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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 professor in the Medical Education Research and Development Unit of the Faculty of Medicine at the University of Malaya. I am the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh who do accredit this program tonight. Our producer is Vanish, who's 1/4 year medical student at the University of Malay and I'd like to thank you for following the Black Belt Academy. We now have over 4500 registrations and we are reaching 133 countries. Tonight, we have 61 registrations from 27 countries, literally from A to Z from Argentina Bangladesh, Guatemala. Namibia is the first tonight and we welcome those from Namibia, Malaysia. Nice to see you and it was great to see you at the Malaysian Student Surgical Society on Saturday. And I hope you had fun. We have delegates from Russia, Rwanda, Spain, Tunisia, UK USA and Zimbabwe right across the globe. Thanks to the reach of meal. We posed a number of questions to you this evening about the blade and what later to use in thickness. And I hope as we go through this evening, we will address some of your, all of your questions. What's interesting as you know, I am learning the Kana and this is at the Japanese Club and when I do a sore draw, if I stop in the right position, I prevent you from coming closer in killing me two centimeters. This way, I'm out of your vision and that two centimeters enables you to come in with a strike. What is interesting in my learning with the katana which for all intents and purposes is just over a meter long of coal rolled steel and razor sharp that the description and prescription and how to hold the blade, how to use the blade. And the movement has been handed down for over 600 years amongst practitioners. Interestingly enough in my 15 years of surgical training, there's only one surgeon who is taught me how to hold the knife. Mr William Walter Frederick Southwood said I couldn't do any Ramstad procedures unless I learned to cut properly. Before we go into that. We need to think about the hands. What's interesting from an anthropological point of view? Sorry to interrupt you. So there, so there have been some uh notifications in the chart that video looks a little blurry actually. Does it. Yeah. Oh II can't. I'm very sorry, I have no idea why that is the case. No idea why that is the case because I'm looking at it pain screen here and I'm just checking all the connections, it maybe the wifi. So I think it's OK. We will just check that later. Ok. Well, I do apologize. Um from my point of view, it's looking clean, but thank you for that feedback from an anthropological point of view. Not many anthropologists have looked into what precision groups are essential to habitual and effective manipulation of prehistoric stone tools. And are these groups shared with other cat species? In other words, monkey species. And are there morphological features distinctive for each species which are essential for the effect of use and precision grips? And is there fossil evidence for the origin and evolution of these features including the human precision grip capabilities? Now precision grip is a term often restricted to grips in which a small object is held between the thumb, distal phalanx and the terminal Bolar pads of the fingers. Now, an anthropologist Marel defined three groups, one holding a round object, two the thumb to the side of the index finger and three this particular movement. And he mimicked making stone tools and concluded that it was can only be the evolution and learning and the habitual use of this fine movement that enabled humans to actually evolve and build tools. All the other groups would be described as power groups. And he concluded there's certain distinctive features of the human hand that might be reasonably explained by the increasing demands for the use of precision grips and evolution of prehistoric tools. No, when we do photographs in Malaysia, I love it. It's 123, photograph, 123, photograph 123 freestyle. And everybody does this. I would say for the Black Belt Academy, I would like you to do this and this can only be done the flexion of the metacarpal pharyngeal joint and extension of the distal joints by the lumbrical muscles which are prin muscles on the hand that arise from the lateral border of the flexor, digital and profundus and extend over the finger to reach the lateral side of the extensor retinaculum of the fingers. They named lumbrical after the Latin word lumbrical, which means earthworm. And they are unique as we said before because they're the only muscles in the body. They don't have a bony origin or insertion. Now, besides being found in humans, lumbrical can also be found in animals including primates and most non primates. And they've been studied in rats in horses, dogs and cats. And in these species, they play an important part in locomotion in the chimpanzee. Moving across the ground requires an extension of the metacarpal pharyngeal joint and a bending and