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Hello. Good evening. Good day. Good morning. Good afternoon. Wherever you are in the world. My name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers and a visiting professor at Imperial College, London. I would like to thank this evening medal for hosting the Black Belt Academy surgical skills. Since I joined the Wonderful Platform, we have reached 51 countries. And last week we reached 30 countries in one broadcast. I think it's incredible that from a spare room in Yorkshire, we can reach the world. And I'm most grateful to fill and sue who are here sharing the platform and answering questions on these sessions. And please do answer the questions pursue will interrupt, and I hope to answer them. I'd like to thank the 3276 followers on Facebook and the 514 followers on Instagram. Thank you. If this is your first time joining the Black Belt Academy of Surgical Skills. Welcome. And if you're returning Thank you very much. Indeed. This evening's talk is around what I call diastolic learning, and I'm sure you as a trainee have been in situations where you've got into a situation where you can't quite work it out or quite can't quite get the stitch to do something for you. And the trainer says, Not like that like this. But you don't understand what this is. And I think when we're learning to stitch, we're so focused on time being a problem, and we stitching against the clock and going faster and faster and faster, Thinking that quick surgery is good surgery, even in cardiac surgery, I do not teach speed, and I recall the first instruction I had as a cardiac registrar from Mr Westby was just be quick. That is, of irrelevance, because taking a cardiac metaform cardiology and not many of you would have had the privilege to see the beating heart in the chest. But it's a beautiful sight as a gently rocks in Sinus rhythm, atrial ventricle, atrial ventricle in the chest, and it's regular and beautiful. It's very easy to see fibrillation and atrial fibrillation as well, where the rhythm is irregular. My thumb being a trim, regular rhythm is wonderfully rocking in the chest, and the contraction of the ventricle is fixed. The Sicily the injection is a fixed period, and what happens when the heart speeds up is the dastardly. The filling period of the heart shortens and in shortening the heart speeds up. But that lovely, regular rocking motion is still there, within the chest, and that is the principle of surgery. Good surgery is smooth surgery. It's a lovely rhythm and rocking motion, and that does not come by focusing on the systolic element of what we're doing. It comes by focusing on the diastolic element, the relaxation and then, I suppose, can we translate it into the negative passive behaviors that all of us are guilty of not using? I've called my consultant train into theater in the past, and I'm sure you've experienced it. They've come in adjusted the light, increased the wound incision, rotated the table and said like that. Any sort. What was difficult about that? The thing is, is that in that moment you did not think of the system and the whole thing, and it starts at the beginning and your diastolic filling up period of thinking about preparing for theater, preparing the team, preparing people around you, making sure you are set up properly and everything is there to do the job, and that is what briefing is about. That's your diastolic time, but also that your diastolic time, as you have alluded to so far, of getting your head in the right place and rehearsing the operation thing is, is that when we get into doing it all too frequently, we focus on the action, the systole, and we forgot the diastole. And what they actually teach in human factors in the airline industry is when things are difficult or go wrong is put your instruments down or hand the control of the plane over to the copilot and take a deep breath and ask open questions, fill with information, understand what's going around you before you take action, and that is an important diastolic element of what we do. But how does that translate into surgery? Well, I'm going to deviate again with another metaphor for sport. I've been running the power courses for 22 years to teach cardiac surgeons the principles of coronary artery bypass graphs and aortic valve replacement, and some of the comments we have had is, I wish somebody had taught me this before and really didn't understand what this was all about. And that's because I believe we teach the diastolic element in the setup. And there's no greater example in setup, as in golf. And I suppose that's where I got the metaphor for my power excellence courses because the Gulf is all summarized in the acronym Gasp Grip, How you hold the club address, how you lie in the club with the ball and how your language, your shoulders and pelvis towards the target stance, how you're standing to maintain your posture and a good line of the back and keep the functional swing of the upper limb and posture. Now we don't do that in surgery, and hopefully, in the past few lessons, I've taught you the importance of posture. And this evening we're going to look at the grip and other elements of your setup and the principals behind it. Firstly, if you look at this golf club, I've highlighted there and read the sweet spot. The sweet spot is where the maximum weight of the club is, and I've colored it in, but to help you, they've engraved marks on the club head, and if you hit the ball perfectly by striking the ground underneath to lift the ball up. The club will do all the work for you, and I've always thought of paradoxical when swinging a golf club. They take you