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Ok, we're live now. Hello, good evening. Good afternoon. Good day. 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 retired cardiac surgeon, the immediate pa director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And they accredit this program and offer CPD. I'm currently a professor in the Medical Education and Research Development Unit of the Faculty of Medicine at the University of Malaya. Thank you very much for joining the Black Academy this evening. If this is your first time, welcome. And if you're returning, thank you very much. Indeed. What we noticed this evening, we have 91 registrations from 31 countries across the globe. And this evening, we welcome Kosovo taking us to a total of 120 countries. And so far over 3500 delegates have been watching us on meddle. Indeed on catch up, 2000, 460 videos have been viewed and that is over 35,000 minutes. So I'm extremely grateful to you. I was very pleased and excited last weekend to be involved. In the Malaysian Surgical Students Society Schools Day. And I was even more pleased that the three students we called ourselves. The Lumbrical won the overall prize. Really heartening to see that they've taken on board basic skills and in a couple of lessons learnt to tie a onehanded surgeon's knot and became better at stitching bananas. Tonight, we have countries from Armenia all the three through the alphabet to Zambia and Zimbabwe and I was pleased with the answers to your questions. This evening before we operate, we need to plan and prepare that. In dissection. We develop tissue planes with attention to bloodless fields, tension on the tissues to an a and retraction to a dissection. I did put it in a few trick questions in the instruments we use and it was remarkable in reply, your favorite instrument for dissection was a mosquito. However, McIndoe scissors did not feature very well. What was also interesting that you favored the 15 blade after a 22 blade? And perhaps there's a degree of reticence using a large blade. But indeed all the instruments I had there apart from the 12 blade, which is the j hooked blade usually used for removing sutures and the mayo scissors which are heavy cutting scissors, everything else there can be used for dissection, including the retractors, particularly the West retractor and the traverse retractor. But remember when you put retractors in tissues, they are causing pressure and cold can cause damage. But we'll talk to that this evening as we discuss dissection. Now, cadaver dissection has a rather exciting history over the centuries. And for many centuries, physicians in ancient Greece gained considerable information about the human body and health. And this com in the school of Greek medicine at Alexandria during the third century BC. And the practice of human cader dissection was a dominant means of learning anatomy. And it was here that two people Opalus of Chalcedon and Aris of chaos became the first Greek physicians to perform systematic dissections of human cadavers. And even though the literature suggests they were religious and moral and aesthetic taboos dissecting humans, they were open to this because these two physicians overcame the entrenched beliefs because of a raw patronage where the bodies of executed criminals were handed over to them for their scientific endeavor. It was also the ambition of Greek rulers to establish Alexandra as a glittering center of literacy and scientific learning. And because it was the center of this sort of cosmopolitan intelligentsia, committed to literary and scholarship and scientific endeavors, they prospered in their studies of human dissection. Now, unfortunately, with the Christianity spreading across Europe, this development of rational thought and investigation was paralyzed by the church and physicians could only copy what was done by previous physicians like Aristotle or Galen without actually questioning the scientific validity of what they're doing. And dissection and human dissection was considered blasphemous. So for 100s of years, Europe valued the sanctity of the church more than scientific quest. And it was not until the 14th century that human dissection was then thought of as a tool for teaching anatomy. And this first started in Bologna in Italy. And this is 1700 years later, and a lot of advances could have been achieved. And the Universities of Paris Bologna, Oxford and Montpellier and Padua became centers of study and dissection. But the holy Emperor Frederick the second helped us because of his rethinking outlook. And he issued a decree which mandated that the human body should be dissected at least once every five years. For anatomical studies, an attendance was made compulsory for everyone who wanted to practice medicine and surgery, terrific. Everybody thought then Pope Benefice came along in the apes and he forbade the manipulation of corpses and their reduction to bones. In fact, there was a macabre trade in bones of soldiers killed in the Holy War. By the end of the 13th century, Bologna became the institution on learning and it was granted by Pope Nicholas a bull which said that all students having graduated from medicine from the university were prepared to teach all over the world. And all of these events eventually correlated in the first officially sanctioned systemic human dissection since Herophilus Antritis. And the first public display was done by delus in 1280 then Bologna in 1315. And the dissections were usually done on criminals who volunteered their bodies. But many dissections were also done in private with informal anatomy teachings. And indeed a lecturer in a small band of students were prosecuted for grave Robing in 1319. And that was Master Alberto. The 15th century saw a flowering interest in anatomy and dissection because of the renaissance and interest in all things of nature and