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Summary

Prof. David O'Regan from the Medical Education and Research Development Unit at the Faculty of Medicine - University of Malaya, hosted an engaging teaching session at the Black Belt Academy of Surgical Skills. This discussion, accredited by the Royal College of Surgeons of Edinburgh, reached 4329 people worldwide and focused primarily on stitching. Prof. O'Regan not only detailed the practical aspects of needle use in surgeries but also eloquently highlighted the symbolic significance of sewing across different cultures. Attendees learned about the history of needle usage, the anatomy of the needle, and the correct way to handle it during surgeries. This session emphasized the importance of precision, clarity, and resilience in the medical field, making it not merely informative but inspiring for every medical professional.

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Description

BBASS starts another four-part series focussed on the art of stitching. The first part of this series highlights the principles of needle control and understanding of the angles involved when aligning the needle to the tissues. The basics are not basic. They are the very foundations of the art of surgery without which complex skills cannot be mastered. BBASS explains the angles and the lightness of touch that is required in all your stitching. We offer low fidelity models that will enable you to 'home' your skills.

Learning objectives

  1. Understand the historical significance of needles, including their usage in various cultures, beliefs, traditions, and the evolution of different types of needles.
  2. Identify the main components of a needle and understand their functions, especially the concept of the swage and the importance of the curvature of the needle in surgical procedures.
  3. Master the correct posture and hand position for performing surgical stitching, learning how to isolate the intrinsic muscles of the hand and the principles of holding instruments correctly.
  4. Develop the ability to carry a needle through tissue with perfect rotation, creating a clean tunnel and avoiding the formation of a space that could lead to complications such as bleeding or micro abscesses.
  5. Demonstrate an understanding of the use of Pronation Supination motion in holding the needle holder, and recognize its significance for precise manipulation of the needle during surgery.
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Computer generated transcript

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

Hello, good evening and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a professor in the Medical Education and Research Development Unit at the Faculty of Medicine at the University of Malaya. I'm also the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And our program is accredited by the Royal College of Surgeons of Edinburgh. This would not be possible without the platform of metal, this now able us to reach 4329 people. Tonight, we have 100 and 44 registrations from 33 countries. I must say a big thank you to my Malaysian colleagues who have joined the the line and thank you to the student representatives and MS Sas for publicizing this event. We have people literally across the globe from A to Z, Algeria, Bangladesh, China, Cyprus, Egypt, Iraq, Japan, Libya, Mauritius, Malaysia, Mexico, Nigeria, Pakistan, Romania, Sudan, Uganda, and a new country tonight, Vanuatu. Now I confess I had to look up where Vanuatu is and it's an archipelago of islands off the east coast of Australia, the northeast coast of Australia. It's probably the last islands before you reach the middle of the Pacific. Thank you very much indeed for joining. And after that, we have United Kingdom and Zimbabwe tonight is part one of the cycle focusing on stitching. But before this, we must think that sewing needles have long been imbued. The symbolic significance representing various concepts ranging from resilience and precision, transformation and interconnectedness at the heart of Na Na symbolism is a fusion of practicality and metaphor. The intertwining of the tangible world of craftsmanship and the intangible realm of meaning. Take for example, a thread of resilience embedded within the eye of a needle lies a narrative of resilience, reflecting the capacity to endure adversity and emerge stronger. And just as the needle pierces, the fabric resilience enables individuals to navigate through life's challenges and stitching together. The various fragments of experiences brings together experience and ago of Ha. Not unlike a Korean sed, the precision and focus cultivated by the slender form of the sewing needle in bodies. There's virtues of accuracy and precision and in a world characterized by all this noise. The needle itself serves as a reminder with the importance of clarity and concentration. Every step is made with deliberation. Echoing values of mindful action and attention to detail. Again, surgery, the act of sewing transcends mere practicality serving as a powerful metaphor of transformation and growth. Pieces of fabric are transformed under the guiding hand of the needle into new garments in the same way individuals undergo their own process of metamorphosis. Because together as individuals, we are weaving the threads of our past, present and future. As a tapestry of our own self-expression crate their act of sewing brings disparate pieces together in a unified whole. Symbolizing the interconnectedness that speaks for the intrinsic bones that bind our profession and humanity transcending barriers of culture, creed, geography like threads in a tapestry. Each individual contribute to the greater fabric of society. The needle and thread there's woven into ancient mythologies. The sewing needle often appears as a divine tool wielded by gods and goddesses. In Norse mythology, the norms, weavers of fate are depicted as using a giant sewing needle to craft the destiny of MS. Similarly, in Greek mythology, the FS are portrayed as spinning the thread of life with a golden spindle symbolizing the interconnectedness of beings. The needle and thread have come into folklore, sewn needles are associated with various superstitions. In many cultures, accidentally dropping a needle is thought to bring good luck while finding a needle in one's path is seen as important to good fortune. Conversely breaking a needle is often regarded as an ill omen. Interestingly, a needle on a thread held over a gra abdomen. If it goes around in