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Hello, good evening. Good day. 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 and have now been imposed as a professor at the Medical Education and Research unit in the Faculty of Medicine here in Kuala Lumpur in Malaysia. If this is your first time with the Blackout Academy, welcome. And if you're returning, thank you very much. Indeed. Thanks to med, all. We have 25 countries connected this evening from around the globe including Georgia, Malta, Syria, Ukraine, Honduras and Australia. And it's only thanks to me that we are reaching 100 and 12 countries and we're also grateful to Gabrielle who is in the production in the background. Do put your questions in the chat room. My fellow sensor and colleague, Mr Chris Caddy is going to join us at the end of the presentation as we discuss further the elements of dissection. You've all clearly identified the factors that help with dissection and your thoughts on changing blades are accurate. It's interesting few of you consider the headlight and the headlight is particularly useful if you're a surgeon working in deep cavities and it avoids the need of having to manipulate light from above into a small hole. The thing about the headlight is in previous years, they were rather cumbersome and heavy. Fortunately. Now, with fiber optics, there are a lot less but it does add to the weight of the head. And if you're not standing properly, the posture and wait will cause fatigue and increase the chances of musculoskeletal disorder. You're quite right. The knife you change whenever you feel it is blunt and that's a personal feeling, but it's something that you need to become aware of. And that is why we emphasize how you hold an instrument and how you apply the blade to the tissues. Indeed, some people would suggest that you change the blade of a knife after the cut to the skin because there's a theoretical risk of carrying bugs from the skin directly into the wound. I want to share with you a piece from the Book of Five Rings. This was written by Miyu Masashi, an undefeated Samurai warrior in 1643. A lot of what he says is pertinent to surgery and hence the metaphor that we use in the Black Belt Academy. But his carder rules are as follows. Think of what is right and true practice and cultivate the science. Become acquainted with the arts, know the principles of the craft, understand the harm and benefit in everything. Learn to see accurately, become aware of what is not obvious, be careful even in small matters and don't do anything useless. Now, to my mind, these are simple precepts that apply to surgery. Every surgeon in every part of the body. If they tend to these simple principles, I think will be good. Indeed. I think a good surgeon can operate in any part of the body provided they know the anatomy. Now, I started as my surgical training in 1987 in bath. Having passed my primary for CS. Those were the days where you literally did know your anatomy inside out because the examiners could stand at a cadaver and point to any part of the body, you knew it. And when I started the job, I was given a surgical list and told you clearly know your anatomy. Now you get on with it, but there's a lot more to dissection as we will discuss this evening. And I shared with you on the page and I will reiterate what Lord Barclay Moynihan said, there are surgeons who operate upon the canine principle of savage attack and the biting and tearing of tissues are terrible to witness. These are they who operate with one eye on the clock and who judged the beauty of any procedure by the fewness of minutes, which is it is taken to complete. There are other surgeons who believe in the right hand whose use of the utmost gentleness and who deal lovingly with every tissue they touch the scalpel is indeed an instrument of most precious use in some hands. A role sector but in others, Amato, the perfect surgeon must have the heart of a lion and the hand of a lady, never the claw of the line and the heart of the sheep. An operation is done quick enough when it is done, right? Every movement should tell every action should achieve something. A manipulation. If it requires to be carried out, should not be half done and hesitantly done. It should be deliberate, fab intentional and final, infinite gentleness, scrupulous care, light handling, and purposeful, effective quiet movements which are no more than a caress are all necessary. If an operation is to be the work of an artist are not merely a cure of flesh. I think that is the most eloquent piece of prose, dissecting tissue and explaining how your hands in an operation should progress. Indeed lower. Barley and Mohan regarded his hands as a handsome servant of his controlling brain. I thought reading this, he was the most magnificent surgeon until I read that he cast his hands in bronze. And that element of ego disappointed me and detracted from getting 10 out of 10 in my book. That being said, his bus to dawns the top of the staircase at the lie General Infirmary where I spent 22 years of my career and I would extol trainees entering the old General infirmary from the Great George Street side to climb the staircase and do their cap to Lord Barley Mohan. So after two years of studying medicine at Royal Naval School at Ham, he returned to leeds to study at the school of medicine. He graduated with an M BBS and joined the le general family as a house surgeon. He