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Hello, good evening. Good afternoon. Good morning. 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 past director of the Faculty of Surgical Trainers for the Royal College of Surgeons in Edinburgh, and a visiting professor at Imperial College, London. I'd like to thank me and Gabrielle in particular who is behind the scenes on production and filtering your questions and posing questions as well. This would not be possible without metal to enable 60 registrations from 25 countries from Belize, Bosnia, Herzegovina, Uganda and Zambia. Thank you very, very much. Indeed. This is your first time. Welcome. And if it's your returning, thank you and thank you to the 4241 Facebook followers, 700 on Instagram and 1241 on Twitter. I'm delighted to report that the Black Bell Academy will be at the asset annual General meeting in Bournemouth on the ninth and 10th and our senses, Alice, Ice and Alex all have had posters accepted for this. I am delighted later on, I am going to be doing an online delivery of Black Belt Academy of Surgical Skills with our newest Sense. Do Luis Cabrera in Ecuador, two between 50 100 medical students. Thank you. So the question I posed this evening to you is can you name the most famous hands Gabrielle? Do we have any answers to the most famous hands and art at the moment? Looks like people are. So while you're thinking, uh we have also asked you to have some instruments at hand and if you don't have any instruments, go to the cutlery drawer, get a knife, a fork and a spoon and all will become clear. I suppose the most famous hands for me appeared in the Renaissance era. Most celebrated in particular are those depicted by Michelangelo in the ceiling of the Sistine chapel painted between 1508 and 1512. And this was God giving life to Adam. His other important hand was in the statue of David as in David and Goliath. He is holding an imaginary stone in his right hand and a sling over his left shoulder and has a focused expression. This is a 14 for pure marble statue and people came from far and wide to look at it particularly marvel at the hand because it had the veins clearly demarcated on the dorsum of the hand. And it was probably the first of its kind at the time, people also said the head and the hand were out of proportion. And the immense right hand was reference to David's nickname Manu Fortis, meaning strength of hand or strong hand. Another interpretation of this is suggests that the artist wanted to focus on the expression and the empty hand to emphasize the role of intelligence in strategy in defeating Goliath. The other important hand was much at the same time by Leonardo Da Vinci and he was known for depicting beautiful anatomical pictures of his own hands. But there are another set of hands in another famous piece of art. And that is the Mona Lisa. She is famous for her enigmatic smile, but her poise of the right hand over the left suggests a virtue and modesty. Some people have have said that the lack of the veins or any demarcation of the hands suggests perhaps some edema and maybe evidence of pregnancy. The hands are more than just pre tools and have entered oh way of communicating. We all know what that is hippie movement and peace but was first there with Churchill with his two fingers for victory. Whether that is because that's how he held a cigar. I don't know. We also know a wave of greeting the master showing respect and of course thumbs up that is friendship and respect and probably a modern interpretation of gesticulation. Fist bump is respect and it comes with a whole lot of floss as well. But how many of you recognize this? Can anybody name this waiting to see that was used by Spock in Star Trek, live long and prosper. So the hand is vitally important in everything we do. Last week, we focused on posture and you correctly named the 17 muscles that support the scapula and move it. But your arm posture is your shoulders, let them drop by the side and your elbows by the side with them partially extended. Now, if you look at David's hand and the Sistine Chapel, it, they're palmi fex like that. And that palmi fex is the relaxed state of the hand. When you want to grip, actually, you extend the hand by extending the hand, you bring in to use the most important muscles of the forearm and they are, this is the radius. This is the owner in the deepest compartment of the forearm on the lateral border of the owner, the anterior surface and the interosseous membrane. You have the flexor digitorum profundus and the flexor digitorum profundus passes underneath the flexor retinaculum and extends all the way deep to the flexor digitorum superficialis, splitting that to insert into the base of the distal phalanx. And it, it does that the other muscle deep in the forearm, the flexor poly longus does the same and inserts into the thumb and that get the grip and the grip. You see, it reminds me of those people who climb rocks and wall faces and it can support the weight of your body on that grip and it forms the bulk of the muscle, the Popeye muscle of the forearm. See it yourself as