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Hello, good evening. Good afternoon. Good day. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a professor in the Medical Education Research and Development Unit of the Faculty of Malaysia, a Faculty of Medicine at the University of Malaysia. My producer this evening, Vin is on call so he can't join us. And my fellow sense, Chris Caddy will be joining the conversation later. If this is your first time joining the Blackboard Academy, welcome. And thank you very much for joining and if this you returning. Thank you very much indeed for your support. Indeed. Thanks the medal. After the past few years, we have now reached over 5000, 111 people in 100 and 33 countries. And tonight, 23 countries 25 actually have registered from Bahrain, Bulgaria, Georgia, Ghana, India, Iraq, Mauritius Morocco, Pakistan, Poland, Saudi Sri Lanka, Thailand, Tunisia, Uganda and USA. I can't think of a better platform to reach out to surges across the globe. And I've been extremely grateful for the support we've had from metal. Unfortunately, they are diversifying in their business model and will not be supporting Black Belt Academy. As of the 31st of March, I have got an alternative arrangement that I'll discuss with you next week and I hope we can move seamlessly from one provider to the next. I'm delighted that the Black Academy I have been invited by popular demand to be at the Association of Surgeons in Training conference in Belfast next weekend. And thanks to the generous support of Bron Club who are supporting five senses, Chris Satyrus Michael Alison Ish will be there and taking you through your paces. I sincerely hope you have fun. I know Louise who has been organizing it on the wrong side has done it to military position and I think you'll find it invaluable this evening. I'd like to talk about deconstructing skin suturing. And the reason I've chosen this topic is because I teach stage 3.1. This is year three surgical students on their first clinical attachment and one of the skills is the need twist stitch skin. Now, this is combined with a number of other skills which is digital rectal examination, naso gastric tube wound toileting, gowning. And we have time in two hours for skin stitching. Not, I'd say not enough time to become practice and adapt at stitching skills, which led me to think what are the key principles that I believe are necessary for stitching the skin because it's very important that we actually get the two edges perfectly aligned. And in doing so, we will end up with a perfect scar. You see the scar is the surgeon's indelible signature. The surgeon's touch leaves an indelible signature, a timeless mark upon the canvas of the human body. While the individual patient may fade from the memory of the surgeon, the scar remains a poignant reminder for the patient of every word spoken, every action taken and the profound emotional resonance of the experience. The wound though healed stands as a testament to the surgeon's presence, an eternal echo of their skill and compassion. In this way, the scar is more than just a mark. It is a narrative, a living remembrance of the journey shared between the healer and the healed. I often think it is strange that we leave skin closure to the most junior person in theater as the most senior person finishes the operation goes and has a cup of tea and fills in the audit. Yet the most junior person is left to close the skin often without supervision or without direction. Well, what's interesting in Malaysia that the ability to close skin is described as a level three Malaysian Medical Council requirement. But when I looked into that, the details are missing, but there has to be level three. And what exactly does that mean? Well, I brought it down to three levels of principles. Now, unusually, the first principle revolves around this and forceps and the forceps are terrible instruments that can inflict enormous damage. Try this yourself, take your forearm and I want to, you to pinch your forearm. Go on like that, pinch your forearm sore, isn't it? Because you can generate a pinch pressure or a pinch force of 25 newtons for ladies and 35 newtons for men. That is the force. That is because that muscle, that flexes the D IP joints. There are supplied by the biggest Popeye muscle of the forearm there. And that muscle is the flexor digitorum profundus and the flexor pollicis Longus and they do this, this is the grip that Tom Cruise uses to hang off helicopters in mission impossible. That is not the grip that we'd like to see with the use of instruments and particularly with the use of these forceps. Now, if you look carefully at these forceps, the end has got a little rat's tooth in it with another side, two rats teeth and it interdigitate even the non two forceps generously, the surface area at the end of that is probably five millimeters squared. So physics for you, if I said the force is 25 mutants for ladies and 35 meetings for men, anybody in the chat room can offer me what the pressure is. You have done. Physics, anybody in the chat room or the formula for pressure, Felipe sur you must know the formula you've seen it before pressure equals force over area. That is 25 newtons good ladies live five millimeters squared and you know, five millimeters squared is five times 10 to the minus 6 m squared. The pressure exerted by the forceps is therefore 25 divided by five times 10 to the minus six and that is 5 million Newton meters squared or 5000 kg pascal 725 lbs per square inch or 50 bar. Now just think about the pressure you put in your car tire and that is what happens. What you see here is a banana and the bananas become synonymous with the Black Be Academy because readily available, we put the banana and suture pads in CT scans and the hands filled units for this are more akin to the tissues. Nine suture pads which are ubiquitously handed out across the globe for stitching. The problem is it doesn't tell you when you're doing it wrong and it doesn't give you the feel. And in 35 years of surgery, 40 actually, I have not come across any synthetic material that's akin to organic material or gives you this level of feedback. And if you look at this and I'll just lift up the edge of the skin here, you can see for yourself there.