then successfully completed demonstrating an anatomy at the medical school. In 1893 to 96 became an assistant surgeon and a surgeon from 1906 to a consulting surgeon in 1926. Until his death, in parallel with this appointment of the surgeon mono was a lecturer in surgery from 1896 to 1909, and a professor in clinical surgery at the University of Leeds from 1925 onwards. By the end of the Great War, Moen held the rank of major general in the British Army and had been chairman of the army advisory board from 1916 and chairman of the Council of Consultants from 1916 to 1919. He delivered a bright short lecture in 1920 Ontario Oration in 1926 and became president of the Royal College of Surgeons of England in 1926 to 1932. What's interesting? I don't think people know it was that in 1935 a year before his death, Monahan and Doctor Killick Millard founded the British Voluntary Euthanasia Society. It reminds me of Christian Barnard who wrote his book in Good Life. Good Death. One hand surgery was in Park Square literally across the road and I often walked past it noted as custom in the UK. There was a blue plaque on the wall marking the place of his work and his office, he truly was a leads man and a pioneer of abdominal surgery. And we can learn a lot from his precepts and I think the description of dissection is important. So I'm going to take you over two of the models that I have this evening. And I went to the N SK supermarket across in Times Square to get some fresh produce. I must say with the Black Academy, I go to supermarkets with a totally different lens looking for opportunities and possible material to use in delivering these lectures. The point being that you do not need a lab, a simulation lab or expensive equipment, you can do this at home and practice these principles. So bringing you over first on the menu tonight, I have a piece of chicken. No, I've previously used turkey leg and I did ask, do we do turkeys for Christmas in Kuala Lumpur? And they said of course, we do, but they aren't available just at the present. What's interesting and rather fun. It literally is a multicultural society and we celebrate every single holiday throughout the year. And I think there were a total of 14, the important element of any dissection is to know the anatomy. Now we eat and cook chicken legs, but I'm not completely familiar with the chicken anatomy. Suffice to say, I've got a thigh and a leg and I know they're major vessels you are going to be using for this two major instruments, the blade and the mass, and we'll go through them in more detail in the forthcoming lectures. Each of them have to be held properly and we'll start off with a blade. The cutting part of the blade is the curve and it needs to be held in the hand blade, held her in the palm, holding the knife like a knife and not like a pen. Mr William Walter Frederick Southwood would not allow me to do a REMS procedure because he said I could not cut straight with a knife. And my first task was to learn that, but the blade is not only used for making incisions, it is actually very useful for developing tissue planes. And in that regard, I open up the blade along the base of my fingers and I'm going to use it literally to brush the tissues. Now, what you realize and I am certainly realizing immediately one of the most important elements of dissection is to have a good assistant and good assistance make for good surgeons because they would intuitively follow and hold the tissue for you. My son is at school, boarding school at the moment, but I have got him reserved for the first of July when we'll go through the principles of dissection. But what I'm doing here is using the blade to brush against this tissue plane and this loose areolar tissue should fall away as I dissect. And the brushing is literally taking a brush and I'm brushing against what I'm developing. I'm not using the blade to cut into this groove at all. I'm using it to separate the tissues. Now, I might come across some resistance and I felt and I'll come down there and I'll focus further and increase the light. And please remind me Gabrielle and Chris, if the focus is out because I will be looking and focusing on the specimen. But as I'm coming down because I'm holding the blade lightly, I've got a little bit of tissue just there. It feels a little thicker. See that, that feels a little thicker and that is a little thicker because right underneath there and I'm using a nerve hook, you can see the nerve hook through the areola tissue there, but there's a condensation of tissue which could be a vessel. It could be a nerve, but because I was holding the blade very likely I felt that not only did I see it, I could feel there's a little bit of resistance. Now, the blade for dissection is very good in brushing in wide plains and developing a wide plain. And each time you come across a bit of resistance OK, you can either use a nerve hook to identify what was underneath it and look carefully there. And again, I'll zoom down. I can put, there's no hook behind and I can see clearly through that tissue there. And I'm now certain that there is nothing important. I therefore can cut. When I'm dealing with shorter areas of dissection. I use my scissors and I'll zoom out again. And the principles of how you hold the scissors is likewise very important. And again, we will be reinforcing this note that the scissors are balanced on the palps of my fingers, my ring finger