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I know. Good evening. Good afternoon. Good day. Good morning. Wherever you are in the world And thank you very much for joining us on the new platform with metal. This is the new improved version of the back part Academy of Surgical Skills. Thanks to fill in Sioux on their amazing platform that will enable you to ask questions And they can feed those to me. I we can interact. My name is David A. Regan. I'm a cardiac surgeon in Yorkshire, in the United Kingdom. I never visiting professor at Imperial College, London. I may have 26 letters off, but these the two certificates that I am most proud of Yes, I am second down in karate on I'm training for my third dime and all being well would be taking that in September. On a month ago, I got my second time with my samurai sword. It is with that in mind and the principals behind our backs that know me to think off a lot of commonalities between surgery on march last on the learning there from I'm usually I'm going to quote some text from my favorite martial arts books. The first is the Book of Five Grains. The Classic text on the Jack Knees. Way of the Sword, Buy Me a Motrin Musashi who's an undefeated summary worrier, living around 16 43 In the practice of everyday way of life, every kind of work, there's a state of mind. Call that with deviant fish. Fry it diligently on your chosen path day off today. If your heart is not going to court with it, they're even if you think you're on a good path from the point of view off the straight and true, this is not a genuine path. If you do know, pursue genuine path to its concentration. They're a little bit of crookedness in the mind related. Turn into major walk reflect on this. The practice of surgery, I think, mirrors the martial arts way with the food away because of the way of the mind and the way the body on I came across. This, which is relevant today, there's a great need than ever before to slow down. We have to learn to pace ourselves to reduce the number of tasks we have to do in a day basis. We also need to reduce our ones instead learn to be happy with what we already have to be grateful, honestly grateful for that there's great power and gratitude that most people today for government, and this is what they teach in some of the martial art schools. Nevertheless, this is part of the checked on meditation in the practice of medication increases our self awareness and expanse our consciousness. We will eventually reach a state of heightened awareness where we are much more in touch with our thoughts, feelings and sensations. I think that, too, applies to surgery in the way No, this session we're starting with the basics. I fainted at the mind body and so, but the mind and body need to work together. And in this book on the secrets of martial arts masters, there's a discussion here on mutants, laws of motion that one of the most important things combat students and teachers should realize about. Any technique is that it is only a method to manifest physics, not the physics itself. The technique is know what gets the job done. Fasting. Manifesting the physics is what makes the technique where I read this and four to myself, really in surgery. What makes the technique work this understanding the functional anatomy off the upper limit on the body. What's interesting is also sports and martial arts. The first principle they teacher is correctness off posture. Posture is there to prevent fatigue to optimize movement, learned improved efficacy as well. On the Bruce Lee one inch punch way stars with his hand against somebody and throws a punch that was copy by sharing Monk in New York with the crash test dummy on it transpired. The force that was transmitted in that simple punch was something akin to be by a car at city miles an hour. Because it's not just one movement, it's a sequence of movement and understanding. That sequence of movement that resulted in the force from the rear leg, from the toe through twist of the hips through the core and then to the arm where we're lacking in our teaching of surgery is understanding the functional naturally of the, uh, plan on how important it is to optimize the movement off the hands and the fingers. The first thing to say is that good posture can be successfully acquired only where in the entire mechanism of the body is under perfect control. Who said that Joseph Pilates, because he recognized the posture, gives you strength, flexibility and balance and what gets me with most of their teams? We do on a daily basis. We stand, however, when we look. And when I saw your review basic surgical skills courses, 60% of you were actually port sitting down. And that is, and I'm taking keep it down. She starts, which is the whole striding starts in karate, at a table with my wrist in the elbow at the same level as if I'm eating. This is not to dishonor to the way many basic skills courses work, but this is like going to play golf sitting down. You don't do that. Certainly in Karachi this keep it actually starts is there for purpose. It lowers your center of gravity on increases your nurse and your mass and makes it less likely that you'll be bolder. Well, no fever. Think about it. What daily activity do you do every day way you so consciously well consciously decide on your