walking literally as we say on the knuckles. And this is knuckle walking and the interosseous muscles and the lumbrical muscles pre provide the resistance to flexion of the proximal internal joints during this motion. But there's something more to the lumbrical and they are very special. They have the smallest cross sectional area in the upper limb extremity, only about 1/10 or the 20th of the flexor Dior Profundus, they're extremely small. And if you look at them in the anatomy lab, they do look like earthworms. They also extend between 8 to 5% and 90% of their muscle length, which is unusual and it indicates that this muscle is designed for long ex excursions, which is that. Now, what is interesting about the lumbrical muscles is the number of muscle spindles. Now, muscle spindles are very specialized sensory receptors richly found in human muscles involved in precision movements. So they are found actually in the ocular muscles in the eye. And they're also found in the intrinsic muscles of the tongue and used for rolling the tongue around the mouth. They also found with closing the muscles of the jaw. In addition, these spindle muscles play an important role in the tonic five movement in the neck as well. And they provide information important to the direction of stretching as well as the position of the organ, especially the tongue in spindle rich muscles. The latency of unloading reflexes are shorter than muscles with few spindles. And the number of spindle cells found in the lumbrical is 100 and 39 significantly more than all the other muscles of the arms. So from evolutionary terms to understand the significance of the lumbal muscles, it's interesting to consider that the number of spindle cells has changed. And these lumbrical are not really considered motor but more sensory because of that spindle cell richness. And they provide important information to the central nervous system. Regarding the position of the fingers in monkeys, closely related to humans, they too have lumbrical but nowhere near the number of spindle cells. And the fact that it can elongate suggests that it balances the proprioception between flexion and extension, allowing a balance of the more powerful muscles of the hands, the interossei. So the lumbricales are only beginning to be understood as a muscle. But their function to oppose the fingers is important to enable that precision grip that marks the anthropologist described in his works. And it's that precision grip that enables the surgeon to do the whack in a black belt economy. When I say, what do we love? The reply will be, we love the lumbrical and that will be our freestyle for all the photographs in future and your respect. I'm writing a paper with a Professor of Anatomy in the Faculty of Medicine, looking at the functional anatomy of the upper limb and the importance of muscles. But enough of anatomy and physiology, what I'd like to do is actually now go and describe and show you how to use the knife and I'll take you over to the camera and I hope the blurring has improved. I certainly see it is clear from my side. I hope it's clear from yours. The blade handle and this is by Swan and Morton. And this round design is a patent of Swan and Morton. It comes with a groove and you can see my fingernail runs within that groove. The blades are designed to fit into that groove, the notch and the notch are matched and you can see there's a wide section and a narrow section. And what you need to be able to do is to slide that on. Now, sometimes this can be somewhat stiff and it's important that this is done with your hands resting on a surface, the blade pointing into the table and only one hand moves at a time, you pick up the blade on the blunt side with a hem start of a large surface area and a firm grip, insinuate the blade into their groove on the handle and gently pull it up and it locks in place. You are now ready to use the blade to take the blade off. One simply lifts the edge slides it so clears the Bevil apply a hemostat and withdraw the blade. There's a one handed movement in it too often. I see the blade flying around two handed movements and that is where we get a problem. The deep breaths, the encyclopedia of etiquette describe how to hold the common knife and the knife should be held with the handle sitting in the palm. We talked about the precision grip. I now I am holding it against my middle finger, my thumb, applying it against the middle finger and my index finger extended down. It is in this position that I can control the pressure with my finger. And usually you only need the weight of your forearm no more than that. And the models we're going to introduce you to this evening. You can pick up in the local supermarket and I invite you to send me examples innovative examples of your own practice. I'll be introducing some this evening. The important thing is is that the blade is held properly and the blade is held 90 degrees to the tissue. Because what happens if the blade slices to the tissue, you see having