and thumb obliquely through the rings rather than through them. So the palp of my fingers are applied to the instrument, my middle finger above the rings like a triangle of stability and my index fingers extended down the scissors giving that direction and appropriate session. The scissors are likely held. I'm not gripping them. They can literally be lifted in and out of my hand like that. But it means that I feel the tissue. If I'm gripping it hard, one, you can see the blanching on my fingernail. There two, I lose the field and I will not be aware of the detail of the anatomy that I'm dissecting. And if I'm actually watching somebody operate, I can see the blanching of the fingernails through the gloves. And I can ask the operating surgeon to lighten their touch because only through a light hole of the instrument can you then caress the tissue as described. Now, the important thing with scissors in section to develop a plane one opens them up, takes it out and then close. You never close the points of the scissors unless in direct view. The reason for that is it is possible to cut tissues inadvertently if it's not in sight. So here I've got that piece of tissue and again, I can use and I'll focus down, focus down. I can use my scissors and I can hold my scissors underneath them. I focus even further. I can hold muscles underneath that tissue and be certain there's nothing underneath there. I'm therefore able to cut it and I don't open up. I says any further than necessary to do the job. See, I'm opening the plane and because I'm going down a small hole, so to speak, again, I can check. Was there anything there? I run my scissors? Yes. And it's the same with ad adhesions, these tissues. If you tear them, it'll cause damage. And sharp dissection is clean dissection. Certainly when doing redo abdominal surgery or redo thoracic surgery. If you're not careful, the adhesions are stronger than the tissues themselves. What happens for redo dissections? If you are not careful, you'll be tearing healthy tissue and not cutting adhesions. So I can just these simple principles of feeling and exploring planes. It is the element essential element of how to dissect. And remember that in embryology, what you have are layers and layers and layers and the vessels invaginate into the tissues and by themselves carry layers. So the importance of being able to identify layers and loose early tissue is v because and certainly in solid organs, you followed the vessels to determine the segments or respective lobes. Knowing your anatomy enables you to dissect with confidence and impunity when you know there are no ns or vessels cutting the plane. And surgical anatomy is best defined. And I still can't find the book on tissue planes and in some parts of the body, for example, the scolen anterior and dissecting of the neck runs down the front, the phrenic nerve runs down the front of the scan anterior and you'll find that in other areas of the body. Likewise, there are important anatomical variations and arteries and nerves usually follow no anatomical pathways. The variation you'll find is amongst veins, particularly around exocrine glands because they're carrying hormones to the rest of the body. And as in those circumstances, the adrenal, the thyroid, in particular, the head of the pancreas that the venous drainage is extremely variable. A lot of it is described in the literature in the textbooks, but you're more likely to come across an anonymous vein than you are an artery. And since they are very fragile, don't diathermy, being able to identify them clearly is important because they require ligation. Don't die for me because as you know, even from a level biology, veins have thinner walls. Two, my combination of knife and scissors here has been extremely useful in me developing this pain and skinning the leg muscles as we see them here. A best note, cut across a muscle. If you're going to need to go through a muscle, the best thing to do is split the muscle cleanly with the fibers. This is where retractors help but it reduces the damage. And certainly the Ortho uh orthopedic colleagues would be splitting muscles to get to the deeper tissue and the bone. As you see here, I'm down onto the capsule and, and now have found a deeper muscle plane and my mode of dissection then can continue to sweep out of the way the muscle pain as I have exposed it, you're gonna appreciate cutting across the muscle is probably, well, it's going to cause more damage. And ok, if I was familiar with anatomy of the chicken leg, I would be calling to myself and reminding myself of the anatomy as I was going as we go down deeper, you can see at the bottom of this hole, I'm now going to a neurovascular bundle and I have got the appearance of what looks like a vein at the base here. Now, retractors are extremely useful to hold things out the way. But remember, a retraction opened up too far is gonna bruise and damage the tissues as well. So don't put a retractor in and open it up. Full thinking everything is ok. That too, an accessory traction will cause problems. Now, as I'm dissecting here, I'm down a deeper hole and I'm getting here quite a large vein. There you go. And all veins see it in a potential cavity. They recall and surrounded by fat because the first response to exercise is to increase the cardiovascular return. Bye, squeezing of muscles. And you know, somebody is working out in the gym because the first thing