a circle, it's a go and if it swings up and down, the fetus is a boy. There are many rituals with needle and thread in Japan. The tradition of Nori involves the ceremonial sewing of Kimono's leaves, symbolizing the binding of two souls in marriage. Semi native Americans use the active sewing as symbolic patterns into garments and have spiritual significance representing the weaving of communal bonds. In fact, the first saying was probably trying to bring animal skins together using shards of bones and needles with a bit of animal sinew on plant red. And the early limitation was the ability to produce a small enough hole. And that's where bone was used to as a GL two actually make a hole and traces of the oils that have been used have been found in many ancient conurbations. Bone needles date back to 61,000 years in a cave in South Africa and a needle made from BBA and 50,000 years ago, found in the Dennis over caves in Siberia. Again, bone needles have been found in caves in Eastern Slovenia and bone and ivory as also have been found in the Liaoning Province dating back to 30 to 23,000 years ago. They've even been found in the Kinky site in Russia again 30,000 years ago. From 8600 years ago. Needle bones have been found in the Dan Zili Province in Turkey. But then when metal came along copper saying needles were found in Egypt between 4400 BC and 3000 BC. Iron sewing needles have been found in Bavaria, a man in Germany from the third century what's interesting. Native Americans use sew needles from natural sources. And one source was the argive plant and the leaf would be soaked and dried for an extended period of time leaving a pulp and long stringy fibers. This meant one end was very sharp and they didn't have to thread the needle. It was in automatically aged and these dry fibers were used to sew things together. The history of the needle really follows the development of metals. I've been trying to find out when needles became curved. But let me just show you something for one before we look at the anatomy of the needle. If I take you over here to this cup and within the cup, I have a straight needle, you can see it's impossible to manipulate a needle, a straight needle at depth and in a combined space. So some bright spark came up with the idea of using a curved needle because a curved needle can be used on the curve at depth. And the deeper you go, the more the curve the needle needs to be. So all needles by definition are actually made on a circle no matter what their size and they have to be carried round through the tissue on the circumference. The important part of the needle is the point, the body and the suage. And this is really the clever part of surgical needles because there you see a regular sewing needle and there's an eye and the eye itself is usually bigger than the diameter of the needle. And it was George Mercer back in the 19 twenties that worked out, we could swage the needle to the other end. And that now for years has been the widest part of the needle is the wage where the thread goes in the end. We do not handle the point and we do not handle the wage, but the whole thing and principle of stitching is to take the needle on the circumference. Such that when we take a tangential slice through the path of the needle, we should see a clean tunnel created bye a needle and the suture sitting cleanly in the middle. Now, if you do not carry your needle through on a perfect rotation, what happens is that you end up with irregular shape. The suture in blue sits in that shape. And this area between the suture and the wall created by the tunnel by a needle passing through the tissue is a space. Uh That space is the space that we see is bleeding in vascular surgery or micro abscess in general surgery. So we need to actually learn how to carry the needle through the tissue on a perfect rotation such that it doesn't help. No, let's go back a little bit and think about how we can rotate. Well, firstly, to take you back to the very fundamental is how we stand at the operating table. Now we stand is incredibly important and vanish is producing. And I are doing a study looking at that because we're not taught. But very briefly is you can try it yourself, lift your hands up as I talk and keep them up there. The thing is as soon as you so keep them up, I'm watching. As soon as you abduct your arm, you're moving the scapular around the shoulder and you're employing 17 muscles on each scapula to actually hold it in that position. Keep them up. The thing is in that position, you are now putting a lot of stress and fatigue on the back. And also with that increasing your chances of tremor, you may drop your arms. And as you drop them, you now feel kind of relaxed and that's because your shoulders are down and your elbows are by the side, you wouldn't iron down there and you wouldn't iron up there, but you iron at a comfortable height and that height is dictated in the functional height of the functional anatomy of your upper limb. That's why we use an ironing board now repeating this because the principles are teaching us such standing in this position with your elbow, slightly extended, your hands, palm are flexed. You have relaxed, all the so called girdle muscles, relaxed the upper arm muscles and really isolated the intrinsic muscles of your hand. What I want to do to do now is finger and thumb, just pinch yourself, pinch hard and in fact, it is very uncomfortable. You are generating 25 to 35 newtons of pressure. Very uncomfortable indeed. In karate, pinching the inside of somebody's arm or inside of somebody's leg is a good defensive mechanism. Now extend the D IP joints and by extending the D IP joints that was done by the lumber course. And they are unique because they don't have any bony origin or insertion with the extended lump course, the D IP joints pinch yourself, you can't pinch yourself hard. So immediately the pressure generated is reduced. But more importantly, you bring the palps of your fingers together and bringing the palps of your fingers together. You're now beginning to feel the instruments and the principle of holding any instrument, including the needle holder is to maximize the surface area on the pulp of the fingers on the instrument because you have more sensory input from the pulp of your fingers to your brain than you have from the eye to the brain. You're literally better at feeling with your fingers. So how do we rotate with this rather complex thing called the upper limb? Well, the fabulous thing is that we can do this