naturalism. Of course, the need for body is increased, the need for grave robbing increased. But the painters such as uh uh Poin Nano and later Leonardo da Vinci, as we know we're dissecting but grave robbing increased. F cadaver dissection was banned in the U UK in England until the 16th century because of the influence of the Catholic church have it with protestant reformation due to the major disagreement between King Henry the eighth and Pole. It meant that in 1565 a selected group of physicians and surgeons at the Royal College of Physicians and Barber Company, we are given permission to dissect a select number of people per year. And John Kas, an English physician who graduated from Cambridge, also a student of pager was the first president of the Royal College of Physicians between 1555 and 1560. And then again in 1562 to 1571. And hence the popularization of human dissections in the UK was established. It's interesting that further physicians also came from Padua, including William Harvey who under the guidance of fabrics did his masters at Cambridge and published the famous treat, the moto Cordis Sanguis on the motion of the heart and of the blood. So the history of dissection has actually been huge and fascinating to read my interest as you know, in teachings really stem for my learning and thinking about being a student in martial arts. This is helping me to think how to communicate how we use instruments and how we should teach. But there's one passage that I think is particularly potent to surgery. And this was described by Miyamoto Masashi, the undefeated summary of 1640. And this is in the book of Five Rings. The Way on the samurai, you had some principles. Firstly, think of what is right and true practice and cultivate the science. Become acquainted with the arts, know the principles of the crafts, understand the harm and benefit in everything, learn to see accurately and become aware of what is not as obvious, be careful even in the small matters and above all, don't do anything useless. I read that passage again and again and think of my career in surgery. The ups and the downs. The successes are not so successes and all those principles resonate. But last week, we talked about the instruments being extension of the fingers and you need to be able to feel the tissues. And it was Lloyd Barclay Moynihan. He said the surgeon must have the heart of a lion in the hands of a lady and we said that we know that ladies on the fingertips have better two point discrimination in men. He regarded his hands as the handsome servants of his brain. And what I love the one passage that sums up surgery is an infinite gentleness, scrupulous care, light handling, quiet, purposeful and effective movements, which are no more than a simple caress. And all these are necessary if an operation is to be the work of an artist and not merely a hearer of flesh, beautiful description, I think of what good and effective surgery should look like. So without further ado, I am going to take you over to our menu this evening. And as you know, I enjoy using low fidelity models and this was a chicken thigh and leg from the N SK supermarket in Times Square across the road. Any organic material is useful. I previously used pork belly, but that is hard to come by. It is expensive, but this was 5.6 ring it which is a pound just to practice at home. So as you've already said before, you pick up a knife, you need to make sure that the right decision, right person, right side, right. Team, right. Consent is there. When you pick up the knife, you hold the knife like a knife with a handle in the hand, the index finger extended down the blade and the sagittal plane maintained between the thumb and the side of the ring finger. Nobody can tell you to pick up a knife. And I've often said the queen of England could not come out me to operate if I didn't feel comfortable that the conditions were right. And it's your responsibility of a surgeon to ensure that is correct before the knife goes through the skin, it doesn't matter what people say if you don't think it's right. Do not make the cut. But when we can cut, remember we cut the belly and that an incision needs to be done supporting the tissues with your non dominant hand and stroking the blade purposefully across the tissues. So they're separating and parting and you use the full thickness of the incision. You'll note that this chicken skin is rather thin and part of your skill as a surgeon, even though this blade is 22 I should be able to draw my blade across the surface gently without cutting the muscle underneath. And this is part of learning to feel how often do you change the blade? You change it when you feel it is blunt because sharp dissection is clean dissection. Imagine that you're trying to shave and your razor is blunt. Now, always between tissue layers, you see this loose areolar tissue. And in embryology, we start as a sort of a flat worm of three layers that folds and folds and folds and folds and each folding is folding of layers. So you'll find that everything is in layers, anatomy. OK. And the vessels develop and evaginate into the mes of kind as part of angiogenesis. And they too, as they go through taken layers. And since arterial anatomy, Israel more regular and predictable to dissect in solid organs, you follow the arteries, but you need to know the anatomy as I'm brushing this layer off here, I've opened my hand out and I'm using the flat of the blade and literally pressing that it's parallel you see with the skin and I'm literally brushing this off. And it's a very effective way you see that little bit of resistance there. Even though I've got a 22 blade, I am able to feel and appreciate a little bit of resistance. Now, that's a condensation of white tissue there. Although I've got a 22 blade, I'm also demonstrating to you that I'm confident using the blade and I can pop it underneath