you notice is that the veins on their arms are increasing with increased cardiovascular demand. So that there is a thin wall vein and next to it. Yeah, it's a thicker wall artery and it uh focusing further and even a chicken leg from a supermarket and in the short period of time, I'm finding myself totally engrossed in this procedure. There is the artery. You can see that that is a little branch. Now, if you're dealing with a ischemic leg, these little branches, you don't just cut in tie. The best thing to do with these little branches is put a loop of silk around it and the silk loop will hold that and occlude that vessel as you continue your dissection. And there, this is the femo see that not there is the nerve. So I've got a femoral artery there, which is the light pink one. They are small branches and vascular surgery. I would put a loop of silk around that and pull it off to the side. For hemostasis, I would not cut these because you need every single branch and every, every bit of blood to an ischemic limb that day is a little bit more solid. You can see it is white. That is a nerve. The femoral nerve in here, thin walled off to the side. You have the vein and we have just dissected out from this side and splitting muscles. the femoral canal of a chicken leg and the size of these vessels takes me back, uh, a similar size to some coronary vessels, but it takes me back to the days of general surgery. And sometimes the thyroid artery is that and the nerves in the head and neck will be like that. But if you were blindly dissecting through and not aware of the feel and not looking for the colors, white nerve, pink artery, darker blue vein and even that little branch there underneath my hook. These are significant elements of anatomy that would be destroyed. If you are not careful, you can't go through the tissues blindly. Now, having identified those I have now come down to the capsule here and I'm not a, I never did orthopedic surgery. Well, I did six months of orthopedic surgery, but I wouldn't say I did any joint surgery or arthroscopy and I'd have to default to all my colleagues, but you'd have instruments to take off and remove carefully and be aware and there's a ligament and insertion of a muscle and that there will be part of another ligament and the joint capsule itself. Once you're on the bone, it is possible to identify a layer that enables you to sweep off all the tissue. Now, I was at a conference of trainers and getting them to stitch bananas and teach them about lightness of touch. And one of the trainers said, well, I'm an orthopedic surgeon. I said, yes, he said, well, we deal with bones and I said yes, how do you get to the bone? When you get to the bone, they're cutting through the soft tissues. And if you don't respect the soft tissues, you can't expect the hard tissues to look after you. So again, as you're exposing bone or getting exposure to a joint, please remember to look after and identify the tissue planes and sweep them out the way such that your tissues will then fold back into place closed properly, tack the two layers of the muscle together with or without a drain in the space to remove the collection of any serious fluid closure of the skin. And because I haven't macerated any of this tissue, I'd hope that the function and exposure, the function of the muscles and the limb will be improved. Yeah, I love dissection. Always have. I liked it at school and I like it here. So, what else have we got on our plate tonight? Well, I thought give this a go. Here's a sardine and I wanted to use the sardine for two reasons. And there's a lot of elements to this that we can perhaps use. The first thing I was thinking about until I looked at the specimen, I'd like to actually take flip some of the skin off because one of the elements of dissection is being able to develop and cut through thin planes without damaging the, the tissue underneath. And I'm probably going to use a bit of tooth forceps. Now, just to hold this skin because I'm going to be removing it. And what I want to do is to again demonstrate the principle, I hope, oh, removing this tissue without damaging, efficient. Now, there's no point with these things and when you start out dissecting and developing a plane, it takes a bit of patience, a bit of time, there's no point rushing it. And certainly, if I am, yeah, we can use that to start right to try and remove the skin without damaging the tissue underneath. Now, all these, all this material is giving you practice and how to feel and what I should be able to do is remove this there and you can see it's a lot smaller. So I'm now gonna use a 15 blade and this is a Barre blade handle that looks like a pencil and I can roll it like a pencil and hold it like a pencil. But I'm still got my D IP joints extended. I'm going to use this to see if I can take that tissue off. But what I'm doing with all this is very simply appreciating the blade and feel. Now this eye is caught by attention as well. And I was wondering, what can we do with the eye? Is it possible to dissect it out? Apparently, when you're choosing fish, the best thing to do is to look for the clarity of the eye. When you buy a fish at the counter, the clearer the eye, the fresher the fish, I I'm familiar with cutting, cutting eyes, but I'm familiar with tissues and feel. And what I'm doing is simply using the opportunity to explore how the blade feels in these circumstances. And you