you're making a grip and look at your forearm. These are powerful muscles and really and truly should not be used in surgery whatsoever. The hand pronate in supernate with the radius, folding over the ulnar and the most can anybody name the most powerful pronator of the upper limb? I'm waiting for your replies. Anybody, if I hold a screwdriver, does that help you? Well, actually the most powerful pronator of the upper limb happens to be the biceps. And that is why or your screws are designed to go in anticlockwise to tighten as you no clockwise, to tighten as it's a supernate action, you tighten, tightening the screw will come back to that axis of rotation and use. But we're not going to be using the biceps in that what we want to be using in surgery are the intrinsic muscles of the hand. Does anybody know how many bones there are in the hand? How many bones in the hand? 24 and it is a network of intrinsic muscles, tendons and 24 bones. The muscles that we are interested in are the four lumbricals. They come off the radial side of the flexor digitorum profundus and they extend across the finger to insert into the extensor retinaculum of the terminal phalanx. And that is important because when combined with this muscle here, the opponent's policies arising from the flexor retinaculum and inserting into the lateral border of the first metacarpal produces opponents action and which is unique two humans. And that is because the carpal metacarpal joint between the first phalanx and the trapezium is special. It's saddle shaped, it's shallow and there's a beveling and sloping anteriorly because the movement is a flexion and abduction and then a rotation of that thumb. And that is why disease of that and pathology or fractures in that area is particularly debilitating because the thumb cannot be brought across to the fingers. Now, I want you to, oh, just imagine you're putting a pinch of salt together. OK? I want you to rub your fingers together as a feel. All right. And that's exactly what your lumbrical do. They extend the D IP joints, they flex the carpal phalangeal joint and with the opponent's policies, bring the palps of your fingers together. And that is where you've got the highest concentration of Merkel cells and my not corpuscles that give you the sensation and feel of an instrument. I want you to do something for me, squeeze your fingers together like that and squeeze your fingers together with an extended D IP joint. And if I hold them up to the camera, you can see that this pinch here is blanching my fingernail and I can see the blanching through the glove when I'm looking at trainees holding instruments. Whereas that movement as much as I try and squeeze my fingers together, my thumb and index finger together. I am not going to get any blanching at all. But then also if you look at the surface area of the my left hand with the thumb and index finger opposed, that's probably one centimeter squared. And you can see my finger blanching on the other side, the palps of my fingers together as if you're massaging some salt into your cooking, you have probably got three times the surface area there. So if you think of pressure equals force over the surface area, the surface area there is less. But more importantly, you have now brought the palps of your fingers together. So instruments are designed ergonomically and should be considered an extension of your fingers. And I was pleased with a lot of the answers that you gave to the questions. However, all instruments must be maintained and must be oiled. And when I visited the B born factory in Penang Island in Kuala Lumpur, my test was telling me the instruments needed to be oiled in my 23 years of consultant practice and even walking the sterilization process. I'd never seen the instruments being oiled. By the way, all the instruments were stacked into trees and we did a similar study. There were all the only 30% of the instruments used during the operation. 70% were not used adding to the weight and the burden are sterilizing as well because all instruments have to be sterilized. But the sterilization process and the handling, particularly in the washing can cause damage. So there's a move particularly by ba bra to actually isolate instruments into individual trees specifically for purpose. All instruments have a shelf life. They're all potentially dangerous. I do remember a side biting clamp that was not meeting, identified this before putting it on the aorta and the scrub nurse said, give it to me. I'll make sure we destroy it. I said yes, but I've seen this before. I'm clamping it to my gown and we'll deal with it after the operation. The operation went well and we went to the theater sterilization unit with this broken instrument to point it out. It was beyond repair. And I said, yes, give it back. I said, no, this needs to be destroyed. And I put it on the floor and I jumped on it. Did I get into trouble for doing that? But at least it prevented the instrument coming back on the train and 40 instruments, where is one alignment like that? It is particularly dangerous. You can imagine an instrument mellow lined