and I can clean off the tissue that indeed might be a small nerve. And in some places like the phrenic nerve runs down on the surface of scans anterior and disappears then into the thoracic cavity, the nerves supplying latissimus dorsi actually runs down on the surface and disappears a centimeter before the edge. So knowing your anatomy and identifying structures like that, you can feel it, there's a little bit more of resistance there, but I can brush the skin off with confidence and ease because there's loose areta tissue. Now, the exception to this spaces of veins and particularly around exocrine glands, adrenal thyroid, in particular, common operations, head of the pancreas because they're actually growing glands, they are secreting hormones into the circulatory system. So you'll find that in those spaces and layers, there are lots and lots of different veins and veins do come in all sorts of variety of positions and hence the variability there. Again, you see, I'm brushing it, you might not be out of here, but I can feel and flick a knife against there. How do I actually determine if that is something significant? I'm now gonna pick up my scissors note, I'm holding them in a very similar manner balanced on my fingertips with my index finger extended down and the curve in the direction I am looking when using your scissors, insinuate your scissors, open them up and withdraw, open, withdraw, open, withdraw, one doesn't ever close the scissors at all when you can't see the point. So I'm opening and we're drawing and again, I can use the scissors all my 15 blade tw two blade to dissect that out a bit further. But even something as small as that because I'm actually holding the tissues with the lightest of touches. I can, yes, I can see that there's a vessel there. I think it's a vein because I can see there's a little bit of blood in the lumen. So slightly purple. Ok. There you go. And I can clean this off, separate the tissues and if it's a vein because it hasn't got any media to it, I'd ligate that because even the smallest of veins will bleed. Now, dissection is developing and finding these veins. But I'd also say to you that I'm going to cut it in this instance, but we said we're tied off and there's another vessel there. You see how my scissors can separate, open the drawer, open the drawer and it can use the scissors to tease out different layers. There you go. And again, I would tile it off. It is tired off two ways of doing it. I can pass a suture underneath it or I can actually also pull it through where this is this. And once you've tired of these vessels, sometimes you can use them as a little stay, they hanging a clip on it. If you want to preserve the vessel, the best thing to do is pass the suture around it. And this is very useful, particularly in vascular surgery. You need to preserve all the vascular supply. And with the suture, you just loop it around and you can hold it out the way and I'm going to tie this. But you can see they are not big vessels at all. It's an artery, you may die, the, it's just a vein you need to tie off. See how that suture here. I've got on the mosquito. I'm just using that as a bit of retraction let us proceed now with muscles. I was just reflecting earlier, one of the most severe incisions I remember doing as a trainee surgeon was an open cholecystectomy and an open cholecystectomy was with a coccus incision and we cut through the muscle and the rectus abdominus. To be honest, you don't do that anymore because I think it was quite a subcostal difficult incision. But what I'm trying to say here is that rather than cut a muscle, if you're actually going in an orthopedic surgery or going deep, it is better to split the muscle along the line of the fibers, then you're not macerating it and you can split the muscle there. Ok. So I'm separating the fibers of the muscle and going through to a deeper layer and I'm not cutting at all. So separating. So let's continue our dissection here and see where we go. I believe as long as you know, your anatomy that a good surgeon can operate in any part of the body, as long as you know your anatomy. So whether it is and I am confident that that there is the tissue plane and the out any vessels and I can feel the thickness of a tendon un session coming up here. I'm gonna take that off because I can feel that insertion there. And indeed, there's an aosis in front of the bone, usually a bloodless pain. And the other thing is with an aponeurosis that is very amenable to stitching back together. Whereas the stitching of muscle is problematic, particularly if there's no aponeurosis. So, underneath here and we'll come down further. I have got some vessels here and again, open, separate loose area of tissue would actually break away, but I'm feeling it. Yeah, there's nothing underneath that. I can cut that. Not done. See there, I've now got not a vein, let's come up there. Ok. It's another vein. I would actually tie it off because that would otherwise bleed and not dieing it here. Looking at it, it looks like a bit of blood in there. That's another vein. I'll tie that off. Ok. So my progression and in this circumstance to actually hold the tissue, what I do is put a retractor in there like a west retractor to hold it open. So now we're getting following this down, we can see that was a vein, although it is actually very small, that vein would have actually caused a lot of bleeding. And now when you're operating, it's better to go in slow and deliberate hemostasis happens as you go in. Not as you come out is not an afterthought, respecting the tissues developing planes and attending to all these vessels. What you're doing is hi broth. Could you adjust the camera slightly? Um Yes, thank you. Just a bit more as well. I think it might be to your left perhaps if you could show more of your left. Yes, that's much better. Thank you. Thank you very