can say the same for anything from the supermarket, any organic material. Because in all my years of surgery, I have not come across any synthetic material that mimics the real thing organic material. And what I also noted here from this fish, it has not been gutted and this is rather fun because most of the fish we actually buy has been gutted. So there's the cloaca, I'm going to open this up and there you go. There is the inside of the fish and the peritoneum is that little bit of thin tissue across covering and these orders gives you feedback and feel. So I want to get a retroperitoneal approach or something. I'm keeping the peritoneum intact brushing it out of the way and taking out the viscera. But I hope you get the gist is anything and everything at your supermarket is a wonderful opportunity to explore on this circumstance because I, I'm feeling my way. My scissors curved gives me an opportunity to gently retract and brush and hold things away. He's got a blunt hand, I'm not gonna stab anything and this is, can be used as a blunt instrument for dissection. I think it's gonna be fun if I can hold this fish up properly to see if we can f enough this and take it out further. We're gonna cut down here because obviously we're gonna to gutting the fish and all of that will come out cleanly if you're cleaning fish and removing the greens. Again, the principle in the kitchen is you don't want the spilling over your meat because it will cause contamination. I could probably go on all evening here and have fun, but I would like to open the, the discussion up two questions from the audience and invite my fellow colleague, Mr Caddy to offer his experience and thoughts of dissection just as I zoom out just to reiterate all the tools at my disposal. I have large blades, small blades. I change them when I feel the blade is blunt. I'm using two holes for the blade cutting or the cutting edge and another hold brushing the scissors. The Metzenbaum and the mcindoe scissors are similar. The Mac and D is thin, the mats and balm is slightly thicker but there were the curve of the wrist applied gently to the hand. And I can see the tips and I can see the belly that likewise cuts. I have a blunt instrument, a nerve hook here to explore and identify nerve hooks and vessels and nerves and small mosquitoes that can use likewise to pass around tissues and stay sutures to hold things out the way. And my favorite instrument for dissection, particularly around neurovascular bundles is this la to gently separate those tissue planes and insinuate it around a vessel to wake up a day. And this again is a very useful tool for dissection of neurovascular bundles. So Mr Caddy, in Fellow Sense, your observations, please and false undissected. Well, my, my first observation relates to your um exploration of the anatomy of the, the groin in the chicken. Uh cos I've seen you do it with the, the Turkey, which is much bigger, but you still found the vessels and the nerve and were able to orientate yourself very quickly and easily with it. Um The next thing is, so you're doing the dissection, you're identifying small vessels. And if this was live, if the patient or the material was living, then those vessels would need to be either ligated or dithered, correct. And that's why it helpful to distinguish between, depending on the type of operation in vascular surgery and dealing with areas with compromised blood supply. You do not want to be dithering or ligating branches of arteries. You want to preserve as many of those veins and vessels as possible. Veins never diathermy always ligate and they could be numerous and they might need numerous ligations. Mr CAD, you turn your camera on and you can join us. So, so the the other thing is it, it's all contextual uh because I tend to use bipolar diathermy on a low setting. So, and the current between the tips of your instrument rather than through the tissues itself. And that is also important, particularly dealing with small volume, a large surface area to volume uh areas like digits or hands. And you do not want to full grade or transfer too much energy to the tissue. So, ideally, bipolar dither respects the tissue better than regular diathermy. I think the rest of us are very lazy and particularly, I note a lot of people use the diathermy to actually develop and burn tissue planes that is going to transfer energy to the tissue planes and you will get thermal injury and therefore a more a bigger exudate from the tissue and with that loss of function and potential scarring and blood and thrombin is a very, very potent inflammatory marker. So if you have a lot of blood in the area and you are messing with your dissection, the thrombin is gonna cause inflammation cause pain resulting in increased scarring and loss of function. Another reason why you need to respect the tissues. So that's sort of a fundamental difference in uh a general surgical approach and either a microsurgical approach is that you tend to be much finer with your use of diathermy and control of bleeding. Um If you're using monopolar, you create tissue damage that increases inflammation, slows down the healing and reduces your end result. So it's all about attention to detail and the way you handle your tissues. Um The other thing that I noticed was was your use of um the mcindoe scissors. So for fine dissection, we tend to use Stevenson's Tono toy scissors, which are much finer instruments. And once