Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Doing good day wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. We are live at four o'clock in the morning in Kuala Lumpur in Malaysia and I arrived here on Monday and the time is convenient because jet lag is still prevalent. I'd like to thank medal for collecting us again. This evening. We have people registered from Zambia, Chechnya, Canada, Syria and Pakistan. Thank you to all are registered in participating. Thank you to the followers of 4243 and 93 countries. 707 on Instagram and 1260 on Twitter. I can't get used to using the word X news. First. The Black Belt Academy is being supported by Bron accredited by the Royal College of Surgeons of Edinburgh and powered by metal to provide a walking workshop and competition at the Association and Surgeons and training conference to be held in Bournemouth the ninth and 10th of March. Yeah, our sets, Chris and John Ish Alice and Alex are looking forward to being with all the UK twenties who are going to be in Bournemouth. We have some fun exercises for you. I'm also gonna be joining the Neurosurgical Society in Leeds Brain on the 16th of March as we actually run through some basic principles. And of course, we are planning to join Luis Phillipe to talk about basic skills at his conference for medical students in Ecuador. We have previously discussed needle holders and advocate that you hold it in the palm of your hand along the line of axis between the middle finger and index finger. Such that the axis of pronation and for super ation of the forearm is perfectly aligned. And you can see as I go from creation to pro nation, we effectively go 90 degrees that way and 90 degrees the other way. So the movement is at least 100 and 80 degrees holding the needle holder properly. Like this enables you to use the curve of the needle. Of course, we haven't covered the other needle holders that are shorter, but in all circumstances do not put your fingers through the rings. Because as we have been emphasizing in this series, it's important to be able to feel the instrument, no needles made of bone or ivory and la of copper and silver have been traced back to Neolithic times through 30,000 BC. And they were used to pierce animal hides to pull the thread through and join things together. Indeed, there's some evidence that the needles with the thread were used to close wounds and was Galen of per in 1600 that was using CC to do exactly that. And an ad 150 there's evidence that suturing was commonplace amongst the Egyptians. Of course, this really became very sterile in the western world in 1876 with the research of Joseph Lister. And shortly after that, silk sutures sterilized were being made by Johnson and Johnson. But it was in the 19 twenties that George Merson in Edinburgh was sterilizing and using cat gut in his kitchen at home. And he invented the su needle. Of course, needles have progressed since bone and copper and silver. And with increasing alloys, they've been able to be made smaller and sharper. The funny thing was that in the latter years of cardiac surgery, the ever point needle was introduced as kryptonite point. This was the 70 needle that was perfect for going through heavily calcified vessels. But of course, needles have always been used by hand. And if I bring you over, you can see that the needle works if by hand, if you're working on something superficial and here we go and I could be able to pass my needle through the tissues, but this is a cup and I'm gonna take the needle further and further down into the kelp. And you will note that it doesn't actually fit in the bottom that doesn't fit in the bottom. And it's because needles straight, needles are depth became problematic to handle and pass through tissue. And you can see this is tapered down a bit like a pelvis. And in fact, it was Ernst Hagar and William Mayer. They're published in 1901 in the American Journal of Obstetrics and Diseases for women and Children, a curve needle which now fits at the bottom of the pelvis and being curved, you can rotate the needle to go through the tissue at depth. And of course, in that circumstance, it was necessary to have a holder. And that is by necessity. The reason that needle holders were developed, of course, Olsen added an amendment to this and he put some blades between the handles because as a surgeon, he was cutting sutures at the same time as stitching and having a blade, there was useful. This was copied by Kilner Thomas Pore Kilner, a plastic surgeon in the 19 100s and others have followed since there's the gillies and my favorite. These, the riders, no, the curve needle enables you to rotate in small places and maintain control of the needle. But this is the first part of four parts of stitching that the hope is going to explain some of the nuances and why we should use the needle and the needle holder in a particular way and close I come down. I need to be sure that I'm in the middle. Sir. We recognize the anatomy of the needle as we've discussed before. There's the suage bit at the back end here and the point at the front with a ratio of the length of the point of 12 to 1 two, the