supinate, pronate, suflate, pronate as the radius folds over the ulnar. Do you recognize that action that you do regularly? Well, does this give you a clue? It's a screwdriver. And we used to using screwdrivers. I'm sure you all are at home on a regular basis. And the great thing is that this action of Pronation Super Nation can happen no matter what position. I put my lower arm. In other words, I can abduct. I hear me slide my scapular forward, but my Pronation Super Nation is still there and that is the secret of how we're going to hold a needle holder. I'm not demonstrated as thus. So look at the screwdriver, sitting my hand and I've closed my fingers around it. That way is tightening, isn't it? I super you can put in the chat room. What is the most powerful supernate of the forearm? Put it in the chart room. Finish any responses to the question for the most powerful supernature. Pretend I'm putting a screw in clockwise. Anybody any answers. Well, the answer to that is your biceps. OK. Your biceps are the most powerful supernate you can possibly have. That's why the screw goes in and tightens clockwise. A deviation. But we hold the instrument in the same way. The axis of rotation of the forearm is between the index finger, the middle finger and the common flexor origin and the radius falls over the ulnar and a clean rotation. And I want to demonstrate this to you. If you watch the end of the straw, I'm gonna pronate and I'm going to phonate. And I think you'll agree that I've got approximately 270 degrees of rotation in doing that 270 degrees. Whereas if I put my fingers through, I'm limited in my pronation and I'm limited in my super nation. Not only that, you'll see that the needle is moving round and round. So the important thing when holding the needle holder is you place it in your hand. So if a nurse is putting it in your hand, you're putting your fingers and applying your fingers to this note to my baby finger, ring finger, middle finger and my thumb are applied with my index finger extended down, giving me direction and proprioception. Take it out, put it in, take it out, put it in. You feel with the pulp of your fingers. If you got your fingers through, you're not going to feel the tissues. I helped samia do an aortic valve replacement and he did a beautiful replacement with meter 40 proline four millimeters apart four millimeters deep from the edge. I could have put a rule to it beautiful. And when we tried to come off, bypass the aorta started doing this and I said I better come round and take over. I picked up the needle holder to take a stitch to try and put it together again. And I went, what do you think? I felt anybody? You're quite right. I didn't feel anything. A needle went through the tissue like a hot knife through butter. I had no feedback or haptic reception whatsoever on that needle not meant that this man had severe cystic needle necrosis. So I got two bits of Teflon, put it either side and put it together because he was not consented for a root replacement. So, although Sam did a fantastic operation, the problem is that he gripped the needle holder too tightly and he could not feel it. You need to feel the tissues and you need to feel the tissues through the needle and the needle itself does become an instrument. So it does mean that there is a critical position that you pick up the needle and a critical angle as well. And I'll take you through those. We often get past a needle holder when it is that 90 degrees to the needle. OK. And we try and stitch and when you look at the needle in that position, he can't stitch it at all. I'll put it against the white background. You can't stitch it at all. Look at it. I can see that if somebody can stitch properly just by looking at the way the needle is mounted. The important thing is is that this is not 90 degrees to the tissue and also is not at the tip of the needle holder. I want you to listen to this. Did you hear the difference? Now, I have now picked up the needle in the correct position. Ok. There you go. It's 90 degrees to the tissue is just beyond halfway. There's no space between the tip of the needle and the needle holder. And you see that angle there. Well, that angle was the angle between the horizontal and my forearm as I was standing with my hand palm flexed and my forearm somewhat extended. That is the angle. So the angle you actually mount the needle is a measure of the displacement of the wrist from the elbow on my wrist, elbows in the air. And sometimes I'll be stitching like that. My wrist and elbow are lined and that displacement would be minimal if not 90 degrees. But the position where it is on the needle is important is and we'll talk about the working shaft in the moment and there's no space you're holding it at the tips because that is at the maximum force applied to this. So let's just go back a little bit and talk about this rotation and this needle that we need to take through the tissues and I'll bring up my needle to highlight the various bits as we go. They are coming over the top. So we said that there's a point age and this is the working body. Now, first of all, the distance from there to there is called the cord. The length all the way around is the length of the needle. And from there to there is called the radius. Now, the switch is usually the thickest part of this head where the thread has gone in the Ethicon have just produced a sw that is thinner than this and this is done by a laser and they do six needles a second, lasering a hole in there. So this is metal and technology advancing needles at a rapid pace. The next thing is the point and to summarize, we need to just go through a little bit about the point because the one thing we must not do is hold the point. Now, needles need to be rigid and ductile, flexible enough to bend slim as possible to minimize trauma, sharp enough to penetrate tissue with minimum resistance and they need to be stable and resistant to corrosion. And most needles are actually stainless steel. And the more modern ones actually covered with a bit of silicone to actually help them go through. They're increasingly made of alloys and Ethicon make their own steel. And each year the equivalent of 100 and six cars of wire is heated and stretched to form needles. And more recently, they produced a tungsten iridium alloy. So one we got to think of is the body, the body of the needle is actually usually no. Then we've got the curve. There's a quarter from there. This wage to the point is a quarter, three eights, half needle