again, you're much less likely to damage your tissues using blunt tipped forcep, blunt tipped scissors than you are with um with sharp tipped scissors. Um But it's just a difference in the way that you handled issues and you concentrate on what you're doing early on, early on. You talked about lighting. And so you often work inside the chest and depending on who your ODP is or who else is in the theaters, it's often difficult to get the light exactly where you want it and need it. And that's where modern day headlights allow you to work without using theater lights where you look is where the light goes. And so you're able to get into places which you wouldn't necessarily using standard theater lighting and wearing wearing light headlight does take some getting used to. You do need to keep it within your field of focus and you'll find that as you look out of that field of focus back into the field of focus for a moment, you could be dazzled. It takes a little bit of getting used to. And of course, as you look up and turn around, your light will follow you as well. It also does the modern headlights are very small. And if you look at the historical picture of Christian Barnard operating, he had a headlight or Lily high, had headlights not too dissimilar to the torchlight that you probably have in your garden shed. Fortunately, now they're significantly smaller and with led and fiber optics, it is much better, but it is adding weight to the head and people often use that then to bend the head and turn to get the light. One of the biggest problems with failure to progress with dissection is not setting yourself up properly. And I recall calling the consultant into theater to give me a hand and they would touch because I hadn't adjusted the table. I didn't use the gimble to turn it. I didn't adjust the light or I hadn't enough exposure and simply changing those elements and increasing the size of the wound made the exposure a lot better. Obviously. Now, with endoscopic surgery, the camera and camera positioning is of vital importance. And although as a trainee, you might be bored to death, standing there holding the camera for ages, keeping it in the right position at the right distance is crucial to that 3d orientation. That's necessary. When looking at anatomy from afar, you cannot operate on something when the camera is moving like that. And you, you lose your perception of depth if that is moving and not in focus. So for those of you who are holding cameras do bear that in mind one day and use this as an opportunity to learn your orientation in a laparoscopic field as well. So when you are, when you are assisting, you need to think what does the surgeon need to see and how do I move the camera so that I can produce the image that I would like to see and which the surgeon needs to see. It's about situational awareness while you're operating. And it's about reflecting on your actions in action, her, her. And that is why good assistants make good surgeons and good surgeons make assistance, good assistance because you are practicing the operation and sort of rehearsing it or following as you do it. And unless you understand the steps and unless you understand anatomy assisting then becomes a very passive and sometimes boring role. Well, one of the other things is that if you've got two retractors, you can facilitate the surgeon operating simply by putting tension on the tissues, holding them apart. So with a very gentle touch, the tissues separate and the the surgeon is able to see and do the next move. Uh Chris, you and I were of the era we remember those flat diva blades for open cholecystectomy, the blades of a retractor at the end sometimes are quite flat and pointed. And if you leave them in the wrong direction, they themselves, particularly if you're pulling hard, can lacerate poor tissue thinking of these divas holding liver lobes out the way I have seen them lacerate and livers and cause problems as well. So even a retractor, as my fellow si said, needs to be held properly and positioned properly and a lateral hole and not a pool. It's also it's how you apply tension through the tractor which facilitates the surgeon doing the procedure. But this is, it allows the surgeon to understand that you understand the operation because you're making it easier for him. And it's a dynamic procedure because there are the surgeons progressing through the different areas you are helping and exposing and holding things out the way. And that should be automatic and intuitive. If you understand in following the procedure as a surgeon, it is extremely frustrating and difficult having to direct those elements all the time, particularly in a difficult operation. And it, it's an absolute pleasure to have a good assistance standing opposite because the tissues part in front of you, as you focus on your dissection, they are gathering and holding things out the way I'm sure you find the same Chris that good assistance completely changes an operation for you. Well, II operate with a lot of different specialties. Um So I'm able to see that the way they do the procedures that I have an idea of what's about to happen. And what I do is I facilitate the surgeon doing the operation and I also speed up and facilitate the closure of the wound. Um So that's how you develop a a very functional high performing team by using people from different specialties to reframe the operation. See what's being done