painted the edges blue that that is not a clean incision, compare it to this incision, which is perpendicular and full thickness. You can hardly see any of the ink incisions and wound healing start with clean incision. But I want to just pause there a moment and share with you a fundamental principle. The in principle is very simple. It's decisions before incision. And as a cardiac surgeon, I would not, could not and will never take a knife to a patient unless I had the right information. The right reason, the right time, the right mindset, the right consent, the right equipment, the right team, the right position, right? Drapes, right? Landmarks. On one occasion, I stopped in the middle of the list because we ran out of 70, Prolene, the second patient was 84 year old lady diabetic. And I could see on X ray she had calcified vessels. I was not prepared to do the operation with one hand behind my back. All of this has to be right. The other thing is to be sharp. You have to stay sharp yourself, nutrition, sleep hydration. All of this has to be right and the knife is then right angles to the skin for the incision, you then proceed with precision and feel. Now everybody laughs at cardiac surgeons. You say you only do one incision. Well, that's true. But you don't laugh at a statin who just buys round and round on Novak Djokovic who with a bat and ball over a net, you try 24 centimeters perfectly down the middle without turning at the other end in the Black Belt Academy, we ask you to do a five centimeter incision, then a 10 centimeter, then a 20 centimeter because the difference is as you get further along, people tend to turn around the hip and the incision cars. It does not happen on a wing and a prayer. And I have a, a number of slides of om in patients with such tattoos. I've done a tiger and a 12 3 Masted scooter. I love these principles described by right warrior think of what is right and true practice and cultivate the science. Become acquainted with the arts, know the principles of craft, understand the harm and benefit and everything. Learn to see everything accurately, become aware of what's not obvious and be careful even in the smallest matters and do not do anything useless. But what he also talked about was the natural rhythms and flows. When using the sword, there is a lot to be learned. So if I was taking my knife down the table, a five centimeter incision is fairly straight 10 centimeter incision, there's a turn and 20 centimeter incision. Most people will put a further turn in. The important thing is when making an incision is to support the tissue between your fingers all the way along as a slow deliberate cut all the way through the tissue. Sharp dissection is clean dissection and I reduced my overall wound problem to a median of zero by including knife only to the sternum. In my incision, there was a bowl cut all the way through the tissues down to the sterum and then deliberate diathermy. In order to do this, one needs to actually think of the feel and one way to feel is use different models. So we'll try something easy. First of all, can we actually take a knife? Feel it, feel the banana? And do you have any cut on the skin underneath? The answer is no, none whatsoever. Try it on something else, the orange gives you an opportunity to feel the cut, but it's thicker and you have to apply a harder force. You gotta imagine yourself at the front end on the sharp end and taking all the way through. How often do you change the blade? Well, gentle shaving, you change the blade on a regular occasions when it's blunt, you find that you scratch and excoriate the skin of your face. So the important thing is feel it and then you can test it, squeeze the orange. Is there any juice that comes out? But we can investigate this further and peeling this off. Have I cut the tissue underneath? And the important thing is you can see in this example that my incision has been perpendicular all the way through it is not, it is full thickness through there. But that at the end, there is an example of not using the full length of the incision. And that's a common mistake in surgery. And you see, I've not completed the incision at that end, that is better a nice flat cut. The thing is it's pretty obvious when you bake and slice and you don't control, you end up with all these irregular bits. What size blade do you use? Well, the blade you use is dependent on the size of the incision and the surface area that you're going to be using. Removal of a lesion requires a more precise and more accurate excision. And that requires a fusiform excision. And in this circumstance, I am now going to be using what's called a Barre blade. And the Barron blade is a bit like a pencil. You can see it has the same shape as a pencil and I'm able to roll it between my fingers. The important thing is is that I gotta keep throughout my incision, the blade perpendicular to the skin, throughout a clean incision. The problem is when many people doing a fusiform incision is that they don't make it long