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Hello. Good evening. Good afternoon. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David 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 Surgeons of Edinburgh and a visiting professor E Imperial College London last Saturday II, having gone across to Malaysia to join my son for his half term as informed that uh Fen and my dearest friend, Ashok cha passed away. No, I wouldn't be where I am today if it werent for Ashok. It was in 1996 when I was on the Brompton rotation in London. I rotated to Saint Mary's Hospital. I recently completed my research at the Thrombosis Research Institute and done a purely lab based thesis. The consultant at Saint Mary's Hospital enjoyed telling me that I was sent to Saint Mary's hospital as a reject. Ashok was there and he had the patience of job and standing opposite. And in 18 months, I did 256 cases with a shock, standing opposite early on in that 18 months. I was rewiring a chest for one of the consultants where the other consultant was in theater, doing a difficult case. It was difficult and he came out at the end of the day and he said the problem with you and Vegan is that you avoid difficult cases. And that was the joke between Ashok and myself for the rest of my tenure at Saint Mary's Hospital. Each time I had a cardiac case, I'd actually joke with Ashok is this case difficult enough for me, he had the patience of job to stand opposite and take me through all these cases. And I invited him to join me on the Power Excellence courses, teaching the future generation of surgeons. Cardiac sat. He had 35 years of experience himself and it was never made a consultant, but it was a convenient consultant appointment when the system felt it necessary. But during that time, he operated as a locum consultant at many hospitals up and down the UK. And there was something about him. He touched the lives of everybody he met and people from far and wide with their families continue to travel down to London to meet him. You've had the pleasure of hearing some of his stories. And for me, he's always not any a good friend but the mental and go to person. Should there be a technical or difficult problem? Because they wouldn't a single k that he had never seen or done in his 35 years of cardiac surgery. So I'd like to just take a moment to pay tribute to somebody who was the most unassuming, gentle kind, so and fabulous human being. Thank you for being with us. Ashok. As I said, I returned from Kuala Lumpur last night and whilst there I visited the Bor factory on Penang Island. Not only are they the world's largest producers of IV Cannulas of 570 million a year. But they are the second biggest factory for making surgical instruments, importing raw steel in sheets from Germany and from a single sheet can make 10,000 instruments, producing 1.7 million instruments. A year of 2700 different types. And one of the instruments they produced was a needle holder. As you see here, this is gold, 24 carat gold put on by electro plating. And it denotes the fact that the jaws have a tungsten carbide inset to hold the needle. But what amazed me is that you started off with her sheet of raw metal punched out with a dye with huge machines, the two component parts. And then from then on over a period of 35 days and 100 and 25 steps. The end product is made not by machine but mainly by hand. And some of the workers are there have been for 30 years in the employment of Bron. What they do by hand is quite remarkable. On an anvil of copper and bronze because the copper and bronze were not damage the steel. They tap and eye up the position of these instruments in alignment to 0.1 millimeters just by picking it up, aligning it, tap tap, making sure and putting the box joints together. Some of the expert workers have their own tools and I took a picture of some of them where their own handprint and thumbprint is evident on the wooden handle from the years that they have been using the hammer to put these fine instruments together just as the little aside is the the American instruments drop. But the b braun needle holder has a sucking motion described by M who's showed me around the plot in German called SG, which is, it doesn't drop in one go and there's a different feel to it. Apparently our American colleagues like the drop needle holder, whereas the European and others preferred where there's a little bit of resistance with that little bit of resistance is determined by a tap tap with a hammer. Quite remarkable to see the care and attention going into the making of a needle holder. So today you have joined me in paying respects. Tua Sensi often referred to as Yoda be in the Star Wars character because the force was strong with him and in sunlight, there was a similar resemblance as well. But the theme of this evening is joining, joining two things together and I wanted to focus really on some principles of joining, but how you orientate and organize yourself with sutures and needles to date, we have talked about the pick up of the needle. One just beyond halfway, two, there's no space between the tip and the shaft and three that angle because