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and good evening. Good day. Good afternoon. Good morning. Wherever you are in the world. And thank you for joining the black out to carry me a surgical skills If you're returning, thank you very much. And if this is your first time, welcome. Thank you to the 3237 for hours on Facebook on 400 century. Uh, on instagram, I'd like to thank Sue. And so a medal for hosting Blackout Academy. My name is David Oregon. I'm account exception in Yorkshire in United Kingdom on the past, director of the Factory of Surgical Trainers for the Royal College of Surgeons of Number under visiting Professor that Imperial College. My passion is teaching basic surgical skills, but I've related that martial arts because it's all of that technique incorrectness. If you get the technique incorrectness right. The power and speed for us on what I've done with the black part academy is taking the individual skills on have deconstructed them into exercises to enable you to home your surgical skills. But as we go along this journey, I'm sharing with you your boo way, the way of the martial artists. And as I share this with you. I'd like you to change the word for worrier Surgeon Battle Theatre on. Look at the similarities and the metaphor involved. And that's before I have been Talking From the Fire. The Book of Five Rings, the classic text on the Japanese way off the sword. I'm second done in the high dose on what interests me is a Every movement in a guy do is explained precisely and has a reason for that movement. Well, I think what is lacking in surgery is that explanation on movement. This one exception was Lord by Plane Morning. Who's busted doors to drop. This does in the old part of leisure of family in grades George Street, he said. A good decision should have the eyes of a needle, hands of a lady in the heart of a line. Interestingly, manager Musashi, who's the undefeated summer I worry and 16 43 is written this text about martial arts on the use of the sword in battle, and I like it because it incorporates the mind body soul in spirit. Their eyes are to be focused in such a ways to maximize the range of breath and vision observation and perception of two separate things be observing stronger, the perceiving eyes weaker, the specialty of martial arts. Are you serving? It's to see that which is far away closely. Let's see, which is nearby from a distance in Martian. Isis is important to beware of the opponent swords and is true assisting. Take the surgeon's scalpel in instruments and yet not look at the opponent's sorts of it. All this takes work, and there we go on and says, When you were fighting adversaries and get the feeling being snowed up in pep, you maneuvers. Remember this rule of military science? Well, just in the midst of unusual some you shift to the large perspective, and I think that's very true in surgery. Although we're very focused on the the new sign front of us, we need to be aware of our surroundings at all times and be able to shift between two and in the context of martial arts, Mary conditions mean or the actions of investors in the theater. Everybody around you, the mind turns with each in every action. For example, when opponent raises his sword, your mind turns to the sort. Few wells just right, your mind turns to the right. Few wells two left, your mind turns left, and this is called turning with marriage of situations. I'm not unfilled Familiar to you being assistant in theater as well described previously in the Black Academy. You are following on working with the session. All you surgeons having something working with you. The turning point is truly recognized. This is the eye of martial arts when the mind does not leave any traces in a particular place but turns to what lies ahead the past dying out like the wake of a boat, not lingering a pool there should be understood as the turning point. Being truly recognized and to be recognized is to be subtle and imperceptible. This means of mine not lingering on any particular point. If your mind stops and stay somewhere, you'll be defeated in martial arts. Feeling go away. In turn, you'll be crushed on as we use and talk about the force. It's this evening without focus. On the end of the century, we must also be aware off our surroundings, and what we did on the forceps is peculiar. Finish mint and should be regarded as extension on the fingers, and the four ships should be able to be used in both hands with equal Xterra. Gee, but there are some caveats on lessons to be learned. I don't like to take you over. Italy can, so we can look at some of these in particular before we do that. We've previously talked about posture, the angles relaxed, shoulders down Albert's by the side, and that effectively removes or the major muscles of the upper limit, and you left the intrinsic muscles on the hand. And if you remember, that action is by the lumbrical. Any muscles in the body? No bony origin on session, the logical bring, of course, the pumps of your fingers together that is your feel in serving. Uh huh. When holding the forceps, it's important that your thumb and your index finger caressed the instrument. You do not hold it like a pen, like a pen you're using. The flexor digitorum performed us and the flexor pollicis longer, and those are the powerful muscles that you use for writing gripping the pen. But we don't want to grip, likely