much. Indeed. Thanks. R as I say, when, when operating, I can't look at the camera at the same time. So please, if it is out. Sure. And if you're watching and want to ask questions about dissection, this is your chance to ask questions. So I'm taking off this muscle here and I did mention the periosteal elevator is certainly very good to get into the plane of the periosteum and sweep off. There's another vessel that I would have cut and sweep off and clean the bone. And of course, it's a vascular. I can use my scissors if I'm in the right plane to continue to expose and dissect off tissue. So the scissors can be used for cutting also. So developing planes, cos it's got a nice blunt tip to it. So we're getting further and further down to another muscle layer here. And what's this? Oh, here we go. Here. We've got a neurovascular bundle and why I know it's a neurovascular bundle. You've got a number of elements. You see that a white cord like femoral vein, femoral nerve. OK, right here. And this is where a number of other tools come in. I like the la, the la he is a nice blunt tool that enables me again, gently open along the line of the vessel, but the la he enables me to separate out the tissues without actually cutting them and I can hook it around there you go and I can hook it around this side. What I've also found very useful in this section, particularly if you got a neurovascular bundle is certainly use a sling and this is an elastic band and I could put a sling on this and I can gently hold it out the way. Remember, not too hard because a neuropraxis is possible, but I can use that now and hold this neurovascular bundle out the way and continue my dissection. And there might be you need to be careful. Yeah, I think there's a little vein there, maybe, maybe not. And I can do to worry it a little bit. The muscles is underneath. No, you see that now come down further to magnify the vein is there OK? But in that tissue, there's no vein so I can cut that. So now I've actually pulled the hole of that neurovascular bundle off to my side. What's interesting about veins in general? It, it's a femoral canal in the jugular veins are not within the sheath, there's always a space. So medial in the femoral vein, medial to it is a fat pad. And when you think about it, you don't want your vein in a sheath because if your vein was in a sheath, when you exercised, you could not increase the venous return and hence cardiac output if your vein could not expand. So veins as an aside and in general are never actually within the sheath So now we have come through the other side and we're holding the bundle out the way all these dissections can be done at home and you can practice your techniques. This little nerve hook is again, very useful. And this leg is a nerve hook. There you go. That's my nerve femoral nerve. The smaller pink vessel there is the artery and the collapsed. Now, the smaller pink one there is the vein and a more thicker cord like structure. There is the artery, ok, which is branched and that's disappearing down. And you see how it disappears into and between the different muscle layers, loose areolar tissue. Remember as you're dissecting that your forceps can be exerting significant pressure as you're focusing. So I'm not grabbing this, I'm reflecting. So whether it's with two forceps or non tooth forceps, simply use your forceps to gently retract. Obviously, all these procedures are helped with an assistant. But as an operating surgeon, you need to be able to direct your assistant appropriately to hold. In fact, good surgeons make good assistance and vice versa because a good assistant will understand and follow exactly what the surgeon is doing and will expose the tissues accordingly. Literally following the train, almost following the train of thought, see how easy it is to develop a plane, pop our scissors in open spread, but I do not close. But this is in the lumen. You can see the, the femoral canal and you've got a whole lot of other vessels here. And this is not too dissimilar to the sino fe junction where there are five or six vessels coming off and the old open long senna vein and sephena femoral junction high, high, particularly if it had a, a varix. And I must have done about five or 600 of those as a junior surgeon in training, that's disappeared with sort of endovascular radio frequency ablation and has taken away a very, very neat little dissection to dissect out the femoral canal. Now, on top of all vessels because they invaginate through and there's vein coming through that's coming through there over the muscles. And this is effectively the floor of the femoral canal. For a chicken leg, we can explore it even further. You can see another little vein there that the top end of a Sephena fe junction, particularly with the varix was extremely useful dissection and really did teach you lightness of touch. You see when I said veins have usually fat to the other side, you see all this fat tissue there that enables the vein to actually expand in response to increased venous return with muscle contraction. And in one heartbeat, the cardic output improves there's another vein. So again, I'm simply teasing off the loose area of the tissue. But all these little vessels, you can see how small they are. All these little vessels I can feel even if I had my eyes closed. And exploring this around, not that I advocate dissecting with the eyes closed. But in this situation, in practice, close your eyes and just move your scissors over it. You can feel almost string like and cord like. Now you look at this and I think of my time doing pediatric cardiac surgery and doing herniotomy on Children and the layers in the hernia sac would be literally as thin as that. There's a vast difference in the artery and vein and it was smaller and thinner than that. And one had to actually dissect that out and appreciate the tissues. One of my