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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 Regan. I'm a retired cardiac surgeon and now a professor in the Medical Education Research and Development Unit of the Univ in the Faculty of Medicine at the University of Malaya. We are coming to you live from Kuala Lumpur on the 21st floor. And as I look out at the Patronus Towers, they are decorated in red, white and blue of the Malaysian flag as today is the National Malaysian Day. Thanks to med, all we are able to reach you across the planet. We have 66 registrants this evening from 19 countries including Bangladesh, Ghana, Libya Maldives, Sri Lanka, Uganda, United Arab Emirates and the UK. It's all possible. I have a feno in Sheffield in the UK with us this evening and Gabriel is in Lithuania. Thank you very much to me. What was interesting yesterday in my IO session and weapons training at the Japan Club in Kuala Lumpur. They had a sense coming in from Japan to teach us your seven done in 58. He watched the class, all of us including absolute beginners like me and the third dance in the class. Then he took center stage and made some observations. What was really fascinating is that he deconstructed all the actions with a joke into how you hold it and its lightness of touch. And they keep, as they keep telling me, do not put strength and power in it just use the weight, the full CRS and the ergonomics generated by the job, which is a 1.5 m stick. It's actually more effective than a katana in the right hands. As demonstrated by the si it was quite obvious when he picked it up that he had practiced for 40 years and was a master and a worthy sensor. He talked about lightness of touch. He talked about posture position and that one needs to actually move without moving the head and describe the turns on the ball of the foot and on the heel of the foot accordingly. And with that, he went on to describe how these basic elements of posture and lightness of touch dictate how you use the Joe. One interesting thing I noted is that in some of the characters, you bun the Joe on your hand. And he said you gotta b it on the proximal phalanx of these two fingers. And I noticed my ring actually got in the way I'll take it off next time because by putting the staff in that position, my thumb can easily go under and over the staff, which I had not appreciated before. It's that sort of nuance in description that makes the difference between a master and a beginner. But above all, it's attention to the basics and that's why I firmly believe that we should be teaching surgery along the principles of Mars and Mars. And it's all about how you stand and how you, you hold your instruments. This evening, we're gonna be talking about the forceps and the origin of the word forceps is from, er, which is the Latin word to grip or grab. Now, I don't want you to grip or grab. And forceps are shown in many ancient documents going back to Egyptian times when they were used to debride wounds and take dirt and stones out of wounds. The Greeks and the Romans also used forceps for various surgical procedures and was during the middle ages that forceps were invented to actually help deliver babies. Forceps actually were used as destructive tools rather than constructive tools because there is little concern for the baby and many were still burn during the middle ages. The mechanical assistance for birth was used by the barber surgeons and sometimes the ladies from the kitchen, the design of forceps continued to evolve and significantly advanced during the renaissance in the Italian position. Insurgent Giovanni Tito Cortezi actually developed the model obstetric forceps, but for the surgical forceps, it wasn't until the 18th 19th century with improvement in metallurgy and manufacturing. Did we see the advances of the modern forceps? And they are countless types of forceps. I've got a handful here. Different lengths, different sizes, different functions, depending on the tissues, the vessels or the structures on which they are used. And I'd like to thank you all for naming correctly. Many of them, they're tissue grasping forceps and the basic one on the absence tooth forceps made by a neurosurgeon. And there's a little tooth at the end, I can get my nail and that little rat tooth and the opposite side is a single tooth that interdigitate that for holding tissues se was used for plastic surgery in dermatology procedures. But as I'll demonstrate, they're not without significant damage. And our fellows and say, Chris cry with us this evening would say that you u should use a skin hawk instead of forceps. So is Adson and Brown Adson forceps. They're also dressing forceps, very versatile instruments with fine tips and non serrated jaws used for holding and placing dressings and other small procedures. Splinter forceps sharp for pulling out splinters. Then you get into the organ grabbing forceps, the babcock forceps with smooth blunt edges that hold tissues in atraumatic jaws spanning for forceps. The Rochester pain forceps, a robust s serrated design and locking mechanism for clamping and including blood vessels. What's interesting looking at forceps? Many of these hemostats I actually described as forceps as well are not typically on a spring, there are forceps, tenaculum