length of needle, this is the cord across and the body of the needle is this middle bit here. No, the rider or in American terms, they call it a needle driver to drive the needle through. And I don't like that term because we're not driving the needle through, we're rotating it through tissue under control this conditions. And the way we pick up the needle and the position of holding is extremely important. Now, not infrequently, I see the needle mounted halfway along. Now, if you think of this as pure physics, that's the pivot there and the pivot and momentum of force times distance is equal on both sides across the pivot. So the force of 25 newtons on a grip across 10 centimeters, 250 that is two centimeters. And of course, the force at the end will be much higher. So it's perfectly designed from a physics point of view to be able to hold the needle. And especially with these diamond encrusted jaws, as evidenced by the gold handle, accurate and stable control of the needle is possible because of the force applied. Now, I agree with you. If you put a needle halfway down, the forces will be more because the distances halved. However, if you look at this, if I am putting this needle onto the table what do you see is actually pressing into the table. You see that is the tip of the needle holder itself. So, if I'm coming down to stitch, yes, I might be able to rotate the needle, but I am taking it into the lumen. The very tip you can see is entering the lumen and pressing on something. And then my banana model is actually mushing the banana because you haven't mounted the needle correctly. So the needle needs to be mounted at the top. And the other reason it needs to be mounted at the tip, this gives you better control. The working part of the needle is the middle bit just beyond halfway. So the important thing, it needs to be at the tip. There's no space between my finger and the tip of the needle. I should feel the tip of the needle holder or driver and the shaft as one, I'm just beyond the halfway. And then there's another crucial element. And that crucial element is as I'll show you in some slides and I'll explain angling the needle out and angling the needle out. If you look at that needle. Now, I'm be able to press the belly of that needle in to the table, which is my ironing board. And it's important that you understand that because this is the first part of the set up. Because if I'm not angled out and I put the needle down, you can see it's not sitting in a 90 degree plane at all. In fact, is way off, angling it out means that the belly now is at 90 degrees two, what I want to teach. So the in essence of stitching are three important points and the three important points are one, it needs to be at the very tip two at the halfway or towards the swage. And I'll explain in detail a little more about the position on the needle. And three, it needs to be angled out. And that angle there is the angle between the horizontal of the forearm and the displacement line between the wrist and the elbow. So if the wrist and the elbow are in the same line, and as far as sitting down my wrist and elbow are not displaced, and the needle is at 90 degrees. And indeed, when operating, I do find myself putting it at 90 degrees, but only when I'm using a needle holder a bit like a screwdriver trying to get deep into the cup as I'm showing and I've abducted my shoulder and I've got my elbow in the air and, and look at that, my needle is now flat on the table and I'm able to rotate otherwise in all other circumstances because we are standing and our paper is now hard copy in the journal of Surgical education of the fifth of February. Now, the other important thing to realize is that the shaft of the needle is in fact, not round but sort of flattened, slightly cuboidal. And that means that the needle flips quite easily into position. Not one of the exercises that we need to actually understand is to be able to hold the needle holder, not on the ratchet, but what I'd call on the trigger. So there's it on the ratchet, but I can hold it on the trigger by unlocking using my eminence. Now, one exercise that I'd like you to practice at home with a needle to understand this effect is mount the needle properly, just be on the halfway, no space between the shaft and the tape and angled out. And you can see this plane is 90 degrees and 90 degrees is a perfect angle because it's the fourth part of the cycle. So 90 degrees in this plane, 90 degrees across what I want a stitch and 90 degrees into what I want to stitch and therefore, the needle by definition will rotate perfectly. Having it angled out, gives me another advantage. And the advantage is that I should be able to position the needle beforehand. I'm back out by gently holding the shaft without the ratchets on. I pirouetting the needle over the top and effectively, I'm s flipping it over the point of the needle forehand to back hand. And this is a useful skill to learn and appreciate with the trigger and five movement of the needle. Because as soon as you start moving the needle with your forceps or delivering it with the forceps, you ruin the rotation, practicing what