to a driving range, which is a good idea to practice but put you on hard bats and ask you to scoop the ball out. And if you're beginning and holding the club too tight, the club hits the ground, shudders through the arms, and I cannot think of anything more aversive to practicing than getting that ricochet of the club through the hands I have recommended to the golf pros. They should take people to a sandpit so you can get used to scooping the ball out. And a good shot actually leaves divots in the course. Paradoxical to our thinking, and that's what I want to address this evening. So the first principle on the grip is how to hold your needle holder, and the needle holder is best held to optimize the rotation of the needle and works pain in the moment. But to get the perfect rotation, you need to line your needle holder between your index finger and the middle finger and the common flexor origin, because around that access that we get pronation and super nation. And if I put a straw in the needle holder and demonstrate pronation to Super Nation, I think you'll agree watching that straw, that I almost have 270 degrees. Whereas if I put my fingers in, I'm limited in my pronation and limited in my super nation and have lost 20 degrees that side and probably 40 degrees that side. But not only that. The end of the needle holder is rotating itself, and it's apprentice that you need to do in your grip is hold the instrument properly, folding your ring and fifth finger. Who's that ring of instrument? Extend your index finger down and use your theater eminence to take it on and off, and this takes a little bit of practice, but over three weeks you should be able to do it, and basically, what I'm doing is pushing it off like that. But that gives me a good control of the rotation of the needle, and why we need to rotate the needle is very simply this. All needles, no matter what their size, are made on the circumference of the circle. Whether that is five, okay, 20 or larger needle, and you can see the degree of the circumference varies from almost 5/8 to a half. Two more. But all the circle needles are made in the circumference and need to be rotated, and the rotation I/O of the tissue is important because the thread should sit within the path of the needle. Zephyr did a tie gentle slice across the path of the needle. The thread should sit with in there, and if I was clumsy, putting my needle in, were taking my needle out. You'll see I leave an elliptical home, and the space between the thread and the passage made by the needle shown in green hair is a bleed leak, some markers of abscess and a problem. So with that principle in mind and likewise, the principle of very simple thing we do stitching a button on too a shirt. I'm just going to reduce the brightness for a moment, and I hope you can see is that the walker and we've of the cloth leaves you holes. And if you've tried to actually stitch a button on and bring your needle off to the side is very difficult, whereas if you take a needle straight through at 90 degrees, it passes through your shirt or material very easily. And that is the fundamental secret. It is this 90 degrees. It's 90 degrees mhm, the perfect angle. Why? Because it's 90 degrees in every orthogonal pain. So it's 90 degrees into what you want to stitch 90 degrees out of what you want stitching. And if you do that with a perfect rotation, you'll get the perfect home. So before we go further, we need to then understand the anatomy of the needle a little bit more. I'm going to put a needle down here for us to look at, so we have the sharp end. We have the swish where the thread is put in, and that usually is the widest part of the needle and the new needles being brought up by the Elocon. This is significantly lower to reduce the whole made in the tissue. Middle part is called the shaft, and this is the area that we're going to use when stitching. And the good news is, is that shaft is not round. It is in fact, cuboidal. And if you look at this needle closely or I'll zoom up closer, I'm not playing with his camera, thanks to Wet Lab and Ethicon. But you'll see that that needle shaft is slightly cuboidal, and that means that you can get a good group on it. But it also has another interesting effect, because in gripping it, if you'd rip it lightly the needle see that flips into position. Yeah, and that simple little movement and nudge, I'll explain as we go along. So the first principle is grip. The next is the pickup, and the working part of your needle is just beyond the halfway. So that's rule number one. The second is that there should be no space between the tip of the needle, and then you can hold her. And if I run my finger along there, I should feel no gap. Now the third, an important one and I have discussed this previously, is the fact it is angled out, and it does not at 90 degrees on the end of the needle holder, and I'll demonstrate the two differences audibly. But that angle have demonstrated there is the angle between the level of the wrist versus the elbow when standing and your arms are in a functional position. Obviously, if you're sitting down and the wrist and Albert at the same level, that would be at 90 degrees. But look at this and listen to this difference. Not too infrequently. The needle is given to you not quite at the tip, mounted halfway and have a listen. But not only that, if you look at this, that needle is not sitting 90 degrees in the sagittal plane to the tissue. See, it's coming in at an angle and you can hear the difference. Whereas if I'm out the needle properly, the sagittal plane of the needle is actually maintained at the 90 degrees. Knock, knock on