tissues, remembering that they can stab as well and enter solid organs and cause damage. So literally they can spear. So do be careful. I hope this has made sense. And as I say, look forward to hearing from you what models you've used to practice your surgical skills. Hope you now appreciate the most important important muscle for us. As surgeons, I believe on the lumbricals because pinching is using excess tissue, tissue, excess force. We need to start practicing and reinforcing basics. So do next time you pick up a pair of forceps, ask yourself, have you extended or the interphalangeal joints? And therefore, are you achieving the perfect feel of the instrument? Because the forceps are in essence an extension of your fingers. Do ask questions or make comment? I note my fellow Sensei Mr Caddy is on the line. He is a plastic surgeon and very aware of the trauma caused by poor surgical technique. Would you like to make comment, Mister Caddy? Uh afraid not. No, no, you're doing an excellent job, David. Really enjoying it. Thank you. Thank you. Thank you very much for joining the Black Belt Academy Surgical Skill. I hope you join us next week as we introduce a new Sensei Malvin Macklin who wrote the book, The Way Of The Surgeon, the Intersection of Surgery and martial arts, his coauthor, we might indeed join as well and I do commend it to you for reading because the parallels of practice, correctness, persistence and mindset are so unique to surgery and martial arts. What is interesting the I introduced you to on the 16th of October Alex, he's now decided to do martial arts as well. And on Tuesday, he starts his first lesson. This is the second sense of the black belt academy who's decided to take up martial arts because in Romania has started as well. I'll be asking both of them to dialy their journey and compare the learning. Thank you very much for joining the have a if you have a moment uh from, yes sir. Is there a book or video series about different instruments? Right way of use. So we can probably suggest previous sessions on different instruments. I thank you, Gabrielle. We are very keen in the blackboard academy to actually teach how to use your instruments properly. So as we have described the knife forceps, the scissors, we have emphasized the importance of grip. It's interesting. This is not covered and your O SA schools, nobody actually looks at this. But the other thing we do is not only emphasize how to hold the instrument properly, but as we have discussed this evening, describe the name of the person who invented it. Cos I think once you know the name of the person and what they have achieved career of surgery, you will show more respect for the instrument. And thanks to our sense, Crista Gara and Gabrielle. If you look at our website, we have summarized all the instruments we believe you should know. But more importantly, if you watch the videos, we will stress how to hold them. And in fact, you have prompted me to think maybe we haven't on how to hold instruments in the first place and we can focus on the grip. I think that and perhaps we can even put a scoring to it and develop an O SAT score for how to hold the instrument properly. I know I've actually described it in a technique based assessment which I've shared with our sensor, but it's something I think we can share with you as well. So thank you very much indeed for the idea. So I'll put that on the agenda. Any other questions? No questions so far. But we do have a few. Thank yous. It's an absolute pleasure and again to have people across 15 time zones joining the session is a real privilege and pleasure. So thank you very much. And also just to remind you, they are accredited by the Royal College of Surgeons of Edinburgh. And your CPD certificate will include the Royal College of Third logo and a statement saying we are accredited. So please do fill in the feedback form, do encourage other people to join us because you can start collecting your CPD points. Thank you very much. Indeed.