Sam, the chef, the cardiac surgeon at called sexy moves. You're now getting the needle to dance for you and it is now working, sir, picking it up off the table. I'm not and necessarily it's at the right angle and I can flip it back and forth. The other thing about this exercise, which is very important when operating is that you're controlling the needle within your maximum focus within two centimeters of where you are. And you can flip forehand and backhand by using your other hand to retract with forceps as a simple method like that. And it's only the lightness of touch that is required to flip it back and forth. And that flipping or pi wetting over the tip of the needle would apply to needles of all sizes. That's a useful angle to use. Note, I have not got the needle on the ratchet when it's on the rabbit. Because of the physics and force times distance, the diamond draws, it is stable. But as you're moving it around like this, appreciate that the shaft of the needle hole is flattened or slightly cuboidal and that enables it and you get that feeling of it flipping into place. And if you got your angle correct on your back hand, you can flip it and the angle will be correct on the forehand with very little in the way of work. Now, there's one element of needles geometry that I have not been able to find the answer for. And if you have got the answer, please share with us, but I'd like to demonstrate it here. So all needles are actually made on the circle and you need to take the needle through the tissue cleanly on the circle such that your thread fits through the hole with no space. If there's space you get bleeding. So it's gotta go through perfectly. So entry and exit has gotta be snug and perfect. Now, curved needles are actually described in eights. So I've marked out eights on this piece of paper. And if we take that is the suage and the blue 18 is that and of course, you can appreciate that movement of that to get the point of that needle perpendicular into the tissue is very minor. Indeed. And this is what microsurgery requires and you're literally growing needle holders. We the finest of touches. The next needle ethalia is 18 that is the quarter from 0 to 90 degrees and a quarter needle. Now, if we take a halfway at 45 and that is your working shaft of the needle. Again, if you assume that pronation super nation anatomically enables you to move 90 degrees, you should be able to rotate that 90 degrees. There you go. It's pointing into the tissue and now I'm going to supernate 90 degrees the other way and it comes out the tissue. If you're following that point, the next needle in this series in a s and as I said, I'd love to know why it is in a si, haven't found a good explanation as yet. I believe it was due to the manufacturing process and the convenience of dividing a circle into quarters and each quarter into the half. But if we take that again as the switch, the three eights, one quarter, two quarters, three eights, there is the three H needle. Now, you can see this is on a circumference a little bit more. But the working shaft in blue here is as I've demonstrated and there and you rotate back relatively easy. I can rotate back on 90 degrees still. And the point comes 90 degrees into the tissue, we don't call them 4/8 because 4/8 is very simply a half. So half needle is literally circumscribed in half the circumference of a circle. Now you're holding it therefore, literally in midline, perhaps a little bit back towards the s swage. But you've gotta to now be able to rotate cleanly all the way back. Such that point is now pointing 90 degrees into the tissue. And the curve of the needle now enables you to go through the tissue round, round, round, round, round and literally come out if this is the tissue of this line come out and it should come out if the rotations clean at a half the next and final needle in the series is 123458 needle. And you can see if that's the way the point is now pointing that direction, the halfway mark or the working part of this needle now is about there. But you can see that it now becomes particularly with some big needles difficult sometimes to swing it back all the way such that the point is pointing 90 degrees in the tissue. But the advantage is with the iterative movement of the needle, it goes through thick tissues and all the way through. And this is the benefit of a five inch needle, particularly if you are at depth. Now, pronation super nation for a person, it's very simply you've got 90 degrees across what you want to stitch. And we're going to describe this in more detail. Next week is 90 degrees across what you want to stitch. I now want to point it 90 degrees into what I want to stitch. So I'm going to pronate, pronate it and I'm pointing the needle into what I want to stitch and imp pronating. I'm naturally unlocking the needle. I have automatically rotated back. And the abduction of the thenar muscles is separating the ratchet. I'm holding the needle controlled but is not on any ratchet. So it means when I start rotating through a bit like throwing a ball, I don't have to stop my movement to open my hand because the need was unlocked. They are