forceps with a hooked point, particularly used in obstetrics and gynecology and for grasping the cervix Kelly Forceps, a pioneering gynecologist and founding professor of Johns Hopkins. I mentioned the mosquito forceps, which is not really a forceps made by August beer. Then you've got all sorts of forceps named by famous surgeons Gillie, small tooth forceps, a reconstructive surgeon from World War One based at Saint George's in London. He actually in, was introduced to sir Archibald Mackinder who joined him as a junior and he was a Mack Forceps and he's the father of plastic surgery at East Grinstead and help pilot in World War Two. There's who William Lane, an English baronet who mastered ent orthopedic and abdominal surgery while working at guy's hospital, William Ba general surgeon. Then Iu Cocker, a famous Swiss physician and medical researcher who received a Nobel Prize from physiology in 1909 for his work on the thyroid gland and his forceps are strong forceps that play his name and reflect his contributions to surgery, particularly in trauma and orthopedics. And then of course, there's my favorite. These, these are DeBakey Forceps after the the Lebanese American surgeon who worked at Baylor University and died at the age of 100. In 2008. He gained 36 honorary degrees and awards, received the Presidential Medal of Freedom in 1969. And President Ronald Reagan awarded him the National medal of science. You see all these famous surgeons have come up and put their names to particular instruments. It was actually to Bake Junior Cosgrove who made a modification to his forceps and instead of having two parallel lines of fine teeth, Cosgrove apparently had three, there was a lot of rivalry there. Now, the important thing about forceps is you need to hold them properly. We don't want to see them held like solid servers. We don't want to see an overhand grip either and we don't want to see a pan grip. The reason why forceps are an extension of the fingers and need to be thought of an extension of the fingers is exactly that you need to be able to feel the tissues. So when I asked you about the extension flexion of the fingers, you answered correctly. The flexion of the D IP joints like that include flexor digitorum, profundus and flexor pollicis Longus. These are in the deep or third compartment of the forearm and they are the Popeye muscles. They are extremely strong. They are the muscles that Tom Cruise uses to hang off cliffs in mission impossible. And I want you to do something for me in a moment. I would like you to just pinch yourself like that. Take a pinch and pinch as hard as you can, ok, hard as you can. And in fact, you can't pinch really, really hard because it ends up painful. You can generate between 25 and 35 newtons of pinch pressure by doing that. That's the force. Now, by contrast, I want you to extend the D IP joint and with the extended thumb and extended finger, I'd like you to pinch yourself again and try really hard. What's interesting is that with the D IP joint extended, no matter how hard you try, you cannot pinch yourself hard. The other important thing is with the D IP joint extended, you now can bring the pulp of the fingers together. So imagine that you're sprinkling a little bit of salt on your food. And that is the action that you require the pulp of the finger. So let me take you over and just demonstrate how to hold forceps and why it is actually problematic f it incorrectly. So the forceps should be held cradled in the first dose of sis balance on the middle finger and you fold your index finger and your thumb around the shaft. That that is the action that you require the maximum field. The thing is I did this earlier. This is a result of grabbing. OK. So the forceps are not grabbing as in the Latin description and using the skin hook, I'll demonstrate here. This is the Aden's tooth forceps. You can see the little rats teeth on both sides. I'll focus down again because this is very important to appreciate the little rats teeth, the A forceps and even this is a noncrossing forceps the side. Ok. But the important thing to note is that if you actually look at the thickness of this banana, you have got a full thickness, full thickness, squeeze of this banana both sides. So imagine if that was bowel and there are papers that have demonstrated mucosal damage or vessels, endothelium and adventitia damage, full thickness squeeze. The thing is with forceps, when you're concentrating with your right hand, the non dominant hand that often is holding the forceps, they're doing two things is grabbing, squeezing and dragging. And that is what causes the damage because there are simple physics involved here. If you say pressure equals force of the area, I've got here 25 newtons over approximately five millimeters squared, which is 25 newtons over five times 10 to the 6 m squared, which equates therefore to 5 million newtons per meter squared. And that is 725 psi and if you think that the pressure of a car tire is between 3035 psi there you have it. That is the amount of damage that you are doing. So the forcep is a dangerous instrument. And another thing you can do. And I don't have my needle holders with me today because they at work as I was demonstrating, stitching is when you're doing stitching and