like that put across the aorta is like a great white shark, taking a bite out. The other thing is they conduct electricity and we're all in the habit of holding something with the forceps. Could you touch the forceps and you get a burn because you have identified a hole in your glove. Like many of you, surgical training has not reinforced how to hold the instruments. And the reason for this evening's presentation is because you asked, could we consolidate how to hold the instrument? And I reflect when I was growing up sitting at the table and being told off for holding my knife fork and spoon incorrectly. Of course, setting a table nowadays with people eating off their lap in front of the television is usually reserved for fine dining restaurants with a soup spoon, butter knife, fork and a smaller fork, dessert spoon and fork. At the top, we were told to hold the knife like a knife, put the handle into the palm of your hand and extend your finger down the shaft to cut. Obviously, you had to hold, it was a fork and the fork likewise was held in the palm of the hand with the indi finger down, the fork, held it the knife cut and the knife cut at 90 degrees. We are also told of if we had our elbows on the table when we ate the spoon, well, the fork should really always be held in the hand and you're permitted to swap it according to the breaths to your right hand and hold it if you got food that does not require any cutting. But when I look around in restaurants, the way people hold forks and hold the instruments and hold the knife like the pen, it's quite astonishing and it reminds me that I was picked up on this mm the time at the meal table at home. But we as surgeons are not picking up our trainees on poor habits of holding instruments. And I will run through the knife, fork and spoon foyer. We will take the knife. First of all, this is made by Swan Morton and the knife and the blade has a patented marking to enable you to hold it. But like holding the knife at the table to eat this knife likewise should be held in the palm and between the thumb, the side of the middle finger with the index finger extended down. This gives you the opportunity to ensure that the blade is perpendicular to what you're cutting because the sagittal plane is maintained between your thumb and your middle finger and the pressure is controlled with the index finger down. Now, the cutting part of the blade is, in fact, I'm just looking for my forceps is in fact, the curve of the blade and not the point and the curve of the blade is at 45 degrees to the tissues. Now I'm gonna zoom in even further because there's another important part of this making of the blade that you perhaps will not realize and are gonna move around. All right, and then move it around and then turn it over and move the other side as well. Now, if you look carefully and I'll try and focus down even further on this side, you see the cut edge is actually on close inspection, got a whole lot of grooves on it. It is not smooth and shiny compared to the other side, which hasn't got any of that. And that cut edge is very smooth and very shiny. And in making these blades, they do that deliberately because if both sides were shiny, it'll be incredibly sharp and you would not be able to feel the blade or feel the tissues. Now, the other important thing about the blade in holding it and we'll just look at it in the sad plane and you can see the shadow change if I'm not perfectly perpendicular to the tissue and you need to be perpendicular to the tissue. Otherwise you'll be bacon slicing. So that becomes difficult if you consider making a long incision because you can draw a straight line. But actually, as soon as I go beyond 10 centimeters, there's a propensity to turn on your hip and rotate and you end up with this calve to avoid that. It's important to continue with an abduction of the shoulder. Remember we'll talk about the knife and use of the knife next week but never align your incision to the drapes. Always align that to bony landmarks. No matter how thin or fat a patient is, you will find the bony landmarks are the most reliable. So the forceps, the forceps, if you pinch it like that is going to generate something like 5 million newtons per meter squared of pressure at the tip, damaging the tissues as you have seen before using the banana. So balance the forceps and cradle them on the first interosseus and fold your fingers over the barrel to give you that this can work in any position. But what you've got is control and lightness, a touch in every direction. The same applies, putting it in your left hand and see how that lumbrical is extending the D RP joint, flexing the phalangeal metacarpal joint and enabling you to hold the forceps and a bit like the knife and fork. This is the fork, it is holding, retracting, stabilizing our next instrument we're going to come across, this is going to be the scissors. Now, the scissors and these are mcindoe scissors and we've discussed mcindoe and the history of mcindoe and on the website, we've got a list of all the instruments and the names applied to them. Now, sadly, a lot of