you were working at depth and that 123 pick up should be there for each and every step. Now, when we are joining things, you can imagine that nothing will hold together if it's physically under tension and you're having to pull things together. So when joining blood vessels of bowel, it's important that you mobilize, such the two ends can be approximated enjoined without tension. But there's a rub because in order for this to heal, you do need a blood supply. And therefore in bringing two eggs together, particularly bowel mucosa, you have to ensure that you have a blood supply. And in the bowel, it is the mucosa that is important and vessels, the endothelin, you have to remember that the mucosa and the endothelium are very susceptible to damage with the forceps, which we will discuss next week. But when you're focusing on the stitching, the four steps, doesnt appear to get the same attention and we end up pinching the tissues and causing damage. So the suture that you use depends on what you're stitching and whether it needs to be there forever or absorbable. And in the bowel in particular. This is important because we need to also remember that continuous over and over sutures are in fact, strangulation sutures and they will render the edge is bloodless. If you go too close to the edge or too far from the edge, that's gonna make a difference as well. And your spacing is going to make a difference too. So I want to bring you over to the table so we can talk through some of the principles of joining things together. So I started out on our journey with a needle talking about going round and round and remembering that on a circle, your needle has got to be perpendicular at each point. And when we're coming around on the dominant hand to this position, and I'm standing at six o'clock here between five o'clock and four o'clock. I'm stitching into my shoulder and that is a very difficult stitch to do. I'm standing on my right foot trying to stitch in my foot and I can't really go further round. This is where I change my weight distribution as we previously discussed now onto my left foot and I can continue round. We have a question from Rinko. Yes. What is the best way to hold the bowel with forceps outside on the cirrhosa? I will come to that when we talk about the bowel in a moment, Rinko. All right. Uh because I've got a couple of models. So I just want to go through principles of orientation first if I may. So there we come almost not almost diagonally opposite. You go back from backhand to forehand to continue round. The thing though is when we are joining tubes, we are not doing it in a two D plane, but we're doing it in a 3d plane. So imagine it is up like that and you are now joining something to it from that side and that requires a little bit of thinking. Now, the very simple principle in surgery with any stitching, it's always better to stitch to yourself because if you're stitching away, you'll be tripping over the suture all the time. Stitching towards yourself with a good assistant holding laterally and I'll pause there for a moment. The assistant holds the tension, it's a lateral hole and not a pool and it's very important to your assistant is not dragging the suture through. So, again, a very important thing to watch when joining things together. So coming back to this, if I'm looking at a two D circle up in a 3d plane, the point that's furthest away from me happens to be that point or forehand to backhand. The right talked about earlier. It's the furthest as I'm standing up, looking down this anastomosis at about four o'clock, that's the furthest point away from me. And no matter where you are in the body in a head or neck descending aorta, you start the furthest away from you. So I can walk down this part of the anastos, the inferior part towards me and I could come over the top towards me. Remember coming from deep to superficial is also towards you. So keeping it towards you all the time and understanding where you're working is important. So if I take a little piece of paper here to illustrate six o'clock is at the bottom 12 o'clock at the top. And that point that red dot There is the four o'clock away from me and I'm wanting to join it to another piece and you can see 6 to 6 red dot to red dot And I can fold these two together and J and by looking at that in three dimension, in two dimension, this folding together gives you some idea on how you're going to organize your sutures starting away from you. So if I've got a couple of carpal tubes here, I am now going to show you exactly what I mean. As far as the carbo tubes, they were just trying to improve the lighting for you. So there's the red green, black, yellow white, there's the four o'clock position away from me and that's the four o'clock position the other side away from me. And in essence, we need to think of whether you come inside out or outside in and which direction and we'll come to that in a moment. But you can see how that folds and the sutures are spaced accordingly along that line and you're coming towards yourself. Now, the other important thing to point out is sometimes you've got different sizes and with different