hold this taking of the top and just show you some principles. So What we have here are two full steps on there, essentially indicating two times truthful subs a non two forceps. Now the two full sips he's a cool Edson's have little teeth, either side, like a couple of rats teeth interdigitation with a single tooth on the opposite side. There's actually quite sure the non two forces don't have teeth, on average is these ago. Parallel ridges on the inside, and they're crushing my favorite forceps for operation well called into baking forceps. Excuse me, I haven't any cough and the debate. You forceps have a room. Very fine teeth. Two news one side in a single room on the other side, the coast of full sepsis, much insane, has three hours on either side. Interesting cause move into baking with cardiac surgeons on. They work in hospitals across from one another could look after each other through the window on to say that what the best of friends isn't understatement. But the most important thing you should remember that I have asked you, in the problem of the forceps, cause damage. Now, here I four hours ago use the full steps to hold the skin of the banana. How's your word to put stitches in. Just have a look at that on the inside, the banana blackens ones crushed. And what you're looking at that with a simple application off normal, off crushing forceps, 1 to 4 cents. I've got a full thickness crush injury to the manana. Imagine if that was a a vessel or the bow. And indeed, histological studies have demonstrated significant mucosal damage. One simple pressure. If pressure equals 47 area by a time, a grip address you can see my thumb is blanching on my finger That was a blond. She was. Well, when this pinch grip has been measured in the average adult, that's about 25 news. It can go up to about 35 Newtons, but on average, about 25 when I'm watching training is using forceps reflection off the distant interferon jail joint on blanching of the fingers. Tell me they're grouping in too hard and why that is important, because if you consider the surface area off, the end of this is about five millimeters squared, and you put a 25 missions and pressure. To be honest, you have got the equivalent of five times 10 to the six Nugent's per meter squared of pressure on there. That's 1700 pierce I. And when you think are the inflating pressure of the time, that is significant. So the two forces likewise is often used to close the skin on. You can see here the little teeth and bite marks that are made by these to the tooth. Forceps. Very dangerous area. Not see. So when using the truth forces I don't actually grip, we'll grab I. Here's the teeth to hold down. I'm not quitting. I'm reverting, but you can see the teeth actually tearing his world. So plastic surgical colleagues we're always advocate using a whole left the skin off Genvoya damage. So that is the first and most important lesson is that your forceps causes damage and indiscriminate use. Poor tickly banning of D. R P drug well cause damage. So close your fingers around it usually lumbrical. So the next important thing is to be out to pick up things accurately. Got a few grains of rice here on the table, and we'll progress from simple, too complicated. The forces named the years accurately need to be able to pick things up and put things down. I'm the simple rice test of picking writes up from the table and putting them in just straws into spirits. It's very straightforward. You could put a number of spirits in there and call out the numbers and practice. Remember, you got to do this both right hand. I love that time, as you need to be out to adept both hands because a CBC said previously, you do know across your hands. And if you pass the mid nine, you got potential in in your hand. So let's take this little exercise and make it a little bit more complicated and challenging. What I have here is some dandy straws we believe grew tack on a place. Um, the idea is to pick the right side and put it in the end of the stroll. Now your news is that the diameter on the rice is that a little bit what longer the like? The rice is little bit on the diamond, the end of the straw. So it means, did you get the have to or intend to rise to carefully drop it in, and that is a trick more. You practice them all accurate you'll be. But this could be turned into a lovely gain off Corning of the color, dropping them in and stopping it for right hand left hand. Indeed, works is put. It's possible to have a foursome in each hand on Did simultaneously note that a bit of rice there's flu off the table that because if he grabbed it too hard, well, slip away. And again. This is teaching your niceness of touch simple exercise for you to practice and gives you confidence in your accuracy. And I shouldn't say the F off fidelity and using foursomes. So first F was feeling the second. If is Fidelity Control and this exercise is it safe can be done with both hands. It's interesting. These larger forceps is not very good at picking up rice from the table because they cramped bulky at the end. So our next it test is drawing on herbs and spices. I would have like about this one we have got in this coriander fell pepper and must in things when the whole idea behind this exercise very simply pick up the seeds and put them in to respect experience. Oh, you will find that they are slippery and the smaller ones particularly