or five eights. So that is all in eight like the cardinal wins and where you hold it and the needle you use depends on the depth, the deeper you go, the bigger the curve. But also if you got a big curve, the needle. I'll explain in a moment where you need to adjust the pick up. We'll come back to that moment. So we also need to think about the point. The point is either round bodied, empty circle or, and taper cut. Mhm. A cutting needle. And that is a traditional cutting needle where the cut is there, there and there on the inside curve of the needle and the cutting needles are used on tough tissues like skin, sternum, oral and nasal cavities. The reverse cutting is the other way upside down like that represented. So they have the cutting surface on the concave edge of it. And they're ideal for tough tissues and tendons, subparticular sutures. And there's less risk of cutting sutures with a cutting edge pointed to the outside the body of these needles as internal wires is often triangular as well. Machinery has enabled this to take it further. And now we get different sort of tapers and diamonds because of ability to handle metals. We are getting better and better at making trocar cuts to make them very sharp and go through calcified tissues. There's a particular needle called a spatular needle which is flat, which only cuts out in lateral directions. And the spatula needle will be used particularly by eye surgeons because they want to go into the different layers of the cornea without causing any damage. And if you look at suture packets, you'll find these symbols on the suture packets indicating the curve. So let's come back to our needle and how we use it. The important thing is that our needle needs to be mounted one just beyond halfway, two, no space between the tip and the shaft and three is that angle that I've demonstrated. When I say just beyond halfway, what really dictates the position of the needle is the ability to actually rotate it back and point the needle into the tissue. Got you see that you've gotta be able to point the needle into the tissue. If I'm holding the needle too far back, you can see there, I cannot point the needle into the tissue. You know this, when stitching a button on a shirt, unless the needle goes through at 90 degrees to the whooping left of the fabric, you'll find it extremely difficult to put the needle into the material. It's the same with tissue. Your needle has to enter at 90 degrees. So where you hold the needle is really dictated by your ability to pronate and supernate. Some people have limited pronation and super nation and therefore would have to move closer to the point to enable you to get the needle at 90 degrees. Now, there's something I want to just test with you 190 degrees and I'm going to should do a little test and ask you to spot the 90 degrees. Now, 90 degrees is actually the most important angle and this is the perfect angle described by Euclid because every angle in our opposite to 90 degrees is 90 degrees and 90 degrees is a perfect angle because it's the fourth part of the circle, we are hardwired to spot 90 degrees. And I want you to look around you where you are now looking at the windows, the desks, floor tiles, the ceilings, the corners, we're surrounded by 90 degrees. And I want you to try and spot the 90 degrees amongst the series. And I'll go through the slides. This is demonstrating the displacement of the wrist from the elbow and therefore the angle. Oh I think I've uploaded the wrong slide, but you can see the mass of parallel lines there explaining the 90 degrees and at the tip, the tip of the needle holder and not in the jaws and using the working body of the needle. And that's the 123 principle at the tip just beyond the halfway and you angle it out for the wrist to elbow displacement and is dictated by your ability to pronate and supernate. So here's a test, I'm gonna flick through them fairly quickly and you tell me which is 90 degrees in the letters. Any idea yet? Have you seen 90 degrees? And this is a series of angles from 86 to 94 put in the chat room. What the answer is, has anybody got any ideas? We got EC H mm OK. FS H FH Good. So when we actually go to have that you spot the 45 degrees here. Not so easy. Is it a lot more difficult? My point being is that we are hardwired to spot the 90 degrees. And that is very important as we think about our first principle of stitching. So we mount the needle properly. I've shown you that it's 90 degrees in this plane to the tissue. We understand the 123 just be on halfway, no space between the tip of the needle and the needle holder and it's angled out. So our first exercise is to take a microwave potato and remember that microwave potatoes are very hot. And what we need to do is take this needle through this microwave potato, let it cool down. You burn yourself. Can't stress the health and safety warnings here and think of this as the Chinese diving team entered the water with no splash. These are my splashing models. You need to be able to go into this potato and come out of the potato at 90 degrees. So once you've picked it up properly, you can see that the needle is actually bouncing on the tissue, ok, bouncing on the tissue and take it back, point it into the tissue and I take it forward, irritated it it and I should come out on the line. Now, the important thing is is that this tissue is holding the needle in position and that's coming out at the tissue at 90 degrees. And what I do is gently ease it through just beyond the halfway reapply and continue the delivery and note that my needle angle is preserved. I'll do that again. I am putting my needle 90 degrees into a potato and rotating it through the potato deliberately. Hello, I have come out through exactly the same hole. I am not grabbing the needle, I'm picking it up and I'm delivering it and there I can use again. Now, this concept of the needle being held in position and not being delivered by your forceps is very important. When you think of the cardiac cycle, it's systole and diastole and the rhythm doesn't change this lovely rocking motion in the chest does not change as the heart speeds up. Atrial contraction, ventricular contraction, atrial ventricule, atrial ventricular, the time it takes to eject Sicily is fixed. And what happens when the heart speeds up is diastole shortens. No, the thing is, is that you and me can put the needle in the tissue and take it out in the same systolic action. And when we're teaching people to stitch, it's stitch, stitch, stitch, stitch, stitch, that's