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Hello. Good evening. Good day. Good morning. Good afternoon. Wherever you go in the world And welcome to the Black Belt Academy of Surgical Skills. My name's David A. Regan. I'm a cardiac surgeon in Yorkshire, in the United Kingdom. I'm visiting Professor Off appearance College London in the past, Director or the faculty of surgical clearance for the Royal College. It says in November I'd like to thank the 3236 for us on Facebook. And if you're joining this evening, welcome back. If this is your first time attending the Black Belt Academy, thank you for joining, and I hope to inspire him. We have 466 people following an instagram on day. I have the stitching syllabus from Read about to black out on Instagram. I'd like to thank fill on Sue who are with metal. Sue is comparing this evening and will receive your questions. If they're burning, you're able to interrupt and ask the questions, and I hope to address them. But please feel free to address any of your concerns. I did put up some questions beforehand and asked you to read them about the and after me of the needle, The most difficult stitch and placement on. I hope to address those this evening Last week, I asked a simple question. What is the most powerful super nater off the arm? I didn't have any replies, but the answer to that is the biceps on. That's been why there is a clockwise screw arm or your screws, um, for tightening, because the most powerful super nater is your bicep muscle. That's part of the black about Academy of Surgical skills I always like to introduce. Yeah, do do the martial arts way because I think a lot of parallels. We've proven Savary and martial arts on when I read passages out, Swap the word warrior for surgeon Swim the word battle or war for theater. Not that theater should be a battle or war far from it. So this is from the Book of Firings by me emerging Michelle. She have undefeated somewhere. I worry from 16 43 and this is the chapter on the water school, the state of mind in martial arts in the science of martial arts. The state of mind should remain the same, is normal in order to circumstances as well as practicing martial arts that they're being no change. A call with the mind Lupron and direct neither tense know lax center in the minds, such there's no imbalance. Calmly Relax your mind saver this moment off east thoroughly so that the relaxing ization does not stop. It's real excision for even an instant that you're in the mind unclouded in okay, placing your intellect on a board plane. This is essential to polish intellect in mind diligently, and once you're shopping to intellectual point, they can see whatever in the world is true or not. Waken tell Whatever Is Google bad on When you can experience of various fields on are incapable of being fooled at all by people of the world. Then your mind will be coming. Beauty of the knowledge. Your list, um, off the art off war. There's something special about knowledge of the out of war. I'd say the art of surgery is imperative to master the principals off the art of war, several, and then to be unmoved in mind, even in the heat of battle surgery. I hope you see that parallel. So we talked about posture last week. Hand relax a shin off the shoulders, extension the hours, the power of flexion of the risk. But like in my pocket, we also stretch the importance off the pickup of the needle that was just beyond halfway. There's no space between the needle on the tip of the needle holder turned. The needle is angled down and they're angle. There is because your wrist is lower than the album on. Of course, we stand up, but when you're standing up, we're not standing rigid. We forever moving. I was reading in practicing my sword the other day. The sore draws and cuts on movement from one posture to the next. So we were four. Enjoyed Wimbledon that weekend and marvel that the skill off them if the men's final final, the tennis players. So naturally, if you play tennis, you'll be aware off standing on a different foot. You playing afford her forehead and on standing on the right foot. If you play in the background on the posture changes along the time now, I'm not suggesting that you deliberately moving one direction or the other at the table. The simple change in posture could be a simple as changing the weight from your right leg, which toting my pelvis that direction and has my shoulders or toting my shoulders and pelvis. The other direction that standing on the left leg and simply changing the weight distribution will change the tilt your pelvis on your shoulders on give you that extra few degrees to make those stitches easy. So the perfect alignment of a needle, no matter where you are. Whatever vessel, borrow ureter. Whatever you stick. Skin is always 90 degrees on going to put out next week a simple test for you to see if you can spot on 90 degrees among 10 slides, and I believe we hard why to do that? Because we surrounded by 90 degrees, though the book when the frame etcetera and we said last week, 90 degrees is a perfect angle because it's fourth. Part of the circle on your alignment is 90 degrees across what you understand 90 degrees into what you want to stick, and then you simply rotate the needle for on the curve and using the needle itself. But it does mean that we do need to change posture and address at the table accordingly. Andare take you over to the banana marvels on my potato models now coming over to the potato morning for the first instance, I have actually drawn here 90 degrees on the potato on all my stitching and enlightenment. Body position is always going to be taken by simple 90 degrees in to work, but across working to stitch. So that's 90 degrees