plate. There you go. And this is vitally important with each and every stitch now in golf, if you notice they stand there for a long time, getting their grip and their position correct before they actually swinging the club. And a lot of this is actually done. It takes most of time, is a setup. They're clearing their head. They're getting their posture right. The grip right, the alignment right of the club and the ball, and then they swinging the club bang, and that takes moments and the ball goes in the right direction. What I like about golf is you're only as good as your last game. So in surgery, I would also say you're only as good as your last operation or your last stitch. And there's only one person now. I heard when stitching would actually say themselves. Good shot, bad shot, good shot, bad shot. Now, this 90 degree alignment is fabulous because it applies no matter what. And in essence, you need to align the needle 90 degrees across. What you want to stitch, you rotate the needle back 90 degrees into what you want to stitch, and then you rotated forward. Now note that the needle is being held in the tissue and what I teach in my power course is is very simply, do this with your nondominant hand behind your back, maintaining the lumber, low doses. So if I'm drawing this out, there you go needles coming out. I now need to pick this needle up just beyond the halfway at the tip and continue the delivery. And there you go. My needles mounted, ready to do it again, 90 degrees across the one you want to stitch, rotate it back and then rotating it back. What I'm actually doing is unlocking the needle holder. All right, I'm actually unlocking this needle holder, so I'm rotating it back, losing my thinner eminence to unlock the ratchet pointed in and intuitively, deliver the needle on the rotation just beyond halfway, and I'll pick it up again. Now the problem is, is that if you do it over and over and over again, you'll find that you'll pick up is lost and the needle rotates back to 90 degrees. But how often do I see trainees correct this as it when they're doing a continuous stitch? And this is vitally important And, it might seem, are just at this stage to drill the setup. But you need to say it to yourself regularly. Is my pickup correct? Just beyond halfway one. No space between the tip and the shaft, and is it angled out? 123. And I know whether training is going to do a good stitch or not, very simply by looking at how the needle is picked up. 123. My next important bed with every stage is simply place 90 degrees across what I want to stitch. Make sure I've got that what I call belly bounce. The belly is pushing against the tissue. Place rotate point and rotate it out. Place point and rotate each and every time. But in a continuous stitch, you need to be doing that regularly, and there again demonstrated the common problem of a continuous stitch that you lose this angle and you need to be doing this on every single stitch. Now golfer hits the ball and then has a nice, leisurely walk to the next set up. But you don't You got one stitch followed by another stitch, and the problem is that people don't focus on the set up for the next ditch and the set up for the next day, which is really dictated how you pick the needle up. So if it comes through, the tissue is holding the needle in the right position, and I'm picking it up, and what I've done in this case is slightly nudged it before grabbing needle. I don't grab it slightly, nudged it slightly, nudging it. I've got maintained that angle. So you need to be able to do this four hand and back hand and what we do in surgery is we stitching round things. So if I go back to my plate and I'm standing here at six o'clock and unfortunately we don't have many clocks anymore, they're mostly digital. But for those of you who don't know, this is a clock six o'clock, 12 o'clock, three o'clock, four o'clock with spaces in between, and your alignment each and every time when stitching around something should be 90 degrees across what you want to stage. So put a protractor on a plate and just think to yourself as you're holding the needle down 90 degrees there. How am I going to hold the needle and how am I going to stand? And I'm standing predominantly in my right foot and I'm facing towards 10 o'clock. How's it come around here to this Advil? I'm now in a position which is rather awkward for a right handed person. 90 degrees on this here is going to be 140 degrees. I am stitching into my right shoulder, and that is the most difficult stitch in surgery and that is where I have to. Now go back hand and going back, and I can now align my needle 90 degrees across what I want to stitch. But I'm standing on my left foot and I'm facing that way predominantly. And as I'm going around, I want you to do the same and just practice and understand yourself what position you got to be in to actually make this happen. So if I put my potato back on here and I'm wanting to stitch across the blue at that angle we've done that, I'm going to stitch at that angle. Hello, my needle up. How am I going to stand in what position I'm going to be in? And only once you've got the alignment correctly, do you take the needle through the tissue? But how often do you actually think to yourself and check your alignment? Because the position you stand on, we'll come back to That maneuver is different for that direction, and then you'll see I've gone back hand and what I did there because the needle's angled out and gently using the cuboidal shape of the shaft, I can prevent the needle over the point and flip it to the back hand and forehand without touching it. So mind enough again, Which foot am I