fine. But the more you stitch stitch stitch you stitch, the more you lose the angles, the pickup and the placement of the suture. What you need to do is think about the time it takes you and me to do the next ditch is totally different as I demonstrated to there when you put it in carefully, the needle is held in the tissue, you apply your needle holder, you can deliver it on the rotation and start again. I have minimized that diastolic period because I am focusing on my set up. So when learning to stitch, it, not stitch, stitch, stitch to use your needle accurately, it's set up stitch, set up stitch, set up stitch and let's go back over and reinforce that on our pot potato model. So the setup is then summarized very easily by talking about place. Is it 90 degrees to the tissue and 90 degrees across the tissue. And I've put some lines in this potato here. OK, point pointed in 90 degrees to the tissue and rotate the needle around. See that I've come off and what we gotta do is continue to practice until we can't get a drum and drawing your lines on this potato is oops, you see that closer to the line. But if I pull it, I've torn, the potato is giving me instant feedback as I'm rotating this needle forwards and backwards again off the side. So we need to consider our rotation and set up each time because the model will determine the accuracy of your stitching and the thread will follow. Now because the potatoes, a hemisphere you can try and do this in different positions away from here to the side. And now I'm actually abducting my arm to get my wrist in the uh what we need to do is ensure that we are accurate on the lines. And this would be stitching the aorta, the junction between the right atrium, the S VC, yes, a node and is called the angle of sorrow. And can you take a needle in and out of the potato without a tearing. The principle of 90 degree alignment of point place rotate is practiced here. And you suddenly realize that you need to do a little bit of movement and that's for you to discover yourself. My favorite. No, for basic stitching is the banana. And what I've done here is made a straight incision in the banana. And I've put lines on the banana as well. OK. So really, what we need to do is we have to take a needle through banana and come out and see if you come out on the line. If you were looking carefully, I'm slightly off the line there. These exercises are not meant to be easy. They're meant to actually test your skill and actually force you to think about the needle alignment because these two edges are sitting together. I can stitch them together. But if I want this wound to heal, well, I need to go 90 degrees into what I want to stitch on both sides and because both sides are together, I can take my needle through both. There you go. I now on target, on the line and out the line on the line and out the line, I'm not using my forceps to deliver this needle at all. And I'm focusing on the accuracy of my rotation. And as I'm going along the straight line, it's as if I'm doing a continuous suture. And what I worry about with people when they're doing continuous sutures, they're literally going stitch, ditch, ditch, ditch, ditch. But they're not deliberately setting up the needle as place point and rotate, place point, rotate when you become practiced at doing that and confident and you repeat it again and again until you can't get it wrong. Simply put dots either side, equidistant, either side. I don't think that's quite accurate distance. I tried seven millimeters, but let's have a go. There you go in the dot at the dot in the dot out the dot So, and I'm actually now using the cord length of the needle. I hope you agree. That's in the dot And not the dot And you do this practice until you can't get it wrong. Once you practice, try doing it without the dots. And the thing is about the banana over time. We'll come back to this. You can see when you've taken the needle in and out. So you look at the holes there that's gonna turn black and oxidize and I'll give you instant feedback. So again, you can practice this, set it up 23 lines, three dots and then spacing and see if it is all equal, all the time, go up and down, up and down until you can't get it wrong each time picking the needle up, ready to use again, picking the needle up, ready to use again. Note that I'm not using my forceps, the forceps will change the rotation of the needle through this tissue. Not only that, there's some dreadful things that happen when people are considering using forceps. What they do is focus so much on their stitching that they grab and squeeze the tissues. And all I've done here is apply these adson forceps. You can see they've got little rat teeth there and a rat tooth there. One inter with a too, the side can get the nail, my nail in there. And I've taken the two forceps along that edge. I didn't use the pinch pressor. I was just doing that and taken non tooth forceps, DeBakey forceps along here. Now, notwithstanding the tooth forceps and the non tooth forceps are gonna crush the skin. What's gonna happen is you are going to cause a full thickness injury to the tissue because if you think of its pressure equals force of the area, your forceps are generating between 25 and 35 newtons of pressure between men and women over an area of five millimeters squared. Going back to your physics, there's 25 newtons over five times 10 to the minus 6 m squared, which equals 5 million newtons per meter squared or 5000 kilopascal or 720 psi which is 20 times the car pressure and your tires, car tire pressure. I'm looking at full thickness damage done to what the tissue there and what you should really be careful of when stitching is. Beware of your non dominant hand crushing and damaging the skin. When stitching skin or crushing the bowel or blood vessels up and down, up and down, put your forceps there. If you're using your forceps to show the skin, all you're doing or should do is just lift it. Better still use the skin hook to lift the skin. Because in fact, when you're stitching, you should be coming 90 degrees from inside out on this edge of the skin 90 degrees. So I literally not squeezing with the forceps. I'm lifting the edge coming into the middle because now I'm going to do it in two, pick the needle up, lift the edge come out 90 degrees from inside out on this side as well. And my forceps have not caused any damage to the tissue whatsoever. Now, as we close the session, some wounds are not linear and are in fact curved. So same applies, draw