these instruments were designed ages ago, predominantly by men with larger hands. And one of the problems with much of the surgical instruments is that we have one size. More importantly, most of them or all of them are right handed. And Robin who's the secretary for the Royal College of Surgeons of Edinburgh is left handed and he noted very early on in his career, the absence of left-handed instruments and therefore taught himself to operate with the right hand and ended up being a master surgeon with equally proficient right hand and left hand. And Chris from New York contacted me for advice and he too is left handed and will come talk about that again in a moment. But this instrument is with a curve and should always be held with a curve of the wrist because the action is like a gathering action. The other important thing held in this position, I can see the belly and I can see the tip. I've always put it on my ring finger, thumb, middle finger with the index finger extended down. And you'll notice this tripod of stability. The important thing is is that the palps of my fingers are applied to the instrument with lightness of touch and pick up a fork or a spoon and feel the difference between gripping it and holding it lightly. You have a lot more maneuverability and a lot more precision with the lightness of touch. Some people would say in holding an instrument should be like holding a tube of toothpaste without the cap on. Because if you start squeezing the toothpaste actually leaves the tube stable accurate and enables you to move and cut. The inverse is similar again, the palps of the fingers, a flight and my fifth finger is extended down the scissors and now enables me to operate down a hole. And I can see the end and I can rotate the wrist and extend the wrist and operate down a hole. But note that I again got extension on my fingers and I'm using the intrinsic muscles of my hand. Scissors are again right handed and it is difficult to use scissors, righthanded scissors in the left hand. And thirdly for cutting suit shits, I would PM the scissor like this and I could cut the suture as if I was cutting it with the right hand, but I haven't got a finger extended down the instrument and therefore it loses stability. The thing about these rings, they do come in standard sizes. So with big fingers, I can't get my D IP joint through, but you shouldn't either no matter what the size of your hand cos as soon as it goes through the D IP joint, you've not got the instrument in contact with the palp of your finger, but it also makes it difficult to pick up and put down. And in fact, if anybody should grab it, you could run the risk of a gloving injury. So if you've got a small hand, I suggest that you apply your fingers obliquely across the rings to maximize the palp of your finger with the ring of the instrument. And that is true with all instruments including hemostats. I have not got the D IP joint through and I'm feeling it and the position I'm holding it is not too dissimilar to the position I've adopted to hold the scissors. The left hand is different because I need to be able to take a hemostat off and you need to be able to unlock it and hold and separate. But I've lost that stability cos I haven't got a finger down the instrument compared to that side, but I can take these off with my left hand and when assisting, it is useful to be able to take them on and off like that with the left hand note that the palps of my fingers are applied to the instrument. And I'm using the intrinsic muscles of my hand. I suppose the most awkward and difficult instruments to hold. And there's a lot of debate and contention about how to hold them is a needle holder. Now, we will have a special session on each of these instruments and show you various exercises. But the needle holder needs to be held along the line of access of pronation and Super Nation between the index finger, middle finger and the common flexor origin. Very much like holding a screwdriver. So you can get pronation and Super Nation, which is about 100 and 80 if not more degrees. Now, to do that, I've placed the instrument and all in the palm of my hand. My index finger, you see is extended down the instrument. This gives me direction and pro perception because when you're pointing at something you're saying it's there, not, oh it's there, it's there. And that's the precision. Your index finger is down the instrument and it's there. The action for this is really using the intrinsic muscles of the theater eminence. I'm folding my 5th and 4th fingers over the rings and I'm using the thinner eminence to lock and unlock. And this is an exaggerated movement. But what I'm doing is essentially opposing and abducting my thumb to unlock that to get hold of an instrument in your hands and practice this. And when I was asked to do it, when I was a training surgeon, it took me three weeks to get that action. Now, this is particularly difficult and I'll write a needle holder for a left handed person. And my American trainee showed me a way of doing it, but he held it a little bit further up in the hand and was able to press