posture? I'll give you a clue. It is now. You wouldn't dream are kind of tired of here with the album abducted from the side. No. Would you dream toe? I'm down here hunched over. You would automatically take your ironing board 200. We always buy the side, Your shoulders relaxed on your arm, complied. The I across your shirt was good. Effortlessly. Do you do the same at the operating table on a note? One of you watching is 1.92 m high. He's very cool. I have no doubt when he's assisting segments. They are not adjusting the table height. What, standing on the stool to neighbor him to operate normally because kitchen counter tops on the height there are because that's the medium height of the population to neighbor you to stand comfortably, you right, we almost slightly extended hands, palm a flexed, shoulders down and to work at the counter. You know yourself working up here, we'll working down there. Ironing is overly difficult now. What we don't do Look after in surgery on my note, one of our trainees said that surgeon should be regarded as a least. Athletes lead athletes, so posture, simple standing. Do you have a straight line from the top of your head through your shoulder? How the Yeah, knee and ankle and then just inclined the head. Well, most people are actually doing. Is they leaning forward a little bit little bit more and protruding the chin? Unless they're doing that, the shoulders are rolling around. And your note now that the line is changing, the chin is protruding. This genotype master, it's a shortening. The pectoralis majors are shortening all your major muscles around your back. I know at risk you've lost the number more doses, the perfect otezla lost and your hamstrings is shortening. But what the most surprising thing is is that for every inch your chin deviates for the midline. You're adding another 4.5 kg. You wait to a head and you had ways about 516 kg. So just imagine this. This is what I use. This is 14 kg. When I was leaning over the trends procuring, I'm actually adding 14 kg of weight to my head, not significant, and that is going to cause a lot of problems. And in a meta analysis off surgeons, they found that the incidents of musculoskeletal problems is it up to 27% on Indeed, in plastic surgeons, it's 95% at 83% were told. Yes, they had no instruction on ergonomics. That sound when If you think athletes, the first principle is good posture to get the strength, flexibility, balance, speed and power. I'm in karate. It's technique comes before speed and power, and that is exactly it in several. So I want you to slow down. I want you to think about your costume. I don't want you to stand properly on adjusted table. Such that, Yeah, this slanted extended has a home a flexed. I always buy this out on the shoulders and down. What this actually does is immediately relaxes all the muscles around the shuttle girl on the scapula, all the pectoralis spine eight is muscles, lettuce mist or see the wrong way on. It isolates the muscles off the upper arm and forearm on what you're left with for movement is that the simple movement off intrinsic muscles of the hand four Lumbrical Zwick's are unique in that there are the only muscles without any bony origin. One session for what they do is extend the distal intraphalangeal Jill joint like that on doing that. The hand, therefore, is beautifully positioned to bring the tops of your fingers together. The thumb can meet war, the other fingers and the props are opposed. So you're mice and cells and you Merkel cells and my Zocor puzzles are getting maximal years, and that is the lightens off touch. And that can only be achieved that's standing properly pierced. Know this. People play instruments. Know this. People who type know this is well because they know it reduces the fatigue in papilloma hand. So, Mr Risk experiment while I continue chatting, just lift your arms up to the side here and this Keep your arbor's out is if you fly and see how long you can keep it up without feeling fatigued, because this is what many of us do. It was interesting that even with robotic, serve your labs complex Saturday. This is happening well, this plenty on the on economics. It was interesting in sports. The Society of American Baseball Research are doing videos, understanding the movement off the throw in the hit in baseball to improve infectedness. But we're not doing that in surgery. Is your balloon tried it yet? Just imagine working like that all day, and then you wonder why you end up with osteo fight formation on a root pain in your back and your leg. So please, first thing you're going to do is a 10 to a posture. Adjust the height of the table and get the functional anatomy of the upper limb on. Why that is important is the upper limit is beautifully designed. It's actually take her hand in any position to work a screwdriver. Put it in your hand. Um, screwdriver can affect it in action at every angle. Kind of not four. National question. What is the biggest super nature? All the upper limit? Why screws are quote wise to tighten. Put that in the child. I'll be interested to know most powerful super nature on the upper limit on my screws on clockwise. So to maximize function off your stitching, therefore and understanding the function of the upper limb, it's important to therefore hold your needle. Hold on