across what we want to stitch. I have now get a rotating needle back, pointed 90 degrees into what we want to stage and simply retain the needle. And it should come out exactly opposite 90 degrees. I do note that the needle is being held in the potato, and that means that I can take it out, just be on the half way, pick it up and continue the delivery and then picking it up. I have picked up already to use again, frequently with repeated stitching. What happens is people do not pay attention to the pickup of the needle, as I described last week, and I'll show you shortly on doing so. The rotation of the needle through the tissues lost, particularly after repeated rotations. So the simple model on the top is for you to practice. You won't pick up and check each time and you say that to yourself. So once you're comfortable doing it for have a great thing about that angle that'll make it enables me to prove that the needle across the top and take it up back hand at a similar angle is well, I cannot take the new, like had through the tissue, but they're I've come off center. So this moral tells you immediately if you not aligned the needle properly or right change of the property as well. Now the great thing about the potato, they go in line. I corrected myself in correcting my body position. The body position is difficult to describe on will be dependent on your height. I already have. It is. But what this model is going to allow me to do is practice in five domains one on the top on this side, away from here. Now, stitching away from you would have got now is I've using the beauty of the movement from the upper leg, have abducted my shoulder over and I've been lying the needle 90 degrees across that 90 degrees. They're all right. That's a way for me. So that did. It takes my body position and you try it yourself 90 degrees across what you want to stick. That is the important element. No, take it through tissues holding the needle for me, delivering it reactively, and I'm taking it out now. The important thing is I'm not grabbing the needle straight off because there's a said before the shaft of the new was cuboidal. So if you grab it, it's not going to fall into place. But if you pick it up, gently squeeze it. You'll find that it naturally flips into position because of the cuboid in shape. And that was a little trick called a trigger is you're holding the needle, but the wretched is metformin and it flips into place. And that's what I'm doing just before and pick up the needle every time. This is true, the big needles and small needles and I'll show you shortly. So coming back to this, I I'm practicing my body position, Um, my arm position to ensure that are 90 degrees across on a one to stitch okay, on you flip it back hand and take it the other way. Note that potatoes microwaved and soft on That's what I call a splash model. Because if I did wrong, I'm going to be tearing the potato. And that's why this bottle is actually working. So I went in night degrees coming out 90 degrees and I'm using the rotation. If I don't take the needle property, I won't tell her the potato. So the other positions this side to my left right handed again. I always up in Yeah, Ally in the needle. Sorry. Cameras in the way makes a booklet. Let's get yourself a body position to do the same again. Forehand on back here on the potato and understand that you're moving an experiment for yourself. That position here on the side I'm stitching. I always again up in the air, 90 degrees cross, one of one to stitch. All right, Taking it through. Taking it out on these teachers, to be honest, are awkward. And you can see that if you pull it out of Tom your attention and it gives you immediate feedback. The problem is, with most models of using several and they don't give you feedback. This will tell you if you're doing it wrong immediately. I'm having to negation with camera here. Sure that you've got a view trying to do is demonstrate the line into the needle in 90 degrees. Cross the water would what a one. Stage four head on back. Hand out. And I want you to try that yourself. Now, the thing is, this can be demonstrated very nicely on my plate. Time on these are the factors very simply in separate. We often talk about. I'm just hoping. Okay, we often talk about a clock. Now I know. Made clocks a digital that o'clock 12 o'clock. Six o'clock, three o'clock, nine o'clock on with. Most things were orientated ourselves. Look. So Michael degrees around a circle was very something 90 degrees to the radius. So I've got a protracted here. That's nine o'clock. Eight seven on what I drink is going from my left foot, changing my balance, coming across to my right foot, Padalecki, your right foot five o'clock. And I'm coming to this position here and hop house for And for a right handed surgeon, the most difficult stitch is in to your right shoulder from that family surgeon. The most difficult stitch isn't your left shoulder. So that is about half past for that long demonstrate here. And it's in that position that I now have to change my body position totally from a right foot now to my left foot. And I can come around four o'clock three o'clock, two o'clock, one, 12 o'clock. I standing equal weight distribution. You learn the clock on finding really enough time the opposite here. How close to 10? I have the same problem and it's in that position. Um, now my right foot back to the left foot and I'll continue forehand, continue around the cloth on. I want you to experience at yourself that you're moving and you're changing your body position to ensure that you're 90 degrees across what you will stick with the time. So a simple incision continuous stitch is can be demonstrated with this banana