favorite dissections in the beginning was epididymal cysts to remove the epidermal cyst in tact to find all the layers. I will confess, I saw a gentleman, we had a large scrotal swelling. I could not feel the testis at all and because you cannot feel the testis and it wouldn't transilluminate. I consented him for a possible orchidectomy. I went in to the scrotum dissected out and lo and behold, it wasn't a hydrocele. It was an epidural cyst. So I proceeded to dissect out this epidural cyst which has got really thin layers like this, very thin be. And I was Johnny pleased, very, very pleased that I had taken off the epididymal cyst in its entirety without actually popping it. And then I had a closer do. And I confess in one hand, I had the epidural cyst. In the other hand, I had the testis, the cord was attached to the epidermal cyst. So in my first job back in 1987 as a, as a surgeon general surgeon, I was so taken enthralled with my dissection. So pleased with my dissection and finding the layers, I failed to recognize the chord was actually attached to the epidermal cyst. And what I had done was successfully separated the testis. I confessed my sins to the consultant. And fortunately, the patient was understanding because I had consented them for an orchidectomy. So that is a confession. And while II am now through to the other side, we're separated and gone through to the other side. So you do have to be mindful and we have separated all the muscles, kept the cord, kept all the branches, kept the femoral vein, kept the vein, kept the artery all the way down and not it. I've got it retracted on a bit of cystic. The other thing often you can do is literally pop a straw in or something to hold it out the way to the side. So there are lots of different elements available that will allow you to separate dissect, unexposed tissues. I'd be very happy to take questions from anybody on what we've done so far or any observations, Ria, do we have any questions in the chat blocks? Well, thanks may act on a beautiful dissection. I've changed somebody's perspective of a chicken thigh and I've made a masterpiece of my favorite food and, and thank you very much indeed, this is not going to waste. I can assure you this will is fresh. This will go back in the fridge freezer and I'll cook it. So I think that the Black Belt Academy also is sustainable. I'm chasing this further down. You can see it's disappearing into another lay there and I can follow the principle it all the way down. I can take that off there because that is you can hear scissors actually cutting through tendon. And certainly in orthopedic surgery, a periosteal elevator might be helpful in the circumstance. And the whole thing about dissection is feeling all the time, you're feeling the tissues. So, you know, the difference between attending session as I've just taken off there and chasing down and exposing, there's a go there is a tendon running over the joint right there, nice and shiny and white and the nerve continues in that plane. So rather than split the muscle cut the muscle, I'm now going to develop the plane of the muscle here, I can pop my scissors underneath and that's a useful trick to do. Putting my scissors underneath there, you can see straight through my scissors underneath. So I am comfortable now cutting that, ok, and continue to do that, separate it. I can use my scissors to feel my way underneath, not force. There you go. And I can cut that. Now, getting into tendons. So note that the vein, the nerve is there. It's a little pinker. The tendon is quite thick fibrous. The nerve is coming off with a branch on this side. There again, I can use my scissors underneath to feel, I'm not sure. I think that might be a nerve. And now she's looking at it is too thin and that's a little bit of condensation of connected tissue. Likewise, that you think, is it a nerve? No, it's not. I can take that off. So there we go. As we're taking this further and further down, we really have explored this to its full extent. And I'm not cutting and separating the sort of aosis of her joint. So if you're an orthopedic surgeon, I was describing this to an orthopedic surgeon and stitching skills and things and say, well, we just look after the going for the bone. Well, to be honest, if you don't respect the tissues going in, even as an orthopedic surgeon, you will not get a nice recovery afterwards. The blood itself is very inflammatory. It'll cause pain, it'll cause swelling, which would be immediately uncomfortable for the patient, but it would also stimulate a lot of scarring and that's not what you require. So, gentle dissection actually reduces and prevents blood accumulating in these spaces. And therefore, when you put this all back together in a systematic way that's from the audience. So um someone from the audience asks for the extraction of a fibula free flap. After making a skin incision on the lateral aspect of the leg are those scissors? The only equipment used to separate muscle attachments until the fibular bone is exposed for extraction. Right? I prefer and I like the mcindoe scissors. OK. I find them ergonomically suited to the curve of my wrist. And also because of the blunt tip, I can probe open, take out, probe, open, take out and is served with a curve of my wrist. The thicker version of that is the Mets and scissors. But the same principle, the longer version of the Nelson scissors again, same principle with a curve in the blade. These I think are truly dissection, scissors. The curve may scissors are a shortened version of effectively. These scissors with a stubby short curve. Those are really good for cutting thick tendinous tissue. But they are not useful. To be honest if you're wanting to feel your way through a dissection. Your question about fibula flaps. I am not familiar with fibular flaps. I'm afraid my colleague and fellow Sensei mister Caddy, who's