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Hello, good evening. Good afternoon. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is Dave. I'm a professor in the Medical Education Research and Development Unit in the Faculty of Medicine at the University of Malaya. And the immediate past director, the Faculty of Surgical Trainers or the Royal College of Surgeons of Edinburgh, who accredit our program. If this is your first time joining the Black Part Academy, welcome. And if you're returning, thank you very much. Indeed. We are here to answer your questions. So please put them in the chart ish who is doing the production is on hand to interrupt if there are important questions and I'll answer as we go along, we do have a feedback form and encourage you to fill that in Manish was on call last week. And unfortunately, I didn't know how to put the feedback form in and reminds me as a surgeon without an assistant, you quite frankly, like a fish out of water. This evening. We uh coming to you live from Kuala Lumpur and thanks to metal, we can reach across the globe. We've now had 5000, 179 delegates register in 100 and 39 countries. And this evening, we got 26 countries. Bangladesh Bulgaria, Georgia Giana is the first time they've joined. India is Mauritius Morocco, Sudan, Singapore, Thailand, Tunisia, Uganda, USA UK, UAE Yemen and Zimbabwe. Thank you to medal for the global reach over the weekend five of our censors, Chris Syrus Michael Ali and I went to the Association of Surgeons in training annual general meeting held in Belfast, sponsored by Ray. They had a fabulous time and literally went bananas and over 250 people passed through the doors getting one on one instruction from my sense and how to teach and how to hold instruments. This is fantastic news. And over the next month, I am going to be going to the University of Malacca to teach basic surgical skills suturing and the University of Cyber as well. We're looking forward to establishing face to face here in the Faculty of Medicine at the University. Tonight, we're gonna be talking about how to hold instruments. And I was thinking of the word grip and grip actually implies power, force, control, manipulation. And I'm not sure that I like the word grip as applied to a surgical instrument. Royd Barclay Moni said surgeons must have the heart of a lion in the hands of a lady. He regarded his hands as the controlling servants of his brain. The one element of his story that I'm not too enamored with. He had his hands cast in bronze to me that suggests a degree of ego and that is not becoming in surgery today. But he went on to describe infinite gentleness, scrupulous care, light handling, and purposeful, effective quiet movements which are no more than a caress, all unnecessary if an operation is to be the work of an artist and not merely a cer of flesh. Now, surgical instruments need to be considered an extension of the fingers and it's the application of the fingers and not the grip that will determine whether you can feel the tissues. An interesting paradigm is that much of the purchasing of surgical instruments is outsourced to procurement who source the cheapest interest instruments. Indeed, while I was a director of counting surgery in leeds, the hospital refused to buy fine instruments for my two newly appointed consultants, Betsy and Kiana. We wrote a paper saying that this was a bit like asking Rory mcilroy to use Tiger Woods as clubs. When you're dealing with instruments as such fidelity. It is important. There is a degree of familiarity with that and I do think it is the surgeon's right to choose fine instruments in those circumstances. Think of it. It's only a two millimeter vessel. No touch is fundamental to who we are and everything we do. And the latest research is coming out by Gentian Loeffler who professors in neurobiology at Harvard Medical School. Touch is so integral to our lives. It's hard to imagine existing without it in part because when touch works as it should, it fades into the background, providing a steady stream of crucial information with without us constantly attending to it. But there's a tremendous amount about it that we don't understand and as describes as we entering a touch renaissance. And that is probably because we are looking at robotics and haptics in more detail. But there's a lot more that's going on behind the scenes and is much more than conscious perception. Most people don't think about touch until something is wrong with it. It's something we take for granted because when we shut it off, we can't feel anything and we injure ourselves, but we can't shut it off. So we don't really know what it's like not to have it even before we were born. One of my most important senses is touch, which is the first to develop within eight weeks in pregnancy. And it allows us to detect and process tactile information from outside as well as inside the body. And researchers are intrigued by the biological mystery of touch on a molecular level and cellular level. And they recognize the significance of their findings for illuminating brain development and developing treatments for touch, dysfunction. So what is touch and what is feel? Well, most of us intuitively understand touch is the way we experience the world with our skin. But scientific definition is more specific and more expensive touch is a process by which specialized neurons send tactile information from the skin and other organs and convey this information to the brain where it's perceived as sensations such as pressure, temperature, vibration and pain. So there's somatic sensation referring to the system of sensory neurons in the skin that allow us to organize and navigate our surroundings. And these are remarkably precise, helping us distinguish from cotton to fine bits of sort between our fingernails to feel cold glass or hot mug, detect us like breeze, agentic, blowing of your hand. Very importantly, they it we have got the ability to take away all the irrelevant cues. So we're not constantly aware of our background sensations, but we know we are wearing clothes and we know we walking through the environment. So the Harvard Medical School researchers are studying both the somatic and visceral sensation and they have similarities and differences, but both systems are integrated and essential for survival. For example, people with autism are overly sensitive to certain types of patch on the skin and may experience pain or discomfort of the gastrointestinal tract and exaggerated visceral sensations. So the the body brain relationship is quite profound and the communication between the two is very important. And this is part of what Gin's group is looking at. But understanding touch as well is critical for understanding how the brain develops and how animals including humans produce complex behaviors and social interactions. They looked at research of Children brought up in orphanages in Romania where the Children sadly, light touch and measuring touch and they scored lower IQ lower language skills and they had higher rates of autism, psychiatric disorders, anxiety, attention deficit disorders and hyperactivity. So historically, everybody has been fascinated by vision and hearing but.