at the advanced level, simply take some staples and put them in the banana. And when you're stitching, hold your forceps and hold the staple. So stitch and hold the staple. I don't want that staple pulled out or removed. And that combining the stitching in combining, holding the staple will separate the action of the right hand and the left hand. But don't do that until you've mastered the basics. Yeah. So accuracy and precision is of fundamental importance and to achieve accuracy and precision, there are a number of different things that you can use at home to practice. So what I've mounted here on a plate or cut straws, different heights, different colors, funnily enough. I couldn't find any bendy straws but doesn't matter. Put straws on a plate and then take various things that you can find in the kitchen I have here some rice and the idea is to pick up some rice one grain at a time. And you see that the grain of rice is in fact longer than the diameter of the straw. So now you've got a problem. You have to move your wrist and drop it in. We have this competition at our roadshows. You were given eight grains of rice, four straws and you need to put all eight grains in the straws and you drop it and the clock stops. What was interesting is I think it got down to 15.3 seconds, 43 seconds, the winner at the last competition. Once you're adapt to doing that, get a second pair of forceps and put it in your hand. And now you can practice right and left hand too. I've just dropped two grains of rice and remember we practice until we can't get it wrong. You can convert these into self assessment exercises and when our app comes out, this will be one of them and you can track your time for eight grains of rice. Anything in everything of different size can be used here. I've got some lentil seeds again, different shape, different size and difficult to pick up. And if you start grabbing them, they start flying off around the table, you can set yourself a timer enteral, put together a very good metronome increasing speed, which is on the website that will test your skills going faster and faster. Not that we teach speed, we teach accuracy much like they do in the martial arts class. No point going fast if your technique is bad and a good solid technique will result and a more effective blue than trying to do it fast, choose different seeds. And here in this part, I've got the number of different seeds. I will actually love mustard coriander, pepper and fennel seeds again. Pick them up one by one and drop them in respect of straws. Some of them are too big for smaller straws as a nut case and therefore I can pick it up. Can I put it in that? Oh If I turn it around, I might be able to get that in all these exercises are simply testing your ability and accuracy to pick up a per of forceps that's not gonna go on that one went in there. The mustard seeds are the most difficult as you can see, they're round and they end up, they skidding across the plate, do this one hand at a time until you're proficient and then try doing it with both hands to make it fun. Practice with a colleague who can call out right hand pepper, left hand mustard seed and even call out which straw to actually drop the article in and not like you to let us know what fun games you have come up with two describe or practice no skills. This is some candy, sugar candy of different sizes and lengths. What is fun about? This is actually it is softer and if you grab it, you can see it's crushing and sticking to my forcep. So I can't afford to grab it too difficult, too hard. Otherwise it's going to stick and interfere. The same principle applies. Again, you can call out different colors and put them in different draws. All of these exercises are helping you improve your accuracy and precision in picking up. Remember all I'm doing is using my lumbrical, my extended fingers and picking up the seeds. If I'm too harsh, they go running off. Now we're gonna start operating at depth. This is a pepper cut in half and inside. You've got all these seeds and you can pick them off one by one from the inside and again, dropped them in holes. Your seeds can either be put on a dish on a smooth surface or nature's provided an excellent picking model in the form of this mapper. And as I said before, with these models, it is rather fun practicing with him. And I personally find myself getting totally absorbed in the process and that's the advantage of forceps. They can reach into cavities to pick things up and hold. Remember, the forceps are never to be used to deliver a needle of covered stitching. And the past couple of months, the needle will go through the tissue and the tissue will hold it in the right plane to enable you to pick it up with a needle holder. Very rarely are forceps required to manipulate a needle. And I often look at stitching examples online and everybody or a lot of people appear to be putting a needle through, catching a root of forceps and turning the needle from forehand to backhand with the forceps. I believe that that actually totally distorts the rotation of the needle. And as previously described causes tissue damage. So lots of different ways of practicing. The next most important function is to be able to peel off tissues. I've, the easy one to use is a tomato. This