a plastic surgeon would be and he could probably answer your question. Unfortunately, he has an outpatient clinic this afternoon and sends his apologies, he cannot attend. But the thing is that even as a trained as a general surgeon and then swapped to cardiac surgery, the fact that one over time to lots of small operations and certainly in cardiac surgery, dissecting out the Lumb venous vein is a wonderful exercise in tissue plains and accuracy and tying of small veins in blood vessels. All of those give you a feeling and practice to appreciate how to tissues feel. So, what I'm hoping to describe to you this evening as I've progressed, this is how the tissues are feeling as I am progressing this dissection. Now, I do not know the anatomy of the chicken leg, ok. I do not know the enough of the chicken leg. I wouldn't advocate, I start started operating without knowing the anatomy. Suffice to say that I know how to identify veins, arteries, tendons and my exploration of a field. Given enough time. Even if I didn't know the anatomy, I would actually be able to dissect something out and not cut anything important like a nerve because I can see and feel it all the way through and recognize it for what it is. So I wouldn't be blunder about going in at least have a feel of the tissues and informed on how to hold instruments and note that all my instruments are being held with a lightness of touch. My palps of my fingers are being applied and note the forceps, extended D IP joints. And as previously described, I cannot put a lot of pressure and pinch pressure with extended D IP joints and that flexion of the metacarpal pharyngeal joint extension of the D RP of the lumber. So a strap line for the Black Academy and certainly our team who won the surgical skills competition, the lumbrical, we say, what do we love? We love the lumbrical, but the whole essence of dissection, as I said is to gentle purposeful movement, feel the tissue and not be a mere cure of flesh. So I hope you can appreciate that. We've actually gone a long way to dissecting this vein out, right? If you don't mind, um carry on, there's a few questions. So um Nora asks regarding the forceps, the tooth, the non tooth one where and when would you use each? Well, to be honest, Nora, this is tooth forceps here. Ok. They've got ugly teeth at the end. I would not be using that to grab any form of tissue. If I pinching my finger, you can see that's leaving nasty teeth marks in it. The only time I'd actually use that is if I wanted to hold some avascular thick aponeurotic fibrous tissue. But unfortunately, people use tooth forceps on the skin and when they're focusing on stitching, don't realize the amount of pressure as we've shown before. That's akin to 5 million newtons per meter squared. 795 psi serious damage, the teeth are already used. Literally, I haven't closed my forceps there. I'm using it as a reflective tool. I'm not grabbing, it enables me to reflect and because I'm reflecting and there's a little hook on it, it's holding it out the way I suppose the skin hook. There you go. The skin hook is a hook, use a skin hook to retract. Ok. The thing is also with a lot of these retractors and certainly one that I was familiar with open cholecystectomy was the diva retractor, which was a blade basically. And that actually went over and held the liver out the way to enable you to dissect the gallbladder. The diva is a flat piece of metal and the thing is if you actually tilted it, it would slice into the liver. The thing is as the assistant for gallbladder or second assistant, you couldn't see it and holding that retractor, I think must have been, my senior colleagues would agree. One of the most so destroying elements of assisting in surgery because you couldn't see the operation and you're holding this ergometrically nasty handle that was cutting into your hand and on a very large patient required a constant and accurate pressure without actually tilting the diver into it. What amazes me as we talk about this, a lot of this surgery I'm mentioning has now gone laparoscopic but consider this, I look at all these laparoscopic operations and what I see is ripping and tearing and burning and diaphragm. I do not see in laparoscopic operations. I do not see a lovely, to be honest. Rarely see a lovely dissection of a tissue plane that is bloodless. And when I look at afterwards down a laparoscopic operation is something akin to a barbecued piece of macerated meat. And I do wonder sometimes have we actually sacrificed the elegance and movement of surgery for something a little bit more lacking finesse. But what's interesting a company has come out with a needle holder, laparoscopic needle holder that actually picks up the needle and rotates it automatically. It's not on the market yet but beautiful instrument that rotates the needle. I am significantly impressed. Then I was thinking to myself, looking at the dissection of vessels and laparoscopic operations. I wondered whether we should be using endoscopic harmonic scalpels to develop planes for the dissection. So I'm not sure if there's one available. You will tell me because I'm not into laparoscopic surgery. But is there a laparoscopic harmonic scalpel? Because this ripping and tearing that I see. I don't think it's conducive for good healing at all and does not respect anatomical boundaries. Now, there you go. And through the other side, you can see that OK. I'm off center. I'll bring you back in center. I've just come down to the other side. You can see that I can run my scissors underneath. Yeah, you can see my scissors all the way underneath there. There is nothing in there. There is an upper neurosis and I can confidently another question of course, asks how to make an appropriate balance between the dissection and operation time. Well, slow is smooth and smooth is fast. I don't teach speed. What I do teach is economy