and think about how can we do this better. And it it it comes down as a surgeon also not only to the lightness of touch but the economy of movement, but in every operation, there are natural pauses. So one surgeon I saw dis called skipping. Yeah, I got all the time. It was really horrible to watch. The end product was all right. But the way he conducted himself was not very good where others were deliberately and purposely as described by morning and go through the dissection. There'd be a pause and at that moment then pick up the diathermy and turn to hemostasis, hemostasis in an operation happens as you go in, you go in slow and deliberate, mindful of the tissues with good hemostasis. Such at the end of the operation, good approximation of the tissue layers, your hemostasis is done making sure the patient is obviously warm because that's critical to that hemostatic ability. But the coordinated movement with a an assistant means that there's no wasted movement, no hesitation, deviation, interruption, repetition. And it just simply progresses and an operation happens. And if you attend to everything deliberately and purposefully, tissues part, you get to there with uh unhurried in a lovely zen like state almost. Yeah, that comes with practice and it comes with communication and it's about developing that rapport within the team. So the surgeons, anesthetists scrub nurse are all singing from the same hymn book. And as you dissecting and coming across tissues or think you've got problems being able to vocalize that enables everybody else to anticipate and respond. I'm going to be using uh could you hold a la he for me next and you're talking out aloud. It's like advanced driving, my colleague, John Rudd and I are writing a paper about advanced driving and surgery and the lessons there in it's anticipating and communicating what you're doing to the team as you're preceding it. So they can help you progress to an operation as well. It's not all about you and it's not all up here. You, you're part of a conductor, I suppose an orchestra and all places, all parts need to play together. So as part of that discussion, if you're the trainer, you can have a running commentary with the trainee to say, tell me what you're gonna do next. What are your alternatives? How else have you seen this done? So you, you use the dialogue to explore how the operation is being conducted? What are you, what's coming up next? What are your expectations? What, what are you looking for? What are you anticipating and, and that can be quite a, a dynamic discussion between trainer and trainee and I think it's the essence of good training at the table. What I do and have noticed in the past is that too often a trainee surgeons at the table and they, somebody would chip in and say, would you mind if this learning scrub nurse joins in and then you got, would you mind if this training in the it just joins in? And I I have concerned as soon as you put all the trainee elements together, each, all of them with legitimate reason to participate and learn. But that situational awareness and that coordination runs a risk of falling apart and errors happening. And I think in those circumstances, the consultant should be present. And certainly with Chinese scrub ns, I think they should scrub with consultant surgeons. And the most senior scrub nurses should be scrubbing with the junior surgeons. And that helps with the situational awareness but also instills confidence in the learning surgeon. Certainly in my early days of dissection, having a skilled scrub nurse at hand who could also say, well, Mr Jones does this or uses this in this situation, there's a lot of learning to be had. But, but you have to be open to that learning. Indeed. And sometimes surgeons say, don't speak to me while I'm operating, but you're then not using the team around you as a learning opportunity and they could see things that you can't and some of the biggest disasters in theater. And I'm thinking of Martin Bromley, his wife died from anoxic brain injury when a nurse was in theater with a tracheostomy set and people were struggling to maintain an airway. Thing is when things get tough as surgeons, we got to recognize we end up with tunnel vision and I had a particularly difficult case and I called for a consultant help and my colleague arrived in theater and said, what needs to be done? I said we've changed the plan but like changing the flight and landing the plane at a different airport, I need this. And as I fixed the immediate problem which took all my focus and energy, I could devolve the conduct of the rest of the operation and the backup to another experienced person because I invited them to be present. Any questions at all in the chat room from anybody, Gabriel, we're kindly monitoring this. Any thoughts, anything from your side, please? Nope, very insightful. We have uh thank you for r excellent dissection and thank you Mr Kddi for joining us this evening. Um I do, I do value our conversations, I think to my mind it's adding more to what we're teaching and uh asking you to appreciate as we do, hopefully impart our knowledge and experience to you. Thank you for joining the Blackboard Academy. We will see you next week. I think we're going to explore the scissors and focus on them as a tool and how you can practice on other things, not fish or chicken legs, but other things improve your skills. Thank you for joining the Blackout Academy.