enough. And therefore, when tries to actually close something, there is more circular than fusiform. The other important thing is when making incisions, all incisions are related to bony landmarks. So even somebody with a large body habitus feel for the ba landmarks. I've seen somebody try and go for an appendix ectomy and they went for mcburney's point, they thought, but they didn't feel for the anterior superior a spine and therefore, were far too lateral. And what happened? They almost went to the table before they realized their folly that they were lateral to the abdominal cavity and the peritoneum. So I have actually done a fusiform incision here. Again, if you look at it, they perpendicular edges. But because it's long, you can see that will bring together is a nice straight line. And of course, we know the anatomist Langer studied the effects of really an ice pick. He took two frozen corpses and noticed in some parts of the body that the circular hole remained circular. Whereas in other parts of the body, it started to close and was flat. So even just taking the orange or using the banana, my blades are now actually blunt. But there are other exercises that I want to introduce and invite you to test this yourself. So, sustainable surgery, we are going to make a sandwich. There you go. I have got two slices of bread and I want a ham and cheese sandwich. So I've got some ham. You can get any sliced meat, chicken beef, whatever add sandwich packs. But I have got this ham and this is actually 1.5 centimeters thick. And I'm gonna put three slices, you put four slices on this. And now I'm going to change my blade just to demonstrate the value of a sharp blade. What we going to try and this is the excitement of live television, so to speak, is cut through each layer respectively, feeling way through the tissues. In essence, when you make an incision, you need to actually understand the weight of your forearm and how much pressure you're putting through the blade. So I've got that on a slice of bread. I am going to hold this tissue. The cutting part of the blade is the belly and it's the same with a katana. The kaki at the end is curved like this and it slices, the function is to slice So there you go. That's a slice. I am going to do a deliberate slice. Truth is um and feel my way through. Not too thick, not too thin. Let's have a look. Shall we all will be revealed? There's no chance of me cheating on this and there you go. That's not wasted. Now, I wonder could I actually cut through two layers at the same time without cutting the third layer underneath. And again, this requires understanding the tissue planes and the thickness. I can feel it through supporting the tissue either side, feel it with a knife a little bit more pressure than previously. And let's see, I hope you agree. I've gone through two layers there and I could feel it through. I have two layers, three layers left. So let's see, this is on a slice of bread. I'm making my sandwich at the moment for later three layers, 1233 centimeters thick on a slice of red. I need to cut through this tissue without cutting the bread. I'm gonna change my blade. Well, I probably let's try it with this one. So I'm gonna feel it through, support the tissues. See I'm parting the tissues and see I am stroking the knife and there you go, I've cut through all three layers of ham without cutting the bread underneath. I was not putting any force whatsoever on that. Not one bit at all. It was all with simple feel and you cannot feel if you're gripping the blade with considerable pressure. So try it with different sort of materials. This is some sliced cheddar cheese. So it'll be a ham and cheese sandwich later on. This is sustainable surgery for you and we'll do the same thing. I'll try because that, that blade is not, I bleed blunt. I'm going to go for a sharp blade. I've got two layers of cheese here. I'm going to cut through one lay of cheese and you're feeling the blade through it. There you go. And there's no cut underneath. And I'm gonna do that again. And no, you can see I'm separating tissues that will make a very nice ham and cheese sandwich later on. And that's what I call sustainable surgery. We don't need synthetic materials. You do not need suture pads and you certainly cutting cloth and things is not akin to organic materials, but you say, oh yeah. Well, that's not challenging. And that's not teaching me how to cut. Well, let's take another blade and you're taken on the splash bottle, a poach deck. Mhm. Now, you can appreciate the membrane of the egg is rather thin. There's a 10 blade. Can I actually stroke a knife just through the yoke? There you go. I think I'll take that down. I just cut through the, the yolk into the yolk. All right. And I haven't slashed it. Simple things that are available to you all the time enable you to practice the feel of the blade. What's interesting learning my katana and at the lesson on Sunday, each week I go, I am lighting my grip and I'm feeling the blade balanced and interestingly