found. Unfortunately, with the hot weather, the bananas going round robin quickly, but it would have drawn him is with a pen drawn 90 degrees centers across each side. And then here dots. The reason I'm doing that is to practice continuous digit, so make it agrees. Across one of one to stitch on both edges are together said That's no problem today and rotate it out. Pick it up just again. This is nice example of how to practice a continuous stitch and making sure you're Lehman. Question is always that I'm deliberately putting my leaving my two degrees across the working stitch. It's coming out 90 degrees offices. Okay. Have you got to see this to yourself all the time until it becomes automatic. And this is the area What I call the setup the diastolic, um, interested in that is not support. So now I have got dos I decide. And can I actually got in the docks and come out the dark? Have 90 degrees. I'm target. This is rather fun. Exercise is to see. Can I hit the target each time finger? Then you could do without the alignment and continue practicing yourself. But what I find with watching people doing continue suture as they come down. They do lose that angle and losing that angle, then control their bodies to try and force it through which does not wear. So what happens then? If you've got something where the two edges are not together the two inches of not together, please stitch them separately because you can see him. The victim's at 90 degrees. I decided this different. Okay, inside. When I see people doing when the two ages are not together, demonstrate here they get a halfway through there, they force the ground to try and pick it up. You have a sign doing, sir? Have a tissue. But what? I want you to do this exercise. Yes. Making sure your lineman of the needle and you pick up each time is different. Okay, Now what happens at the end of this and vascular surgeons of my new recognizes since it here on toe the alignment of 90 degrees in here is effectively parallel to the two walls on a simple exercise, I take it a little bit further back than half way. I can use the belly to push the first year war away, then come up 90 degrees from inside. That's a little trick. Cardiac surgeon, vascular surgery. And you'll never, ever hit the person war. No, that I have a sign of this. The alignment of 90 degrees forms like a train. And okay, and that's we're going round. It's been like a circle you will find. You'll reach the position where you have to swell swell up this situation. I'm going back in here. I use you find myself coming to this position taking dark, her wedding on being it again. Note that I'm not using my forceps to hold the needle or directed me. I'm using my knowledge of angles. Nothing or the needles pick up a baby. I got questioned. Yes, of course. Okay. It's from a reem on. They say I'm a lefty. And a long time ago I used to do perineum repair after appease IATA me. Okay. I just want to say right now I'm not medical. So if I pronounce is really going on continues to say I had to use my right hand to do so Because I know I have never been taught to stick with my left. It's a struggle. My question is, can I do stitches with my left hand? Will it be the same as to how you hold the needle holder? It is exactly the same as holding the needle holder, But the difference is that the wretched mechanism for a right handed needle holder, you would find difficult taking off. Okay, so if you got a needle, hold it without Roget. That's after you find what's interesting when I'm doing Korean last immerses of top ends. I recently went around the top end and I said to my assistant, Did you notice anything as a background? They said, no, I said, Well, actually, I'll swap homes because I got to a position where it was so Walk would stitching to into me that I had to put my needle holder in the opposite hand and I did my stitching with my left, But he hasn't noticed now. Unfortunately for that time, surgeons left hand instruments are hard to come by on. Regrettably, the answer is, do you practice with right out? But you're gonna have significant advantage of the rest of us because you'll end up more and bit extras. Okay, I trained a left hand surgeon for 18 months on, actually swap my instruments over and train myself to be left handed to help him, and he had better access to some parts off the battery in the chest, and I did on indeed, you. If you're able to stitch but right and left hand, you can't get to the orchid ankles. But of course, to the ultimate change of address is go to the opposite side of the table and you get a different angle in different perspective. But please never compromise on that 90 degrees. So going round circle again, I'm sorry. The hot weather means the banana is difficulty here and sweating my alignment each time going around the clock, as it demonstrated with a protracted on. I am moving my weight distribution now to my right foot, picking up a little each time, and I'm predominantly on my right foot. And now you can appreciate. I'm coming to that position where it's going to be very awkward for me to do the next stage. So I know having practice their anger to change position, I take my meal out, your prorated of the top swap to my left foot and I can come back. Yeah, other way. All right, now, this marble is totally unforgiving. Unfortunately, because of the hot weather is browning very quickly. But if you do this on a nearly right another and let it develop, you want to see your holes. Reagan Needle has come out, and that will give you an indication off how accurate your placement in rotation is So now I'm on 12 o'clock. I am standing equal. District weight distribution 50 50 coming to 11 o'clock. I know that how plus 10, I'm going to be