the mustard seeds, particularly awkward to pick up. But what is giving you is teaching your fidelity and find control. And remember again, you should be out to do this with both hands so korean to see there. And if you grab them hard, they go flying off. And I'm sure some of you would have seen goal stairs. Very sizes. Oh, stands in the So every ducks not too dissimilar to this again. Do you send me pictures off for me? Other seeds from your part of world that you might like to use to practice on? Of course, we are frequently operating a depth on the exercise. Are sure you know I collected Jason. Hand off the modern surgeon. Pick this up. I broadcast this across America. What I've done here is taken a pepper Americans call it old pepper taking the top off. But what you've got inside the whole it recedes, of course. And now your task is to pick up those seeds on for difficulty on the right side. I got a green straw on on the left side. Port side with the restroom. Yeah, challenge here is to pick up the seeds gently and drop them in the end of the straws again. The straws here about the same diameter as the seeds. So you do have to or intake proceed accordingly. Jason suggested that we should run a competition for this and see how this each you can pick and please. Within a minute. And I saw picking the seeds out of the peppers. I thought, there's a term twisted here. Peter Piper, Privately picked pepper prints, putting that in parts. But you can't say that I've quit me. What's nice about this morning was well, is I found with many of the other models of shared with you. I find myself being you most in this practice and to be honest for getting that you're there because I'm having so much fun. But let's move on because the last bitch off, using full sense is being able to whole tissues gently that are tearing them and separating them. So what I've done here is I've got a martyr on the idea of this ball tomorrow, too, is I want to see if I can lift the skin off Mr Martyr, peel it off without tearing my forceps. Yeah. Now the skin is actually thick. It's relatively easy just to show you one trick I can use in surgery sometimes is I use the blood into the forces, actually develop a plane. Did you see there? So it becomes a motive. Functional tool on the championship of this is to be able to take the skin off the tomato honestly without sticking it in, because the tomorrow is not like in inflammatory tissue, and you can very easily 100 and damage it. Sewer from Baghdad offered this morning, which I thought was a fabulous extension off the tomorrow. This is boring potato. Now the skin on the bar potato is very fine indeed. As you can see, that I was is useful exercise and practicing or fidelity? Yes. Trying to see if you can lift the skin off the potato and take it off and peel it off big strips without it actually tearing or breaking, you can see it's cost, um, a thin, but sent a video which were put on the website, and she did this beautifully on a certain lovely model changing your accuracy because if you grab it, you're gonna be tearing the potato underneath as well is teaching your likeness of touch. And what I'd suggest is that you put a little these exercises together in your force of practice and you, if you do this 3 to 4 times a week, your forceps skills will become extremely good. Yeah, taking the skin off the potato. So why is this or important? Well, I think it's very important because your forces in there to help you with your operating. They should not be there to his damaged tissue and a bit like a fork helps the knife and the knife hopes of folk. So you're forceps, the needle holder on no scalpel. She work into dependent. What I found with introducing the forceps into stitching is that the stitching fooled by the wayside. But the biggest problem is that the forceps will leave the crab drift or drag as you're focusing on the stitching. So this is an extension on the stitching model that I showed you in the first episodes. I've taken an Apple court to been on it on. Now I've put Staples in all the way around on the hour on exercises to do the stitching because remember, we did it with that non dominant hand behind the back. But I'm introducing the forceps into the exercise now. And as your stitching and coming around this one on a you are to move your forcep stable, mimicking holding tissue. And the idea is that, well, they're your focusing on the stitching. Your forceps should not. Who the staples out? It's, in other words, your eyes. Now seeing both needle holder um, four cents remembers, I'm going round. I've changed position and change direction again. I'm going to hold, retract and continue my stitching around the banana exactly as I can has demonstrated previously. This time I'm having to work with my needle holder David of a question from John. Yes, hate that, he asks, What are your views on Michelle Clips on their use for skin closure? Closure? I hate him. Uh, not to put too fine a point on it. They cause a lot of damage to the skin that I think it's a a shortcut. They're extremely awkward and painful to take out. I think nothing beats a good stitch. If it's a clean wound in this day and age, I would suggest, um absorb a little sub continuous stitch, but I would be very careful are putting their not in the skin because they're not actually is a surface for biofilms, and I've actually noticed that's the PDS not