has been put in boiling water. And my job now is to carefully lift and remove the skin of this tomato and out cutting without stabbing a flesh, sometimes a little bit of teasing along the edge, the blunt edge on the forceps can actually help separate the naz we have a question. Does the tooth at forceps provide greater tissue crush versus non toothed? And when would you use tooth at forceps? Well, that is a very good question. And the answer to that is both the non tooth forceps and the tooth forceps cause damage. As I've pointed out on the banana Chris Lincoln as a cardiac surgeon at the Brompton and one of my trainers, he used tooth forceps for doing com stitching. Now they were fine and had teeth and if you did not handle them properly, they could punch a little hole in the vessel, but he had such delicate hands. He used them and used that to laterally hold and the tooth meant it didn't slip out, but he was confident using it because he wasn't actually squeezing the tissue. So both cause damage I think is perhaps is preference. And we'll ask Mr Caddy in a moment when he comes in as a microsurgeon microsurgical instruments, likewise of different sizes and shapes and also have teeth, non tooth, vertical row of teeth and others have a horizontal row of teeth, all of them can do damage. Notwithstanding the fact that they can stab and penetrate tissues very easily. So what I have here and I'd like to thank a delegate from is watching off the disc model or boiling a potato. And can you actually take this fine layer of potato skin off without tearing it? I end up getting quiet because I find myself concentrating. I am feeling. But you can see how thin I'll focus down on that. You can see how thin that potato skin is an excellent model for really refining your skills, very thin that not too dissimilar to some of the tissues that you will come across in surgery. If you're too rough, you start peeling the potato off. You can see I've got some potato there already. There you go. It gives you immediate feedback because to get it wrong, you can see, I've got potato on the end of my forceps there. I've got a little bit of potato on the end of my forceps and the idea is you gotta do it without much potato. So I'll just give that a wipe off. Let's try this side. That's interesting. You see now that's much better. But again, in the beginning, I got some potato off. Can you actually pick off these thin layers without damaging the tissue? This is, it all depends on how much cooking you've done. So you do, you can make it easy. You do well cooked and you can see that is well cooked, um, as well cooked and that is just perfect. The well cooked one has started to split already and I'm in the wrong layer, the feedback is potato on your forceps. So there you have it. That is simple exercises that you can do at home to practice your full set of skills. And at this juncture, I would like to ask my fellow if you'd like to join us and he can make some observations and we can chat about microsurgery and the use of forceps as well. Thank you very much Chris. So when you're doing microsurgery, we tend to use jewelers forceps. Um, um And so once again, if, if, if those who are watching this can go to jewelers and ask for a set of jewelers forceps, you can see how fine the tips are and you do very little damage with them. All of this comes down to developing a feeling between the pulps of your thumb and your index finger for the tissues you're holding up and the tips of the instruments, the Anson's tooth forceps have got teeth on them which are used to lift up the tissues. The other ones tend to grab and crush the tissues. And so you will injure the tissue simply by touching it. That's, that's why we tend to use the, the skin hook in order to move skin edges around. Um, the other thing that was interesting watching you was the way that you hold your forceps. But if you look at how other people use them, they treat them as tweezers for removing eyebrows and the completely different handling of it. And if you look at photographs of people operating, you will see that they're holding the instruments wrongly. Um So those who follow the Black Belt Academy of Surgical skills will be able to look at somebody holding their forceps and instantly ascertain as to how well trained they've been. Um Because you'll see David's using them very specifically, that comes back to exactly what I said about our lesson at the Japan Club yesterday. Is that the sense looked at the basics and look at the way we were holding it even down to whether our thumb was over the end of the stick or not. And the lightness of touch was interesting. Apparently with e io that the sense can tell how good you are with the very first move. And if you get the very first move wrong, it's highly unlikely you'll pass even if the rest of your car and presentation is good. But I think if you go back to, uh, surgical exams, you can usually tell within the 1st 30 seconds as to whether or not the candidate is going to pass by the way they hold themselves and present themselves. But this is actually in theater, in the way you hold your instruments. Absolutely. And, and the way you hold yourself and the way you hold the instruments is indicative of the way you're going to handle the tissues before you even