sizes, the same clock principle a applies. That's the clock, that's a smaller clock and that's even smaller. All that's happened is you're gearing the different sizes all the way down. So if I show you that as a sock, this is the same sock on this side, I've actually stretched the sock and you can see the spaces in the ribs are quite separated and that's two ribs there. But on the side, I haven't stretched the sock and there's two ribs there and the spacing and the numbers set is here in here, Acence the same. But the spacing between the two are slightly different to gear it up. The caveat being in bowel surgery. If there's a major discrepancy between the two sides to try and get that into, that becomes very difficult. And that's where it is necessary to then join it as an end to side anastomosis because it'd be much easier to get parity of diameters. So let's come over and rinku hopefully answer your question on bowel anastomosis. Now, it's so many years since I didn't gi surgery, but the principles of stitching remain the same. So what essentially in gi surgery is quite u useful to do is you put an anchor stitch on the anti mesenteric side just to the serum muscular layer and on the mesenteric side likewise, you do the same. The reason to do that enables you to pass the hemostat around. Yeah, come on this uh hemostat underneath and you can turn it over and do the other side. So the bowel is very useful to put these stitches in which enables you to rotate it and complete the anastomosis. No, the mucosa is the most delicate aspect of it, but also a bowel anastomosis depending where it is in the bowel is very dependent on a good blood supply. So therefore your decision and which sutures to use and how to stitch it not only means you dissected out, such as the edges are pink, particularly the mucosa and there's no dusk in the at all there and there's no tension. But if the blood supply, for example, in the esophagus, low rectum and other places is precarious. The best thing to do is interrupted sutures. And that is where the staple guns come in because it is as quick, easier and they're interrupted staples, but simple interrupted staples, interrupted sutures are a seromuscular and avoiding or just picking up the surface just above the mucosa but not through the mucosa and the other side and picking it up. Now, for convenience sake, we often do instrument pies. But remember with these sutures, all you need to do is bring your two to the two together. There should not be any strangulation whatsoever. And when I first started m Sadri, we used to do a continuous full thickness, absorbable suture on the inside and supplemented with interrupted se muscular stitches on the outside and was a catgut and Siler as we used to reply in a primary exam. But of course, cutout is no longer appropriate because of bovine and infection. And prions and silk is very inflammatory and we have a lot more sophisticated material, do not ever pick up the mucosa with the forceps. And in fact, your forceps do lots of damage. You can use your forceps to gently evert or hold the edges out the, the way. But what I do like about the sock model is the, the ribs, give you a clear marking for alignment of your suture of 90 degrees across and 90 degrees into the tissue and exactly opposite five millimeters apart or 3 to 5 millimeters apart, 3 to 5 millimeters deep and take it through. No, there are a couple of variations on a continuous suture, but a continuous over and over suture, you'll appreciate strangulates tissue. 72 variations of this, the coral stitch and a cushing stitch. They're similarly horizontal mattress sutures that are inverting the tissue and the horizontal mattress sutures are going in and out 90 degrees opposite 90 degrees into the tissue. And as you pull the two together, it's inverting, the anastomosis often supplemented with a interrupted seromuscular stitch on the outside. But the stitching and the suture material that is used is really dependent on which part of the bowel you're working on. But the horizontal or effectively horizontal mattress suture is the coral or cushing suture is not strangulating this tissue at all. So this is bringing the two edges together but it is not strangulating. And typically we used to do it in two layers with an outer interrupted seromuscular seizure. No, having done that ANAs sis in the bowel, you should always close the mesenteric side because you've created a potential hole or space for hernia and strangulation. So the mesenteric incision that you have made needs to be closed as well. Now again, to so model to represent the blood vessel. When thinking about the blood vessel, it's important to think what is upstream and what is downstream because you want to ensure that upstream, you're coming from inside out. They're noted here in the red pin coming inside out, stitching the endothelium to the vessel. You do not want to run the risk of upstream if that's the direction of blood, blood dissecting in that space. And that is why whenever you're stitching vessels, you've got to make sure you're coming inside out on the upstream. So therefore to start, I always come downstream