properly. Needle Holder is home benediction Sign and his health are on the line off rotation pronation Super nation between index and middle finger on the common flexor in Not Down but like a screwdriver. You had no problems with screwdriver. Look at the range of movement. Look at the range of movement off my needle holder now. Okay, Sounds degrees. I've almost got 260 degrees of rotation. Um, not to pronation super nation movement is the action. We want to be on a rotated. I need a tissue. I could do that at any angle. This is what I call my screwdriver. That position abducting the shorter Oh, a flexed on without any prompting. You have done the same. If I put my figures through the needle holder immediately, you can see I have limited rotation. Probably reduced two little ever 180 degrees, but not any of that. The point of the needle itself is rotating. So the idea behind this lesson this highlight that your upper name is perfectly designed to affect the perfect rotation off a needle. What you need to do is not practice putting gone needle holder on the palm of your hand, folding before from fifth finger of the needle on there, literally using the abductor policies to take the needle or enough on one deputation is vitally important, is very simply this. We want to ensure that the needle goes through the tissue perfect on all needles, as you see here are made on a circle on the needle needs to continue through the tissue on a perfect rotation subset. The whole made read by the new is filled with suture for my behind it, whereas if you actually clumsy with the entry and exit of the needle, you'll end up with an elliptical whole on a tangential slice on that path, and that there is the micro abscesses for bowel anastomosis is on. That, too, is a spirit or a bleed. Now this has important and very important consequences that then late to the pickup off the needle and you understand that pick up on the needle, we will actually look at the anatomy of the needle itself. First thing is, there's a sharp end that's good, David. Different cuts this wage where the surgeon comes in and the main body of the needle is the shaft, and the important thing to realize is that the shaft is not. It's high round. Indeed, it is slacky cuboidal, and as we get to learn to use a needle understanding, this too boy dull element of the shaft means that it's easier to pick up and move around. Okay, What we do operating is really great on death. I'm really disappointed to see us teaching surgeons with organs on tables or on top of the box demonstrate why. Firstly, a needle is often past to you mounted like that. It's not at the tip angled out on just in half way. That is incorrect. And if I tried to take my needle down to the bottom of this boat one, you can hear that by needle order touching the bowl and two that I have completely lost any angle, a tool for entry into the tissue. So what I need to do now is I know my needle out and I go. My needle out is the ago. Between the forearm and the horizontal is because my wrist is learned. Them over on now can align my needle to rotate through the tissues, and that alignment is important. And there's a simple rule of pick up on your heels. Simple rule is this. Just be on the half way. It is angled out from the horizontal, says not 90 degrees. See that angle there? That's the angle from the horizontal of your forearm. Let's just beyond the halfway, and there's no space between the tip of the needle holder in the shop. I'm now in a better position, actually, a lineman, even properly across water, want to stitch, and that alignment is absolutely crucial. Listen to this, as opposed to that is the value of the needle in your surface because the perfect alignment of the needle is going to be 90 degrees. Why 90 degrees? Because it's fourth part of the circle on a perfect angle, and this is friendless angle for us to think about underneath linemen because we're surrounded by 90 degrees. If you look in, the room is standing in now. The window, the door, the covered, the floor tile. The book is all 90 degrees on. All you have to do is a line a little 90 degrees across what you want to stick. Well, I take it back 90 degrees into what you want to stage and simply rotated needle and take it out. Repeat the process, maintaining that angle and that precision all the time. Why that is important. This demonstrated here with a bit of tissue cloth straight across. That's true. You can see the what? We've off the cloth and the needle will pass perfectly through this in 90 degrees. But if I can't put this needle on a candle you can see is Terry. So the reason to be major degrees is passed through the the walk and we've off the tissue as in this cloth. A needle? Then do the work for you, sir. Very simply, we have the posture. You're standing this game. Do you mean that are risk is lower than a number. That means the needle needs to be angled up. The pickup on the needle, the 3 lbs just be on the half way. No space between the shaft on the tip and angled. You're lying needle 90 degrees across. What you want to stick you simply right. Take the needle back into our ward. Just itch and you let me do the work for you and pick it up again. It's a simple as that note, the tissues were always hold the needle ready for you to pick it up. And every time I am stitching, I'm