standing on and simply reverse the angle to the other side. And the great thing is, is that you can try this at every angle, and I want you to experiment yourself to find out what works for you. Because it's slightly different for each person. The height and the body habit is, but the principle of alignment is very simple. It's 90 degrees each and every time, and it's the needle alignment that will dictate how you stand in your dress. And that must not be taken for granted in any continuous stitch, even when it's closing time or coffee time, as most people like to think. And you're rushing to close the skin because perfect rotation and needle is respecting the tissues in causing minimal damage. But it also improves your anastomosis and reduces bleeding win for all but in the early stages of practice, not addressing this diastolic element and set up. In fact, you're shooting yourself in the foot because once you've mastered it, you'll find that your operation and your movement and control of the needle become smooth because you built it in to the unconsciously conscious actions, unconsciously unconscious actions of your stitching. But unless you go through that process focusing on your setup, each and every time you're stitching will continue to be irregular. Some people need to come in and address needle each time. And Professor Yakub I worked with in my first years of cardiac surgery, he regularly used his fingers to deliberately allow the needle. Now, you wouldn't say he was a fast surgeon, but he was a smooth surgeon and the smooth surgery meant for safe surgery but effective surgery. Think of it this way. If you're driving along the road and some persons running up behind you, breaking the speed limit screams past. You see them up ahead, put their brakes on when you get to the next junction. Guess what they are. They're waiting at the traffic light, but what they have done is spread great spread, break and really not driving the car as well as at all. I spoke to Sir Jackie Stewart, the famous racing driver for the faculty of surgical trainers, and what was interesting. He talked about drivers with a lightness of touch that they didn't break aggressively. But they understood the car and understood the movement and understood the diastolic elements and therefore save the tires, save the fuel and made for fast, effective race. Why not? Because they're fast, because they had focused on all these elements that, quite frankly, I don't think are taught in basic skills courses. So I want you to try this yourself from each and every direction, and you let me know how it's working for you. Simple practice. 10 minutes a day to do it. I'm just going to come back to that what I call a sexy move and you can try it yourself now because you're holding it out in an angle. 123. The sexy move is really poor. Rating your needle over the top four handed backhand, so I'm not actually grabbing the needle at all. I'm holding the needle lightly, and I'm able to flip it beforehand to backhand and because, as I said, the shaft is to boil. The needle holder flips, the needle flips into position and therefore I can move forehand backhand too, Forehand, backhand beforehand. So going backwards to the beginning, you have passed a needle in a packet, and the simple thing to do with a packet is hold it out and an angle. Bring the needle holder into the packet at an angle, apply the needle holder and take it out. See that I go. I have naturally was 90 degrees. But I want it out. So you come out an angle to pick it up. Similarly, in mounting it, check it with your finger. You're not going to stab yourself, feeling it that way to mount it backwards. Hold the needle upside down against your finger and now you've got it backwards. Uh huh. Forehand Mountain. Uh huh. Turn the needle upside down to the same application there, and we've got the needle mounted backwards. It's just as straightforward as that. And on a low fidelity model, you, too, can practice these basic skills at home. And what is using there is a baked potato, my microwave. So the skin is soft and put on a plate, and simply putting markers down will help you in the beginning with the alignment of your needle to keep those 90 degrees. Indeed, when you're learning to play golf, what they have a mark is on the ground to enable you line your shoulders, align your hips, align your feet and align, Know club and what they teach in the driving range before you hit the ball is the grip. How to hold the instrument? The pickup, as we have discussed with the needle, the address and the alignment, and you need to work out the alignment yourself with your forehand or background and your posture always to maintain the vertical stance. Now the good thing is about operating and understanding. The functional anatomy of the upper limit is that pronation super nation can occur at every angle. With these the abduction of the shoulder reflection of the elbow, I can actually rotate a screwdriver anywhere, and you know that. So the potato model also gives you another option. Being a hemisphere we've just stitched on the top. So what, you've understood moving your potato round different angles. Let's look at it from different sides. Is that from each side away from you towards you, towards your right hand towards your left, you got a number of different angles. But the alignment of the needle to all those angles is the same. So what I want you to practice and understand is that 90 degrees is dictated by 90 degrees across what you want to stage, and that's 90 degrees to the tissue. And what I've actually done here is reduced the angle because now, with my elbow elevated my wrist in Alberta at the same