swapping to my forehead. And I've changed my weight distribution again. And this is for you to experiment yourself to find what's comfortable. Now, you might think. Does that work for a small hole? So I have used it. Tip of a pen. All right, on. I've made a small hole on. This is a fine needle that we use for top ends. And I'm using a castrate. Taking on the same thing applies same principle. Okay, Place rotated back. It pointed into the moment they take the needle forward and taken out and you'll see as this develops your exit points or accuracy of the exit points, we'll be there literally in black and yellow. Has it been on develops again? Same principles, Small needle. I'm at my heart plus four. I've got to go to back hand. I've changed my legal position, my body position and I'm continuing round. No, I'm not using forceps to deliver my needle. My forceps are there to hold retract on a very, very very seldom should be that toe. Hold the Neil. Because most circumstances, the tissue is holding the needle for you on. If you start putting your forceps in there, you will lose your angle. So mentally, I just lost my angle there. So even in my stage, I have to come back, set up a check my position, three points and pick up place. They take that point. Everything out and stitching is a simple as that. But it does require you to deliberately sexual self off each and every time. So if you look at my banana here, I notice developed a lot. So a cream accident. That's a skin. That's the key nexus. A nice whole. And the banana will tell you when your damage room. So I hope that this makes sense to you. I have demonstrated that with this fool. One last thing. Oh, you like this one. Let's go back to the table again. You don't like this one? Definitely. Like this one. So what I have here? Yes, it's, um Baby sucks. All right. And you can see with the baby sucks their ribs. Yeah, if it's floppy, it's like, Wow, isn't it? And It's not rigid, your lineman in practice on your bagel socks. It's very nice, because the ridges we'll demonstrate where you need to take the sock if your alignment perfectly through the rich each time. And, of course, there's a demonstrated last week you got to be 90 degrees to the sock four to go through, says another fabulous away from practicing. And now you're effectively doing simulating bowel anastomosis on vascular anastomosis. But what I usually do is start away from me, had noted. I went back out okay, and you can practice yourself. You see, my alignment is important. Get the body posture in the right position. So whether you're going outside in inside, out for restless, several outside in for bowel surgery, the same applies the alignment is always there. So this little sock, we'll give it enough. My forceps retract. It's holding. There is enabled me to place take it through and pick up What, Um, a round? No, just I have to get back out and make sure I go to leave Now the we've on the salt. It's probably not relevant to you as a general surgeon, but what's interesting in cardiac surgery? Well, the cuffs heart fails, have the same we've on. It's very important, therefore, to be able to take the needle I/O on that we've because if you don't, you're going to be putting some talk on the valve. These simple exercises you can do at home they're not difficult on. Concentrate on your set up. Get used to the idea that you're moving around the table Ultram times. Even when you're stuck, you don't know what position Pause a moment. Make sure your needles 90 degrees across what you want to stick, and then just your arm position or your body position literally stepping or changing your weight to give you that extra angle. You remember, Master, you can only take your needle two edges if they're sitting together. Otherwise you do it in two and there's no compromise. What's the matter? I hope this has made sense. Please feel free to ask questions. So if you can answer some questions, have you delighted to answer them? Onda, Please fill in the questionnaire. Any other questions soon? Uh, no. We do have some feedback when you were doing your potato, Um, I said it was interesting and I really, And he said, It's a new thing to learn so that that's positive. Good field. I would like your ladies and gentleman to try them myself. This is what I call sustainable surgery. I'm not sending you plastic to practice on on. The important thing is with the banana and the potato. I call them my Splash Morals. They will tell you when your needle rotations poor, and that's when you need to pause and think about your set up your address. Alignment, accuracy. The great thing about the banana you can go around around the circle without a thread. Just a needle and see if you can come out on the same hole each time. It but like target practice, you don't enjoy it. Thank you very much indeed. I want to see you next week. So maybe just one question, um, it asks, Is it possible that we can get access to the previous session? So the previous session is on metal. We don't have any beyond that dewy David, but I'm sure you guess there are available on the website and there are available on Facebook. Have, for the moment, I'll be putting them on a lot of sites, but eventually that they're being hosted all exclusively with metal. Uh, but we've put the link out there. Do share it. Do encourage people to and do some feedback I've used Been on this potatoes. People have turned in from the pool in Tanzania. What fruits do you have? I heard that would be good for practice. And do send me your pictures. I'd love to see them. Thank you. Thank you, David. And hopefully we'll see everyone next week and hopefully they'll come prepared. But lots more questions, everyone. Good night. So you still there?