lines across the curved incision and the banana. And I want you to think about this point placed, rotate, place, point, quot, place point and rotate. And as you practice this, no, your body position in this position. I'm standing on my right leg. OK? On my hand and arm is slightly abducted, but I can't use that needle position in this. When I'm standing on my right leg, I now have to change to my left leg to get to this position. So you're fine as you lining your needle up from that end of the banana to this end of the banana is, in fact, subtends an angle of these vectors of 95 degrees. And that means to go from one end of the banana, from this end where I'm standing on my right leg, you'll find that I as I progress along this banana, that my posture needs to change to enable me to maintain this 90 degree alignment. As I am coming to this position, our weight distribution is, in fact, syna on both right and left legs um no coming down the side. And I'm finding that to get this position, I'm moving my weight to my left leg. So stitching therefore becomes a dynamic process where simply changing the weight from one leg to another, tilts the pelvis and therefore changes the position and angle of your shoulders. In essence, when we are operating at all times, we need to be thinking of keeping our elbows by the side. We can't keep them by our side all the time. Obviously, because a bit like putting a screwdriver in a cabinet in an awkward position, you find you have to abduct your arm, but we should reduce that to the minimum because any abduction of the arm is gonna increase fatigue and therefore increase the risk of tremor. And that is why when you're finding your arm is actually abducted and your elbow has left your side, you need to consider your body position. So now having we come from there to there, I'm actually finding I'm on my left leg. So stitching is very simple. You need to understand the mechanics and the mechanics and angles are not, are ready to your body habitus. One do stand properly. We cover this posture in a separate letter with that angle there which I showed you on the parallel. If you draw parallel lines and the principles of parallel lines that drink green triangle is that angle of displacement of the wrist and elbow. You can imagine when my elbows up, my wrist and elbow is not displaced. But if I find my elbows in the air, what I should do is step into my elbow and turn around. So my elbow comes down to my side and I'm not using all that stress and all that muscle activity to abduct and to do that, I either step into it or just change the distribution of weight from my right leg from holding standing on both legs, turn to the right on my right leg. See the movement turn to the left. Yeah. And I'm not moving this simply changing weight. And this is why I also went standing. You shouldn't actually have your legs locked out. They should be slightly bent as well. The curve and where you pick it up on the body really depends on your ability to pronate and supernate the five eights needle you will unlikely be able to get. This is a half circle needle. And therefore, for me, on the half I can rotate and that pin pricking into the skin. There you go 90 degrees into the skin. Yeah, on a five eights needle, I'd be unlikely to do that and therefore hold it closer to the point. The thing is no matter how sharp a needle is, especially in colony surgery. Sometimes you come across even with these kryptonite or ever point needles semi oh the size of your eyelash and the size of the is the needle and the thread, the thickness of your hair, even that needle has difficulty sometimes going through calcium. And because you want to control the needle through that calcium, you hold it closer to the point. So the force you bring to it is perpendicular and direct end to that calcium and you don't stab it, you support it the other side with a forcep and you try and pass it through. If it doesn't go through, you don't force it because it couldn't crack and ruin the coronary vessel. You either go over it or under it as well. But the nuances of using your needle and understanding your needle again comes down to the force that needs to be applied at the point. If you need to apply a lot of force with calcium, you need to hold it closer to the point. The other trick also for vascular surgery, I showed you the fact that the belly can push the tissues down. And when doing vascular anastomosis, everybody's worried about picking up the posterior wall. What it is quite useful to do is use this alignment. You push the posterior wall away by the belly. You can slide the needle under and it bounces up through the anterior wall and you've got a perfect stitch. We'll show that to you next week in more detail as we explore our stitching in greater depth. But this is where understanding the anatomy of the needle and using your needle as a tool, it does become very important. The size is dependent on the tissue that you're stitching. And of course, they go from very big needles to very small needles to microsurgical needles. But the principles of pick up and the principles of the rotation are exactly the same. No matter how big or how small for the microsurgical instruments. The rotation might be a simple role like that or your fingers, especially if it's on the surface. And you're using a 3/8 needle and you don't have to move it much to get that 90 degrees in and 90 degrees out. The important thing to remember is that your forceps are going to ruin that rotation. And what you need to practice and be aware of is get the needle to work for you. There's one little other trick to demonstrate here for the needle working for you and that is getting the needle to pirouette over the point. And what I mean by pirouette over the point because I've got it angled out. OK. I can now practice getting my needle forehand and backhand, stick you on the surface, but practice picking it up forehand and backhand. So I'm not grabbing the needle and rotating it in the jaws. And this is where that cuboidal shape is actually becomes important. You'll get the impression and hopefully you'll see it actually flips into position so I can control the needle forehand and backhand by getting it to pirouette over the point. So I never have to use my forceps to change the direction of the needle and we'll talk about that further again next week as well. So simple needle skills are important. The thing is is when you're operating your field of operating and focus is usually within three centimeters, you don't