checking my pickup 123. But I'm also thinking about my posture on my posture in the way I stand to stage is really dictated by the alignment off this needle. Then we will come back to you in next week's discussion because having a line a needle at the perfect angle of maintain degrees across well, one stitch, we now have to get ah, body into position. Little neighbor us to affect a perfect rotation. Where is enable you? Okay, let the needle be the work for you and that's it. All there is to stitch in. It is a simple movement on a simple flow of understanding the anatomy carnexiv movement or the upper limit today. Were you with perfect right? A shin and smooth rotation to take a needle through the tissue. But of course, yeah, beginning of your career, and it's important that we actually get you to do it right, beginning the calls. It's very difficult. Undo bad habits, and we'll said, If you've got to 20 a career in front of you, you do not wish to actually have degenerative muscular skeletal problems off the neck. So posture pick up and placement of the three piece that I believe are critical foundation. Just tissue in training. Thank you very much indeed, for joining a black belt can't be a surgical skills. I'm extremely grateful to meddle filled, and soon I see we've got some questions in the chapter, but that's 1.5 m away from May. You're welcome to put questions in, if you wish, fill in soup. Well, ask them on. I will try and arms to. The questions were demonstrate something that you do not understand. Please feel free to answer your questions. Fill suit. Do we have any questions? So we've got some great comments. David way. We don't have any questions just yet, but we've got broody Elliott, who has explained that you're very right. Most are not accommodating when it comes to table height. Although I'm currently lucky with a consultant exactly to operate on a platform, um, commenting on the correct posture off operating, I I think that is not being deliberately harmful with sound figments my only recommendation to you, particularly if you're very Paul and operating the short surgeon. If you think of the way a giraffe drinks, what they do is actually spread the legs out so I can maintain a good posture, my back and spine, and come down significantly why spreading my legs are now. I can hold that position maybe 15, 20 minutes or so, but enables me to least maintain a good posture through my spine. But otherwise, may I suggest that you discussed it with a consultant and perhaps offer them Uh huh. Stool to stand on. Michael is 1 87 I think, and right with me for six months. And I was the first consultant you have worked with who actually stood on the table to allow him to stand on operate. Probably. But of course, when I mention it's in my assisting lecture, both of you need to be in a comfortable position to enable you to synchronize the movement. Otherwise, I think Arizona mistakes could happen. What I do employ you all to do is to think about fitness. Surgery is a sport. In some respects. We are athletes. You do need to consult a sport's therapist. If you have got muscular skeletal problems, put a bubble get fit and they're plenty off exercises and flexibility exercises on social media to help you. Simple ones standing against the war on in the score position. Another simple one is maintaining a plank, but the number of stretch techniques is, well arching the back cow and cat arching and also hand stretching your shoulders back a swell. You can do some of these up against the wall, but if you experience any tingling or nerve problems use, seek some health advice. But I always felt that after 6007, it would have been wonderful to have the physical therapist come down and just relieves some of the tensions in your back and neck, particularly if you're wearing loops and wearing headlight, because that will be adding weight. Yeah, you know, head light is not 10 kg, but if you leave for it, that's awful lot of weight to be home, that you're unconscious about this until the end of the day. You think you're exhausted. Effort E. So it's worthwhile getting your career, getting it right because you got a long road ahead. Any other questions? We have a question from Social Inter, who is asking When will the next question What When will next session be? We're hoping to get all the basic surgical skills guest sessions from you. I will be life with metal every Monday evening, eight o'clock. You will find on Facebook. YouTube. I have a number of these videos already done. This is offering a new level off interaction, which I really appreciate mental being involved on. Do you will see me next week as well on the week after. Any time they would do it is if I've been on holiday. What I'm trying to do is go over the basics. I introduced a different way of thinking. All right. The Marshall Way off Saturday, the Buddha way of mind, body spirit and soul Because I do think surgery is a sort of way of life. There is a general, thank you very much indeed. For your attention's evening. I do look forward to seeing you. Next week they will talk about angles, the address on how to improve the accuracy obvious, Dejan and introduce a number of other mornings. Well, thank you. I wish you well be safe. And thank you for joining the black thought Academy of Surgical Skills. Good night.