of movement. So good surgeons when you watch them operating, there's very little in the way of a rush. There's very little in the way of frenetic movement. It is all poetry in motion, quite frankly and smooth surgery is fast surgery because you are tending to detail. The thing is if you go and smooth and deliberately like this, when it and you've tied off all these little branches and you've attended to all of them coming out, it can come out quite quickly because your hemostasis is there. And I think if you do this deliberately going in, go in deliberately, you could come out a lot quicker because you're confident in your hemostasis and you can close a lot quicker as well. I do not teach speed at all. We're not in the business of speed freaks. We're in business of purposeful, deliberate movement. And if you go back to the 10, 9 rules that I described by Miu Masashi is do not do anything useless. Now, as you're operating, they will become natural pauses as you're operating. And those natural pauses are when you put your scissors down and you tend to perhaps a little bit of diathermy and tidying up. So you use your natural pulses, there is another neurovascular bundle down there. Isn't that interesting as we explore the depths? There's another neurovascular bundle down there. Fantastic. So we've really taking this apart, haven't we? So again, on the plane, there's another nerve there. See, and in fact is that a nerve that underneath, you see, shiny, that is a tendon. Ok, shiny tendon. But underneath that there, there's a bit of blood there, it could be a nerve because nerves sometimes actually have a vessel running in them. That is a tendon there. Bit of fat around there. And all this is main telling me now, what I'm looking at here is another extension of that neurovascular bundle. It's another neurovascular bundle. It certainly is. So, what that's there? Yeah, I'll get my hook. Where is it put down to my left? To my right there it goes, I can use my hook here. That's the vein, that's a tendon. Uh, that's the vein there. Ok. And that's underneath that, there's a nerve. All right. So that's the vein, actually, that's the artery and the nerve is in there too. Ok. Again, simply by feeling and by looking. So what I hope to have actually demonstrated to you this evening and talking through good surgery is not fast frenetic surgery far from it. Indeed. Although it was a laparoscopic exercise, they took 10 videos of a laparoscopic operation and they showed them to other surgeons and said, rank these operations and rank them and which ones had complications. This actually reached the front page of the New York Times because then they gave the same videos to a bunch of lay people and said, watch these and tell us which ones had complications. The patients could see economy of time and movement and could see respective tissues. This comes with practice. This comes with feeling your instruments a new deliberately progress through the operation. We've dissected out this whole of this leg in an hour and chatted away. Have I felt rushed? No. Should operative time be of importance and need to rush. Definitely not. If you need to take longer during the operation, it's best done properly. More haste, less speed and with time you'll find that it's a bit like the cardiac cycle. As I've described, the rhythm is always there. The sicle, the action is the same. The difference is the wasted movements and the wasted picking up putting down instruments. There's one surgeon I worked with who was tatting all the way through frenetic surgeon, frenetic. It actually was irritating to watch compared to another where the tissue is parted like the Red Sea and each movement was purposeful. Each break was deliberate, but each time they made a cut, it advanced the operation. Now that is good surgery. Time has got nothing to do with it at all. Thank you very much. Indeed, for your attention. I'd like to answer any other questions. I am conscious that Rio is kindly stepped in this evening and Rio is a final year student at Imperial College and wants to do vascular surgery. I did put pot scissors on the list of instruments for dissection and the pot scissors are small sharp instruments that are only used to open vessels. They're not used for dissection. Wonderful. That's lovely to know. We've got a kind of comment in the chat and I think you kind of answered it recently, but I was just thinking, I'll give it some air time for you to perhaps expand on your answer. So Mohammed has asked, I have a problem in differentiating the layers from each other and they put in brackets here, subcutaneous and dermis during any subcutaneous procedure like lipoma or things like that. OK. Uh Removal of a lipoma, you'll find that the subcutaneous tissues. People are very hesitant, cutting the skin because they don't know how thick the skin is. I cut the chicken skin today with a 22 blade and you see it parted with very little in the way of what appeared to be false. In fact, I was feeling it and I was feeling with the weight of my finger and the weight of my forearm. The thing about skin and skin incisions, people are very worried about one going too deep and they end up scratching the skin and going through each of the seven layers. So my favorite question to a student doing that is perhaps you could look up the seven layers of the skin and describe their function. The subcuticular fat is arranged in two different layers and certainly on the front and the abdomen, there's a little thin fascial layer called SCP fascia that can be approximated. Remember that fat is avascular. So certainly you do not want a continuous over and over stitch which is strangulating in hemostatic. The best thing to do is a horizontal mattress suture in that layer of that. But if you can't identify that I've actually resorted to certainly closing stenotomus. I do not think that over and over multiple