upstream, that's the direction of blood flow. I just saying upstream, that's the direction of blood flow, which would be downstream. Yeah, and you got to come inside out. So approximately I'm coming outside in and I'm coming at that four o'clock space which is furthest away and commonly, well, always in vascular surgery, we use a double ended needle because we want a continuous suture throughout the anastomosis to ensure that you got something that is effectively watertight. Now, the two layers I've got here of the endothelium and light pink and the adventitia in dark pink are separated and this is not too dissimilar to what one would find in a dissection. And it's important that the two layers are brought together accurately and you're effectively reverting and inverting the adventitia sit all together. So having locked at four o'clock, my stitch at the back, I usually continue along the posterior wall coming from outside, in upstream and inside out downstream. And sometimes you're in peculiar positions where you do have to pause and just rehearse that in your mind before you start. Cos otherwise you'll get it very wrong. Indeed, you'll probably see here as I noted to myself before doing the joining session that I do not have an assistant, but this is where a continuous suture and having an assistant is vitally important to ensure that you're not tripping over yourself or tripping over the suture. I'm gonna go and help myself here and do not, that I was coming from outside in rather than inside out as I looked at that. And it's quite easily done if you're not thinking about it or not concentrating and often and vascular anastomoses. This posterior wall is an area that you're not going to get to, again, by definition, you cannot actually rotate the vessel as you can rotate the bowel. And often this area is the area. If you're not, you're not going to see again once the anastomosis is complete. So it's therefore worth your while spending time ensuring that it is sitting together properly. And I continue the suture all the way until the point that I'm gonna speed up a little bit a point where the suture is starting to go away from me. And that's where I then come over the top. So all the time, I'm not tripping over myself, but I'm keeping to the inside and uh without an assistant, you can appreciate that. This ends up very awkward and I'm very conscious. Also my fellow sent Mr Cady sitting there saying, well, the last time you did this, you were tripping over yourself. But you can see the need for an assistant is evident because the monofilament has got a memory and if it has didn't have an, if I had an assistant, they'd be able to hold it out the way for me, the sutures themselves, I've just come in from the wrong side there. Do you see that? I hope you spotted that as on the outside, I need to come outside here outside to outside. Mhm. I worked with Steven. We, he's a very eminent aortic surgeon. He was extremely good at doing Marfans and aortic dissections. And one of his sayings was if you can't do an aortic anastomosis in a single layer, you shouldn't be doing vascular surgery. A certain amount of truth in that suffice to say that actually for very old patients for aortic valve replacement, those over 75 more like 80 plus have very thin aortas and a single layer. Aortic closure would not be appropriate because it can tear out. And in that situation, the stricture we use is a horizontal mattress suture followed by an over and over continuous suture in two layers. And that is the way you routinely stitch pulmonary artery alos a bronchus. So now I've come back on this anastomosis and I'm working towards myself, same principle outside in, inside out, the inside out is downstream, always has to be inside out. And that is what is gonna determine the direction of your anastomosis. I'm holding the adventitia. I'm never putting an instrument on the intima. Likewise, I hold the serum muscular layers and I never instrument the mucosa is the forceps will do a lot of damage. As you're completing this and coming over the top, you're working towards yourself again this side. So there's a lot of orientation and a lot of thinking to do in a continuous stitch. But fundamentally, a continuous stitch is a series of single stitches that we've discussed to date where the passage of the needle through the tissue in each and every one of the stitches needs to be accurate. And that means that you need to attend. Do you a needle pick up 123 and you also need to attend to your place point, rotate. Now I'm doing as I'm coming around the corner here, I working at two different circles and two different angles. And therefore I do need to make sure that I'm stitching it into as the anastomosis nears the end, you'll find that if you've done it carefully, the two edges will sit perfectly well together. And then, and only, then you have permission to do it in one stitch. But that is, can only be achieved if you can put your needle down across both upstream or downstream or both edges and confidently say your needle is 90 degrees across both. Now, the other important thing is is that certainly when you're stitching vascular tissue, people