enough in the precision grips and the sword. So there's another aspect, two knife skills. And again, don't worry, this is going to go into Risotto tomorrow. It's a piece of salmon. You can use any fish you like. I'm turning it upside down because now what we're going to do is explore how to actually dissect this without cutting the salmon flesh. Now, I've deemed just by operating on the banana and the orange and there's few incisions that for me to actually effect a good dissection. Here, I am going to use another blade. Remember when taking the blade off, lift it off the edge, put a heat on and take it off in a movement you see, even on the flat surface, that jerk, if you didn't control it, that would be seriously problematic. And I have seen a member of staff stabbed and a pota patient potentially stabbed as well. So the idea for this exercise is now to actually think of the blade literally as a brush, we are going to brush our blade against the fascia as a sweeping motion to dissect of the tissues. And in this circumstance, I have now moved my hand from holding it in the palm between my thumb and the side of my ring finger with my index finger down and now holding it across the base of my fingers and I'm gonna be using it just as I demonstrated with a brush. The secret of this is patience and what we want to be able to do is developed a plane. Then it's important that I don't take the knife in to that plane. But you can see that I'm brushing against Diskin and I'm brushing against the skin. And this is where a second assistant is most helpful because you'd ask them to hold the skin in two positions and hold it and maintain the tension. But the idea here is to brush your knife without actually leaving lots of salmon on the skin and without cutting the salmon itself. So once you start in one of these planes, you can practice yourself feeling the blade and feeling the tissues. And also because you're in a low fidelity situation, be brave, see how much provider you can put in to doing this. So you understand the limits and now you see that I'm making pretty good progress, taking the skin off, brushing the blade against the skin without cutting the salmon. These are the skills that Mr Southwood taught me in 1987. Once I first started surgery and at that time, this particular technique was a very effective technique for defining a plane for a mastectomy. You can use this technique in many surgical planes. The important thing is a good surgeon can operate in any part of the body provided. They know the anatomy. I remember doing a mastectomy on a very big voluptuous woman and as dissecting out the axillar tail, and I came across a big nerve and this was the intercostal nerve that runs across the axilla and I cut it. And for a moment, I actually felt red because it was so big and I've been dissecting a lot. I thought for some hideous reason that I was somewhere near the brachial plexus. But of course, I hadn't anywhere near the axillary vein, but I had a moment of, oh dear in my experience forgetting that part of the anatomy. But also remembering that the nerve to latissimus, Dorthy actually enters the muscle before the edge of the lattice Dorsey of the posterior element of the axilla. So therefore, when you find that border, you can cut with impunity because you know, your knowledge, the important thing is is that I haven't, I've left minimal tissue on there. And what I'm doing is I'm appreciating the knife as a blade and a brush. There's one other knife to consider in our Armamentarium and that is the 11 blade. Now, the 11 blade is extremely useful for incising and puncturing abscesses basically and for skin abscess because at the point, I would not use this to cut in any form or fashion. The secret to use in this plate is the depth is determined by placing it against your thumb or placing sorry and placing it against my middle finger. I'm holding this in a precision grip again with my thumb, my index finger and the blade is positioned against my middle finger. And it's in this position that I can confidently incise the skin of the banana without you have a look without cutting the flesh underneath because I've controlled the depth. And it's this, that technique that I always used when cannul the aorta, I'd lift up the adventitia and put a pur string around, make a little incision in the adventitia. Lift one edge, insinuate the tip of this deliberately into the aorta to the requisite depth because the depth I needed was a little bit longer to get the cannula in and then slide the cannula in in one movement. But you can see if I held it up there that would cause a significant puncture. So I can control the depth each time. And you can see the point is only just come through the skin of the banana. That is how you can control your knife for an incision and drainage. All of these things. I put it to, you can be practiced at home. Simply go to the supermarket. Let your imagination run right. I bumped into Lawrence the manager at the supermarket at this evening and he