unlocking movement of the ratchet otherwise will translate into an inadvertent movement of the forearm. And if you're stitching fine tissues that is going to tear. And I've seen that repeatedly watching trainees in coronary artery stitching. It is almost automatic. When you unblock the needle that in trying to unlock it, you're pressing it down. So the best thing to remember is pronation and as you pronate note that my thumb is actually pushing this handle away and unlocking the mechanism. And now enables me to deliver the needle smoothly, such as it comes out on a clean path. This and that was you to stitch using the geometry of 90 degrees the perfect radius and circumference of the needle. Whilst your left hand is employed, retracting tissues. And if you do it properly, that needle should come out of the tissue 90 degrees in the right position, such as you can deliver it until you just see it beyond the halfway mark again. And you pick it up and continue the rotation and take it out very simply. And I'll come back to the slides now to talk through this and give you a further picture representation. So this is trying to bring the physics angles, movement to what you're wanting to do. Uh click ahead and find the button naked, putting the needle at the tip. I hope you now understand that putting at the tip enables you to flip it forehand and backhand and the tip itself is not pressing into the tissues. It gives you better control, enables you to maintain the forehand and backhand angles. Remember the body of the needle is where you're working. You do not put anything at the tip of swage and you do not put anything at the point you working in that area. And the cord length or length of the needle is across the cord as you see there. So it means when you're actually using the needle, you're rotating it, remembering particularly with 5/8 needles that if you rotate back with your focus on the point, I have seen cases where not paying attention to this quite rounded needle means that the swage itself is potentially causing damage and pronation super of this needle is difficult to control the entry. And I suppose this is where I'd use the word drive the needle through calcified tissue. You want to hold it closer to the point, not at the point, but certainly closer to the point. And when you're standing up your wrist and elbow, as if you are eating at a table at the same level. And it's quite appropriate that angle is 90 degrees to the needle holder because 90 degrees is the perfect angle. But as we've pointed out in our paper, as soon as you start with this extension, if you look at these angles in the geometry, the horizontal between the elbow and cross and the forearm and you look at the parallel lines, you will now see that you need to angle the needle out to maintain that 90 degrees. And there you have it from that point of view is to maintain that 90 degrees. I'm just gonna and I hope this is GG CSE physics of parallel lines and you'll appreciate yeah, ankles that are involved and that green ankle between the horizontal and your forearm is actually the same as that angle. You need to angle the needle out. It's mathematical. It's as simple as that. So I also believe and I'm testing the maths on it at the present moment that that rotation is not going to be complete or accurate if the needle's not in the jaws. So the perfect pick up of the needle each and every timer ditch is the same. And you need to apply this check 123 before we take any stitch. Even if it's a continuous stitch, even if it's a delicate stitch, your focus before you make the stitch is one. Is it at the tip two? Is it just beyond the halfway? Remembering that with the eighth, the half and a quarter needles, it is not as crucial because the anatomical movement of pronation and Super Nation will enable you to easily get the point 90 degrees into what you want to stitch. And lastly thinking of those parallel lines is it angled out. Now, I can tell watching any student do any stitch, whether the stitch is going to be accurate or not, by looking at these simple checks, one at the tip, two just halfway and three angled out. And if you don't attend to that, each and every time your stitching is not going to be accurate but not only not accurate, you will not be able to establish a rhythm and flow. The essence of good stitching is not the action of putting the needle through the tissue. It is the set up. And unfortunately, I don't believe we reinforce that, set up, set up. And I don't believe that you check your needle each and every time what I'm teaching, I'm watching that each and every time. And I'd like you to do that. Now, as you can see, place it 90 degrees across what you call a stitch and then I am pronating backwards and as I'm pronating backwards, I am unlocking the needle such that when I supernate through the movement is smooth and has not been interrupted. And those angles in that position of your pickup relates to the geometry of the circle, relates to the geometry and size of the needle. But more importantly relates to your ability to pronate and supernate. I would like to hear from you. And if you've got any questions, please