look at the outside and think it's the outside and spacing. That is important. What I'd recommend that you do is try this on a banana, focus on your spacing stitch and then peel the banana and have a look at what it looks like from the inside because then, and only then will you become aware or the need to actually evert the edge and see the placing of your stitching from the inside of the vessel? And why I say that is, is that for if you look at it from the inside, the palms of my hands being the endothelium, I should not see the stitches as you see there with a ring, I should be able to see endothelium touching endothelium. And you'll only appreciate the spacing if you're actually thinking that you are spacing and aligning your needle by looking at the inside of the vessel rather than the outside. Try it on the banana and see for yourself. Although from the outside, you might think it looks absolutely fantastic from the inside. If you're not careful, it'll look a complete mess. The other important thing about the stitching is that you do need to hold your needle holder lightly in the palm of your hand and you need to be able to feel the needle holder. I stood opposite Samia who did a beautiful aortic valve replacement and doing the beautiful aortic valve replacement. I looked at a perfect and I often say with the order four millimeters apart, four millimeters deep and a fop proline, a four by four by four. And I could put a rule up against this and he done a beautiful job and looked really, really fantastic. And I was very pleased with him. We started to come off bypass and the vessel start to fill and take up tension. And as it took up more tension, the heart started to beat, they order started to unzip. I was flabbergasted to be on standing opposite and wondered why, but it wasn't just a single stitch. It literally started tan zip as you would expect a stamp would separate with perforations. So I went to the opposite side of the table and said I better take over here, picked up the needle holder and went to make a stitch to try and rectify the problem. Can you guess what the problem was? Could you guess what I could feel? Yeah, you're quite right. I couldn't feel anything at all. Nothing. I took the needle through this aorta and there was no proprioceptive feedback. No feel of the needle going through the tissue whatsoever. I sent a sample of the order of histology and it turned out he did have severe cystic medial necrosis. I closed the aorta by bringing the two edges together between a sandwich of teflon because that was the only material that was going to give me a secure binding for a continuous ditch to render it watertight. I believe the main issue was was though Samia did some beautiful stitching, he was actually gripping the needle holder so tight that he did not feel the tissue. And as I think of those craftsmen making these beautiful instruments, tapping with a hammer to get the box joint just perfectly to get that sucking feeling as you open the joint. It was all done by feel and tap, tap, feel, tap, tap, feel. If you're gripping your instruments really tight forceps or needle holder, you're not going to get a feeling of the tissue. Likewise, if you're following a suture and assisting in theater and grabbing it and pulling it, you're increasing the tension as well. And the most important bit when joining things is not to knit them together tight like that. Not even the water needs to be stitched like that. It just needs to be brought together a master, particularly when vessels and bowel are in their relaxed form. Because as soon as they feel the tension in the suture increases, this means the tissue tension increases together with the healing and edema, which is maximum of 4 to 5 days that increases the tissue. And you can imagine with the tension of the suture, increasing tissue tensions, poor attention to the blood supply. You've got an anastomosis at risk. So there are simple principles to adhere to in joining. It is worth rehearsing in your mind where you start, where you fission ish. Are you inside out outside in respect the mucosa, respect the endothelium and always stitch toward yourself. Take a pause before you start and think about it and make sure that downstream always on the order, you're putting the endothelium to the adventitia. Are there any questions from anybody, Gabriel? Not at the moment. No questions. Next week. We'll continue our discussion. I will look at the forceps because the forceps should be there to hold and retract tissue, not to deliver needles, but also the forceps can do damage and the two actions of retracting and holding and stitching should happen interdependently too often. I see the needle being delivered by the forceps, certainly on small vessels. And sometimes bowel, the needle needs to be held in place because the tissue is either thin or our bowel. The needle will move. But the holding does not mean that you use it, the forceps to deliver the needle, practice some of this on a banana and c what it looks like from the inside. Thank you very much indeed for joining the Black Belt Academy this evening and we will see you next week. Thank you.