want to be taking your instrument further out of that field because you're losing your focus. So learning to get your needle to work for you big needles, small needles is very important for coronary surgery. And a 70 needle. I use poached eggs as my splash model. They make a little arteriotomy in the membrane of a poached egg. And yes, a register did ask me how to poach an egg. And we practice taking a needle in and out of that membrane of the egg without scrambling it. And that is another one of my models. So one last advanced thing I've actually said to you place at 90 degrees across what you want to teach, point at 90 degrees into what you want to stage, take it through the tissues and I was offline there, pick it up and do it again, reduce the diastolic period. Now, what I didn't say is an actual little bit. How do you unlock the needle? Well, if you look at the needle holder at the end, there is only a small ratchet of millimeters, 1.5 millimeters. So to take it off, the ratchet is literally a me. So pushing it August with your thumb like that and learning to take it on and off. The important thing is, is that think about it this way, I'm going to place the needle down. I'm gonna rotate and pronate back to point it in the tissue. The pointing bit is showing me precision and I'm putting it right there. Nowhere else. I'm putting it right there with the point. But as I'm going on over, I'm unlocking the needle. That means that I can start putting the needle into the tissue and it delivering it through without unlocking one the needles in the tissue. Because certainly I've seen this in coronary surgery, in particular and fragile tissues that people don't unlock the needle before going in. And what happens is it tears. Think about it this way, when you throw a ball, you're holding the ball, you don't stop midair, open your hand and let the ball keep going is part of one process. So part of learning the understanding and the feel of your needle holder is learning to actually take that little ratchet off. You see that little ratchet there, not much and slippery 1.5 inches. And that is a simple movement of the thinner eminence of your thumb. I would like all trainee surgeons to have their own set of instruments so they can practice. I'm still working on it. That is my goal and that's what the Black Belt Academy will do. When we open up live face to face in the Faculty of Medicine at the University of Malaya. We will have instruments for you to practice. I hope that has made sense. It does involved practice ish had a lesson with me the other day. Perhaps ish. You would like to describe to the audience your experience with this practice. Mm Yeah. Hi, everyone. So I think the only thing I would like to highlight that uh it is actually harder than it looks. Uh So if you have been practicing on a skin pad for a very long time, this will be a totally different experience. Uh I think it will give you more feedback. Like what David mentioned and give it a go. I think it will be really an interesting challenge. Well, you mentioned that dirty word skin pad, the thing about the skin pad is that it's not going to show you the accuracy of the movement of your needle and it's not gonna give you the feedback. We've done a study that has been written up. We're trying to publish it where we have put skin pads and we've put bananas in a CT scan. And I can tell you now, the Hounsfield units for a skin pad and a banana are totally different. The Hounsfield units. In other words, the density of the skin pad bears no relevance to human tissue at all. I don't think they should be used. On the contrary, I don't think it's sustainable either. See the advantage of doing this, this is sustainable surgery. You can actually peel the banana. It's been tiring. You're hypoglycemic. I need to eat the banana. It does not go to waste. More importantly. Look at this, I told you that I didn't use any points or pens. There was an entry in and an entry out the banana will tell you when you skid the needle in or skid the needle out. See that and what you need to be seeing is a perfect round exit of the needle from the tissue anana. It aa it, that was on ink dots that was without ink dots. I hope you can see now the value of using the banana. Any other questions and thoughts finish. Mr Caddy is a fellow sensor and plastic surgeon in Sheffield. He's been with me on this journey for a number of years since they cut. Would you like to add any more to our discussion on needles? Yeah. So my, my observation today relates to context in which you're using the suture. Um So the needle that you are using has got a trocar tip to it. Yeah. Um Usually when we are closing skin, we use a reverse cutting needle. Um So I find some of the things much easier whereas in the context of using it that obviously works well, but there are lots of different needles that the students could choose where you give them some guidance as to which needles to seek out and start using. Certainly we did, we did go through the different needles and cutting, reverse cutting and trocars and it really depends on the thickness or density of the tissues. The reverse cutting are usually the more stable needles and used for tendons and ligaments. Also, the trocar cuts are used in particularly uh vascular surgery and coronary surgery because you're going through calcified tissue, the round body needles, you want to be doing minimal damage and therefore are used in solid soft organs like liver and spleen where you don't want anything cutting and the needle passes through with minimal damage. If you look at the needle package, you'll have circles and triangles upside down, et cetera with various different marks in them indicating the degree of taper. The tapering happens within that third end of the needle. And it's only because of improved machinery that we are now able on fine needles to get these incredibly complex tips and cuts. The other thing I would emphasize there is that the needle is a surgical instrument and particularly the tip of it, you do not crush that you do not grab it, you stay well clear of the, the very tip of your needle. Uh Otherwise, you will need to ask for a fresh suture and often you don't want to do that indeed. Um And we find as our ability to machine needles at a finer diameter, you're now getting things like premium cutting needles and composite um tapering needles with diamond cuts and reverse cutting all being improved to actually maximize penetration and minimize tissue damage. And the advancement of needles