start. And to my mind, we have basic surgical skills courses run around the globe that are not addressing how you actually hold the instruments. And what's interesting is that on the O SAT scores, they do talk about flow or modicum and they do do talk about tissue handling but correct me if I'm wrong, I have not come across any course that focuses on how you actually hold the instrument before you start and how you actually stand. That's where the problems start. And that's what you need to address and think about before you start operating, get those things right and practice that it will translate into a smoother, gentler rhythm and motion, just like our self then sense. He said he was effortless in what he did. But his understanding of motion, body mechanics, how to hold, how to position yourself. And the thing is it's individual, it depends on body type. So in many respects, you've got to feel it as well and that's why we haven't actually prescribed exactly what you would have to do because it would be different for each of you because you are different size, different width, different shape, different height. What we're trying to point out are the very fundamentals, lightness of touch, practice these basics on a regular basis and you two in due course, will end up like our master Zenz seventh time, whether they're big instruments, long instruments, fine instruments or forceps do the same thing. What's interesting about the forceps is they expected to be used in the right hand. And the left hand by the assistant, a surgeon, a scrub nurse and almost anybody on the ward doing dressings in tissues changes. The other element of the forceps is to use it as a fob. Now, the fob is used for sign writing. And if you have a tremor entering the operative field and you find that your dominant hand has got a bit tremor and you're a bit nervous. Hold the forceps out as a fob, the fob is a wooden stick with a leather ball on the end that was used by signwriter to hold against the sign as the brush worked over the top and holding the forceps like that, you can rest your scissors on the forceps and accurately cut and then withdraw both that is lost and final use of your forceps. I'm not sure Mr Khadi. Can you think of any other uses of forceps that we haven't covered this evening? I, I'm sure there are some but they don't spring to mind at the moment. So if anybody's got any ideas do let us know, I'd also be very keen to hear your ideas on what you've used to practice your pick up and tissue separation skills. I've used somebody's got here um in the chat room. If you could put any of those ideas down, that would be most helpful as you know, we did advertise for in a global competition to find out the most innovative and creative practicing and models. And we asked for photographs and a short description. So I'm gonna ask our producer Gabrielle to join us and she will tell us, oh, Forceps with Cautery. Very good. That was the other one, neurosurgery. Very good Forceps with Cautery and bipolar Forceps for accurate hemostasis. So, thank you very much. No, I had had that on the list and I had forgotten that and thanks for reminding us, welcome, Gabrielle Gabrielle is a medical student in Lithuania, qualified lawyer and also a very talented photographer. She's been looking at your pictures and I have as well and Gabrielle is going to announce our three winners. Yes, and I will actually show the pictures as well so that you can see what we're talking about. Um So he the he here are the winners. Um As you can see, we have um a wooden workstation with various different um tools that can be easily find at any household. Like I think that's a soap and a sponge. Uh Then we have a plastic glove filled with water which can be used for tying and uh it's got exactly what we're looking for. So, something that is easy. Um And that gives us immediate feedback because if we don't tie it properly, then the water will leak. Um And then the last one you can see is a pen with a tooth floss. So again, something that can be easily used anywhere to practice your tying skills. I think they're very innovative, simple and covering a number of different aspects. I particularly like the pen and the dental floss when I was teaching not time to students. The other day, we asked them once they appreciated how to tie knots. And we'll address this next week to tie knot on a pad padlock and then reduce the weight down to an aluminum can and something lighter. I like the pen in particular is can you tie a knot on that pen without the pen leaving the table or moving? We were using metal objects the other day on a table and there was an audible sound as they scraped along the table if they moved again, very useful feedback on a a not tying station. And we hope to demonstrate that to you next week. Thank you very much. Indeed for joining the Black Belt Academy. Please send us your ideas and thoughts and we will run another competition in due course to explore your ideas and thoughts. Thank you very much indeed, wherever you are in the world and we'll say good evening, good afternoon or good day. Thank you very much Gabrielle for being on the adjudication panel. And thank you very much Mr Catty for your insights as well. Thank you to, to metal for enabling us to connect across the globe.