layers of continuous sutures and fat are helpful. A few interrupted, single interrupted sutures may be useful. But between the skin and the deeper layers, if there's any more than a centimeter and a half or two centimeters of fat on the sternum, I used to put a ready VC in, I'd leave that for three or four days because the negative pressure would actually hold the edges together, but also any serious fluid would be drained and take it out. It was part of a tissue care bundle that I introduced into my practice in 2009. And my all wound problem. In other words, any problem, what I call anything less than the perfect word I described as a problem. Reduced to zero, a medium of zero, neither nothing. So again, it emphasized attention to detail attention to the attention in your sutures is important. Lipomas themselves actually have a different type of fat. It is more lobular than the surrounding tissue and you get in the right plane and you'll find that it separates and that loose area, the tissue becomes evident and you can almost deliver it in its entirety and squeeze it out. But it's important to recognize that subtle difference in the quality of the fat and the fact there is an loose areolar tissue around but be confident in cutting the skin. So if you look at my knife series, I take you through a whole lot of exercises. They simply get some sandwich meat, put it on a slice of bread. Practice the feel of the scalpel going through one slice of meat and then say, can I cut through two without cutting the third underneath? And when you get to the last slice of meat on the bread, can you cut through that without cutting the bread underneath? Then you are starting to feel the blade. And my favorite instrument to be honest is this is a 22 blade. So just because it's a small piece of leg or a pediatric case, I love this 22 blade one. It is a lovely curve for making a cut. You never actually use the 0.2. Look at that large flat surface for brushing and developing as I showed a tissue plane. So my favorite tool in the box for dissection coming back to the ver to put are these two instruments? The mcindoe scissors and the 22 blade. All the others you're using, even the mosquito. It's interesting. Everybody use the mosquito as well. It is useful. Yes, it's got fine tips. You can use to put in open, take out close. Same principle applies. Any other questions? There is a few more other questions. So Adnan asks doctor, do you think the GS and GS stands for the general surgery board is important in providing skills and surgical methods that may not be gained in direct specialized surgeries like cardiac surgery or orthopedic boards directly? I had a debate with Richard Resnick who is the guru of surgical education from the Canadian College about generalist versus specialist. I trained as a general surgeon and as an sho had done at the end of my 2.5 years, 2700 operations as the first operator, my logbook at the end of my first year registrar would be satisfactory for me to qualify as a breast surgeon, endocrine surgeon, upper gi surgeon, colorectal surgeon and a urologist. I could say those were the days, but they weren't really because my first operating list, I passed my primary for C and the surgeon said you clearly know your anatomy because you've passed your primary fr CS, your list is upstairs and you have a few lumps and bumps and how to do and you got on with it. That was not training. And I like in this training to my training in martial arts and I'm second done and I thought I was pretty good, but actually learning from a sense who's watching my movements, watching how I stand. I'll hold the blade all the time. He's saying too much power, let the instrument do the work. In fact, the sense the other day day demonstrated to us the one inch punch, he had my son wear a, a kind of armor. He said, do you mind if I demonstrate the one inch punch? Now, it's not a bulky chap at all. One inch bang. And he hit, he hit through, but in hitting, he didn't hit with the arm, he moved the movement from his big toe to a twist of the hips and his arm and his fist carried 85 kg of weight behind it in the one inch punch. So the essence is, is technique before power and speed. What we haven't done. And I think I'm trying to change is one of courses and basic surgical skills do not emphasize the technique. They have to be practiced until you can't get them wrong. And the thing is I took my trainees to the wet lab to practice, to reach a certain level of skill before I allow them to operate on a patient. And I think we do not use wet lab enough in our practice. But a simple dissection of a chicken leg translates to me to a herniotomy in a baby. It translates to me in dissection of the femoral canal. All those skills are implicit but it starts how you stand, how you hold the instruments and understanding that is all the lump and the palps of your fingers, there's no force, no force whatsoever. And just like in martial arts, there's no force. There, there is understanding the mechanics. So I think basic surgical skills courses quite frankly, show you what to do. Don't explain why and don't indicate how you can practice the skill in some respects. I on a mission. But I hope that I have stimulated your thinking. What I would love to see is that all prospective surgeons get their own set of instruments and we can practice together. I'm still learning as I am with my sword and that's it. Mastery is not a destination. This is a journey and you continue to lower and refrain your practice. So mindful of R's time. It's quarter past 12 in Kuala Lumpur. Thank you very much for your attention and we look forward to seeing you next week. We had a request to talk about sutures and certainly we will do that and talk about sutures in due course, Ria, thank you very much and thank you, ladies and gentlemen, please fill in the feedback form. It's always valuable and useful.