over the since 1922 has been quite incredible. And really, that's down to the different alloys that are being used. What's interesting, I was given a 70 needle and I used a Visy black on coronary and that was a particularly hard needle, which is great for the internal mammary artery to the led. It was my preferred needle. But I found on one occasion and repeatedly that this needle wasn't quite working the way it did. And I spoke to the rep and I said you have changed the needle and he said, nope, we haven't changed the needle. Not at all. Three months later, he came back at cap in hand and said, actually they did change the tip of the needle. They didn't tell marketing, but I had picked up the tip of the needle had changed and that was on a 70 needle, the size of the eyelash, I actually felt they made this fizzy black in Germany and in Michigan in the States. And I actually felt there was a difference between the two needles cos one and I don't know which one was, which one was just perfect and the other one I felt didn't quite have it. Although they assured me it was exactly the same. But I maintained that the alloy process in one factory compared to the other was not quite the same. And I feel II could feel the difference. I suddenly picked up the change in the tip of this needle. And the marketing person told me no, but came back cap in hand eight months later. Well, three months later, the thing is when you get used to using an instrument and you understand the feel and the precision and use it as a tool, you know, immediately when it's working or not working. On another occasion, I had a patient on the table who has done an emergency in the morning. And a 45 year old man and the and he, he took priority because he had a men's down and there was a 74 year old lady diabetic with three vessel disease. Second, after the first case, they told me they had no more Visy black on the shelf. So I said to the theater team, yeah, this lady was stable and I was not inclined to do an operation on a 74 year old lady with calcified vessels without the right suture. And all the theater team actually agreed with me and said it was foolhardy. So I didn't proceed with the operation. We didn't have busy back in the hospital. Well, I was actually told off by the medical director for doing that, but I maintain, it would have been foolish to embark upon an operation and find myself with my hands tied behind my back on a 74 year old lady with diabetic vessels at that age and with diabetes, there's no room for error and no room for chance. And I certainly wasn't gonna chance it. We got the busy black. I did our operation and we didn't have a problem. So did, did you inform the medical director of your actions? And what was the response? Uh I am here to stop. Yeah, he was a vascular surgeon as well. Uh I informed the theater staff and the the head of theaters and ascertained that there was an ordering problem with sutures in theaters and a system error. And I said, well, that's fine. Well, we learned something from that, but I'm not prepared to put this woman at risk. And I understand he was walking around afterwards with two different 70 needles saying, I don't know what planet he's on. Yeah. But did he actually mount it? Did he mount the needle and put it through tissues? Because part of what you've been saying is, is a lot of this is the feel of the instrument, correct? And particularly the needle. And, and that's not something that you, you, you can't look at it. You have to feel it correct. And this person or there was a vascular surgeon didn't quite appreciate that. It is the feel. But hey, no further comment, it, but I think it's a story that emphasizes the feel even on a small needle. I'd like to thank you, ladies and gentlemen, for your attention again. Thank you to all the Malaysian students who have signed in. You do get CPD points for this. We do welcome your feedback. So please fill in the feedback form and very well good. Welcome to Vanuatu as a country. You're taking us up now to 128 countries globally. And that's only thanks to Medal and thank you to finish, continue the practice and we will continue the story with part two next week as we explore stitching further than the nuances and we will expand on some of the principles we have demonstrated this evening. We have some. Yes, of course. Yeah. So the first question is uh what happens when the incision is not the same as the cord of the needle? Ah, well, there's so many different types of needles that you can use. So you will find a needle to close the respective tissue at the respective depth. And this is why when you look in theaters, there are all sorts of different types of needles. You need to understand the tissue. You're working on the depth. You're working at the thickness of the suture material that's required to maintain integrity of the tissue as it is healing, that will determine the thickness of the needle. The depth is really determined by the rotation above the tissue. If you take the rotation down, lower you go deeper. If you take the rotation up higher, you're more superficial. But this is where you need to be able to understand the needle, the uses the points and what tissue you are actually stitching. It's complex and there's a lot more to it than meets the eye. I off in this, I cannot talk when we talking about, I have a needle. Never mind. Second question, sir. Yeah. And the second question uh as I understand the longer the needle, the more to the tip, I will put my needle driver to make a perpendicular entry to the tissue. Correct because this comes back to this pronation, Super Nation. Uh If you look at my pronation super nation, I've got a wrist injury on my left. So I can't supernate completely on my left. I'm limited and pronation. So the not everybody can supernate to 90 degrees. Most people, 80 some people are limited. So that again, as I said, according to your body habitus and your ability to rotate, the important thing is that you're using the anatomy of the forearm to rotate. None of this is actually with the wrist. All right, like this is catching fish. Ok. This is not really controlling the needle at all, especially with your fingers through it. Any other questions? Uh That's it. Yeah. Well, I thank you for your attention and look forward to seeing you next week in goodly numbers as we further explore these models and hopefully gives you. So I'm thinking, I do remember the damage your forceps can do. Thank you very much. Indeed. I wish you well, wherever you are in the world.