can cause information at the top of a word. So what I've done is used a simple Ligaclips toehold that in place as a quarter subcuticularly chin. If the word is contaminated or dirty, I believe the best it's to put it will be a monofilament interrupted because should there be any discharge or local information? Because the wind was dirty, they're easy to remove. The other thing is to remove the suitors. Anybody could do it. Where's where the clips? It's necessary to have a special piece of equipment. I had a lesion removed from a a brown month ago. I have interrupted Suture is in my era. My wife had no problems, and I trusted her. To come with Suture is out with these, and they do not cause information, John says. That's exactly why that's he says exactly. That's why I asked the question. David, he says. But I've got one from fellas. Well, fill that one. A is watching. He says. I'm loving watching this day, but it's very therapeutic to watch and amazing techniques. And he asked, asked the question. Do you have any views on whether palm in your needle holder versus not palm ing your needle holder? Is there a time and place for both? Or should one approach always be taken right? Well, thank you very much indeed for answering that skill on seeing that question as I've demonstrated before with harming, you have to use my I'm an advocate for powering your needle holder. The reasons that that is, yes, the rotation of the needle holder is Super Nation formacion, and if you look in the degrees of freedom of the straw on the end of that needle holder from it's information to pronation, it's probably 260 degrees. I can affect that movement. Know what which position my lower arm is in? You know that because you've put flat pack I care, covers together or work in a car or put a screw like interesting and difficult place. If I put my fingers through what's in my pro nation is really limited. Well, Super Nation, it's My Christ limited that the end of the needle holder itself. Move, child, They're too. They're I've probably got 200 degrees as a person from there to that to 70. I think the irritation is smoother and Kina and you got better control. The other thing is often people put the distant of filling Deal joint through the needle holder. You lose. The feeling assumes you got that. Now if you get to hold it and set me some needle holes, particularly for stitching skin are rather short, so difficult to hold. I would then possibly put my fingers true the rings But you know, I have not put my fingers through. I've gotten held obliquely such that the rings are still on the helps my fingers Yes, I can feel the instrument. The other thing is, if your finger goes all the way through the ring picking it up, putting it down becomes problematic. That should somebody reaching grasping You were injured, your thumb. So that is why I would recommend. But sometimes the needle holders are not cannot be used that way. And yes, I put my fingers all the rings not through the links index finger is always extended down the shaft of needle holder cause that gives me direction. Proof receptions control. Another question from area anti. I was just wondering if there are is any difference between using tooth and non tooth forceps during closing the skin or uterus or rectus sheet? Right? As I've demonstrated to you, the two forceps should be used literally just in reflect not to ground. I hope that demonstrated to you the damage that can be caused by two forceps. If you grab what I do, use two forceps on the skin. But what I'm doing is actually reflecting. I'm using it, but like the skin hook that plastic surgeons use. But any surface this is going to cause damage, as you can see on that banana and you can see the full thickness damage. Don't on those edges, that's you know that is a bow Vessels. Serious damage on Sony for vascular surgeons on D see eye surgeons. Well, even urologist is in the transitional. No, not transitional, but the endothelium off the ureter and bladder that's very susceptible to damage. I be very, very careful with your forces, and that is why your pressure is significantly ridges by extending or drp joint and not gripping and flat any other questions? Does that make sense? If you look after pictures, the tissues will look after you on the whole thing about surgery. There's no speed. I don't teach. I'm teaching technique. You get the technique right rhythm and the flow will come and you respect the tissues. Your heart comes will be better. The wound infection will disappear. Your scar or reduce mobility will get better. The end of all of this of good technique is better patient, Arkham and better patient recovery. Can I answer any other questions? Are you gonna go home? Practice yourselves now and the chapter books. Can we see Hands up? Well, I hope it's certainly giving you excuse the pump food for thought as we used our foods and spices this evening. Thank you very much indeed. For joining the black market cavity of surgical skills. I look forward to seeing you again next week. Next week we get to move on to talk about the other most important surgical instrument. The knife I've been talking about. We're learning with my sword. This is 1.2 m surgical. Blame that that comes a specific instruction. What surprises me. There's very little instruction and how to use a knife. Probably. It's a joint me next week. Thank you very much indeed. On be well.