his thumb in to unlock it. So I am practicing with my left hand with a rider needle holder and you can see I can just about unlock it, but I am not quite sure as yet whether the rotation of the needle around the point is still in line with the axis of rotation or pronation super. So I've asked him to practice these exercises with both the right hand and the left hand and we'll see how he gets on with stitching. But his movement when I witnessed it on camera was very elegant indeed. And it looked relatively effortless. And I might get him to actually record how to do it to help those of you who are left handed. But I suggest a bit like my colleague and secretary of the college professor Robin Payton. If you started your career, I'd suggest you start exploring using the instrument was both right hand and left hand. Now, on the two other instruments that required the pen going back is something that we're quite used to using. And you notice that we've got flexion of the proximal and distal interphalangeal joints. And it's the flexion extension together with a bit of wrist movement that gives you the ability to write, but also grip the pen that grip and precision we sometimes use with a smaller blade. And thank you to our fellow Mr Caddy, a plastic surgeon who sourced this Barre blade holder for me. This gi me like a pen that precision and the ability to rotate the blade to maintain at 90 degrees to the skin, particularly with a fusiform incision. And the octagonal barrel enables me to do that. The last instrument that is worth thinking about. It's Casa Ye. And as a cardiac surgeon, this is the instrument that we use for the 7080 or 60 note that there's a barrel again, this should sit in the hand in a similar fashion, just turn that upside down in a similar fashion to force them. There you go FP. But that is got it squares. It's difficult to roll. This has got a round barrel, my D IP and proxil interphalangeal joints are extended. The palps on my fingers are applied to the barrel and the movement is literally a subtle movement, not too dissimilar to rubbing a bit of salt in your food. And considering the needle is the size of your eyelash. Not much pronation, super nation of the needle is required and not much movement is required to ensure that needle continues on a perfect circumference. And we'll be talking about that as well when we go through our stitching series. So coming back, if you've got instruments, I'd like you to put them in the hand. But if not get the instruments and cutlery that you've used, feel them. All right. Don't grip your instruments where there's blanching of your knuckles, blanching of your fingernails, allow them to sit lightly in your hand. For that is a movement that you are required. Surgery is not gross movement and does not require major muscles. The 17 muscles of the shoulder in the scapula, the biceps or the triceps. No, the flexor pollicis Longus or flexor digitorum profundus, all of which are the biggest muscles in the hand in the arm. Surgery is all in the hands. And that's probably because of the delicate function and feel why the Renaissance artists marveled at the functionality of the hand and put it in to the most iconic pieces of art that we know we've got a competition and the competition is asking you to share with us and that. And Gabrielis kindly put it in the chat room, share with us a photograph, your email and a short description of your practice at home. The most innovative photographs and descriptions of low fidelity practice at home. We run their own set of instruments in here. You have your knife, fork and spoon, scalpel blade, hemostat, riders, forceps and mcindoe scissors to allow you to practice. It is my impression as the Black Belt Academy grows and more surgical organizations become familiar with it that we are able to get you your own set of instruments. Thank you very much indeed for joining the blackboard Academy of Surgical Skills this evening. I appreciate your company. Welcome any questions or comments from anybody. So next time you sit down to and hold your knife, fork and spoon, you're not gonna grab them. The spoon is gonna be delicately balanced a bit like your instruments between side of your index finger and your middle finger. And that lightness of touch required to feed yourself, the fork is not gonna be held and used as a stabbing instrument. It's being held in the hand and directly applied and likewise, your knife is gonna be held like a knife en lot like a pen. So although you don't have surgical instrument yourself, you can think about how you hold your knife and fork. For those of you who use chopsticks, you are even more gifted because though it does require very much intrinsic muscles of the hand. Thank you indeed for joining the Black Belt Academy. Look forward to seeing you next week. We will be talking about the scalpel. The scalpel is something that I think a lot of trainees are worried about because when you make a cut, you can't undo it, not like a stitch, which you can take out and do it again when you make a cut that becomes indelible and hence perhaps the reticence. Thank you.