said, what you're operating on tonight. He said what you're cutting tonight. And I showed him the banana, the ham the cheese, the fish. I said I'm cooking some eggs. All of these are low fidelity models that help you feel. That's interesting. Think about it. Yes. You practice feeling an instrument and that movement using your toothbrush. What's interesting about a electric toothbrush? Look, it shows when you pressing too hard and dentists will tell you if you're not using that fine precision movement, you're actually rubbing the enamel away and brushing your gums out of the way as well. So there's a regular thing that you do every day. Hopefully twice a day is brushing your teeth and learn to feel and lighten your heart grip to make it more a precision grip on your toothbrush, to feel it across your gums. You don't need force at all. And there's that sort of pressure that we are using for cutting dissecting and scraping. I hope that has made sense. I look forward to hearing from you and your examples of how to practice surgical skills. And I'd love to see photographs of innovative models. I must thank B Broner Swan and Morton for supplying me with scalpels. They've also given me this very nice disposer. I can put the bleeding played off. How are you doing? Blade off, blade in blade off? I think this is a brilliant invention and laid off and it's your responsibility as a surgeon whenever you're practicing, to think about how you're handling instruments and played safety. The important thing with passing the blade is to pass it face very safely. Indeed, I wouldn't pass it to your blade first. I passed it to you, hand it first blade down because when you took it for my hand, I'm not gonna be careful. A blade. That's the old fashioned way of doing it. To be honest, the safest way of passing blades is pass them in a kidney dish, be done laid off. Thank you very much indeed, for your attention. I hope this has made sense and I hope it has stimulated you to think about how you can practice yourself at home. Next week, we're going to continue with sharp dissection and the use of the scissors. And we'll introduce some more models that will emphasize the need for you to use lightness of touch, particularly the sharp objects. And then in two weeks, time by way of an example to mix it up, we're gonna put the knife and the scissor together to talk about dissection. But my son's on half term and he'll do the operating and I'll do the assisting. He's looking forward to it ready and has on his CVA statement that he is teaching on the Black Belt Academy of Surgical Skills. And what I'm impressed with is that his skills are coming on rather nicely, although he doesn't want to do surgery. Thank you for your attention and I look forward to seeing you next week and thank you to Namibia for joining our Global movement vanish. Thank you very much for supporting and delighted to answer any questions if they are in the chat. I wondered, did the blurring resolve itself? Because certainly from my side it looks very clear. Uh, hi. So there are no questions in the, in the chat. But, yeah, the blurring actually was still there. It persisted throughout the session. Persistent. Mm. Ok. I'll have to look into that because I can't, I can't see the blurring myself. Strange. I'll have a look at that for next week. I sincerely hope I don't have a camera issue, but I'll look at the connections. Thank you, Venice and thank you for joining the black belt. I wish you good night. I'm sorry. There is one last question actually. Yes. Yeah. So uh MZ has asked, how many, how many times is it generally recommended to change plates? Well, a good question and I haven't, I agree specifically answered that there are those purists who would actually suggest that you do not change the blade, you change the blade after every skin incision because they're thinking of the microbes being carried in to the deeper tissues from the skin. I would suggest that after in skin incision as well, the blade itself is fairly blunt. We have discussed previously the manufacturing of scalpel blades and in fact, one side is shiny and the other side is actually serrated and this is done deliberately because if both sides are shiny, otherwise sharp it would be so sharp, you would not get the feel. So, yes, you can have a blade too sharp and you do not have the fuel. Simple thing is if you think the blade is blunt change the blade, gentlemen, if you are ra shaving, you would not use a blunt razor on your face. It's certainly less uncomfortable, think of that on the tissue, but I'd certainly change it after the skin incision. Some people would say it's from antimicrobial point of view and others would say it's blunt after the first skin incision. After that, it really depends on how much dissection you're doing and the tissues itself. But as soon as it feels blood change, the blade sharp dissection is clean dissection. Any other questions? Uh No breath. That's all. Super. Thank you very much. Indeed. I look forward to seeing you next week.