alignment. So practice getting a needle I/O of the tissue on that plane, taking out just being halfway, picking it up and delivering the needle, maintaining the alignment. Likewise, let's try. The next easiest side is opposite my stitching out, having to work around the camera here. The land at 90 degrees Yeah, the take a bag 90 degrees into what I want to stitch and rotated out. So 123 relatively easy. What about here in this angle is now becoming a little bit more difficult again. I got my elbow up in the air, but my needle is aligned 90 degrees to cross what I want to stitch so I can rotate around, take it through the tissue, take through just beyond the halfway and pick it up again. And then these extreme positions that open angle you'll see is reduced the most difficult. One is here towards me, and I could come across that an aortic survey at the angle between the aorta, the superior vena cava and the left atrium in closing and aortotomy. This angle is called the angle of sorrow, because it's very difficult to get to it when the heart is full because that part of the order you'll find it in, quelled into the heart. And it's very difficult to get another stitch in. And that is why this particular stitch is called the angle of sorrow because all of us have experienced bleeding in that area. But what you can do to prevent it is work out yourself. How are you going to stand and you'll set up to and you make this ditch? And even if it is bleeding to eventually putting a finger on it and pausing for a moment to examine your setup and that 90 degree in alignment, that moment will pay dividends in ensuring that your stick it is accurate, and you only have to do it once. What I like about this thing is you get it right first time and to get it right. First time you stick to right angles, right? I think so. So I hope this has made sense to you that we have brought together some principles about the diastolic elements, which I think are all the setup elements. And if you run into trouble in theater Paul's, there's very little that can go wrong in surgery. The most important thing is the anesthetist in the airway. But if they've got control of the airway, you can deal with everything else by simply holding it. Putting a swab on taking a deep breath for your nuns diastole taking information around you call for help, but think how you're going to set yourself up, rehearse it in your mind a bit like a golfer rehearses their shot playing golf. Do that vocalize the 123 principal. Each time you pick up a needle, vocalize to yourself the place point rotate each time you make a stitch, ensuring that is 90 degrees and every time remembering. You can only go to two layers if they sit together and not like that. If they're separated, you need to take it in to and then again, there's no compromise. Get it right, right angles. First time, I hope this has made sense to you. Thank you very much indeed. For watching the Black Belt Academy of Surgical Skills. Sue. Are there any questions from our esteemed audience? No questions at all. David. Know we've reminded them about reminded them about the competition, though, if you want to remind them again, thank you very much, indeed, for that prompt. We have a competition to test your stitching skills on a banana, and we'll be covering this next week, talking about perfect practice because perfect practices you practiced till you can't get it wrong. Not until you get it right, and the perfect practice requires models that show you when you get it wrong, and we'll go through that next week. The banana is one another's your stitch in competition on the website, you'll see pictures of bananas that have been stitched one by me and one by Cialis in Sienna and another by Vlad in Romania, who is also one of our senses. Take a picture on your mobile phone, high definition, change it to black and white, and post it on social media. Hashtag black about Academy of Surgical Skills and medal, and you could be the winner of a set of instruments. We'll post this to you wherever you are in the world. And what it includes is scissors. Forceps. How states Scalpel blade and a writer Needle holder, a friend, a needle and a scalpel blade for you to practice as well. And we'll post that to you wherever you are in the world. You've got two weeks to get your entries in. Post them on social media. Have fun doing it. You might want to do a little bit of practice before hand on your potato and think about your set up and do it deliberately. Good luck. And I look forward to seeing your entries and sue. Thank you very much again to meddle you and full for hosting BBA's and the fact that we reach 51 countries. I don't know how many countries we're broadcasting to this evening. Soon. Yes. Sorry. Do you want me to have a quick check? Hang on. You will have a check. You caught me. You were It was beyond my bedtime. Hang on a second. We have got registrations. Statistics We have got Sorry, everyone. We have got people from Bahrain, Hungary, Ireland, Lithuania, Nepal, Nigeria Pakistan, Sudan and the UK What can I say? I am extremely grateful to all of you for joining us. Please pass the word around. I'd like to see more of you and look forward to seeing you next week. Thank you very much indeed for coming. I can't work out the time frames of all these differences. But that is certainly wonderful. Thank you. Much appreciated. Hope it makes sense. Do enter the competition. I look forward to posting the instruments to the most exotic places and we'll put your pictures on social media to and trumpet your triumph. Thank you very much indeed. Wish you well and be safe. Good night. Good day. Good morning. Good afternoon.