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Summary

Join retired cardiac surgeon David O'regan for an in-depth examination of the surgical needle, its evolution, and correct use in a surgical setting. This on-demand teaching session, accredited by the Royal College of Surgeons of Edinburgh, will delve into the history of the needle from its earliest archaeological findings to the cutting-edge tools we use today. You'll find parallels drawn from lessons learned in martial arts to understand the ideal technique for maximal impact, minimal disruption and increased accuracy when using surgical needles. O'regan will leave no aspect unexplored, covering everything from needle anatomy to needle holder usage. Don't miss this most educational global event, targeting medical professionals from 27 countries.

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Description

Part I of our stitching series will focus on the anatomy of the surgical needle and how to pick the needle up properly. We will describe different types of needles. We will focus attention on the pickup of the needle which will help you improve the accuracy of stitching while maintaining the relaxed posture of operating. This needs conscious attention at first but will become automatic with practice. Technique triumphs over speed and power. BBASS focuses on flow, rhythm and lightness of touch. Does your needle sing for you? Learn how to use your needle. BBASS is the first in the field to deconstruct and attend to the basics by drawing learning and inspiration from the Martial Arts.

Learning objectives

  1. Understand the historical developments and improvements of surgical needles, and how these changes have enhanced surgical practice.
  2. Be able to identify and describe the different parts of a surgical needle and their functions.
  3. Learn about the different materials and manufacturing processes used in needle production, and how they affect the needle's performance.
  4. Understand the importance of needle handling techniques, including how to properly grasp a needle driver and effectively use a needle holder.
  5. Develop an understanding of the importance of needle angles and how they influence tissue penetration and wound healing.
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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. Good day. Good afternoon, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon, the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And this course is accredited by the college and we offer CPD POINTS. I'm currently the Professor in the Medical Education Research and Development Unit of the Faculty of Medicine at the University of Malaya and we're coming to you tonight from Kuala Lumpur. It's 23 30 100 hours and thanks to me, we are reaching 27 countries, Uganda, Peru, Sri Lanka, Lebanon, Honduras, Ethiopia, Bulgaria, France, Germany, UK Qan Philippines. To name a few. Thank you to all the followers. 1733 on Twitter, 4240 on Facebook and 771 on Instagram. I have recently taken up or restarted my journey in learning yo at the Japan Club in Kuala Lumpur and all there. I may be second down with a sword turning up to be taught y sense in yo. I suddenly realized, I don't know anything. One of the most important lessons that he taught by holding the sword is let the sword do the work for you. Do not chop slice, relax. What was interesting in his instruction? Each and every movement is prescribed and described. And I'm holding the blade and thinking I'm holding it correctly and it come up and say that's better and moving it by a few degrees, learning to use an instrument with that sort of instruction is significant because they have looked at how you hold an instrument, the angles, the fulcrum, the physics to minimize wasted movement, improve the flow and maximize the impact. It's technique before power and speed each and every time. And he was able to deconstruct many of these movements and get us doing exercises to reinforce the basics in one part of the kneeling carter, you have to kneel down again to check your opponents dead. I wasn't doing this correctly because I was going down with the weight being born on my front leg and my front leg was at not at 90 degrees. And when I lifted up again, I was leaning forward and the weight distribution was on the front leg and not pushing up with the back leg. And therefore I did not maintain an erect posture. Apparently, this is something that the examination sensors look at when doing. I heard somebody else being coached and instructed across the room and he was practicing for his grading. And the word was we want to see you demonstrate this with confidence and that's what it's all about. So tonight, we are looking at the e of surgery, the needle and the first form of sewing was probably trying to sew animal skins together. And they used a piercing instrument to make holes in the leather and put a thread through this. And obviously, the limitation to this was to make a small enough hole. Such the thread would sit comfortably inside and not to damage the rest of the material. And traces of the all the piercing instrument have been found in archaeological sites. A point that might be a form of bone needle dates back 61,000 years discovered in the caves in South Africa and a needle ma made from bone of a bird found in the Dennis sovereign caves in Siberia 50,000 years ago. And a bone needle dating back to 47,000 years was found in Slovenia and another in ivory birds in the Jin Province 23,000 years ago in China, ivory needles have been also found in other parts of Russia and 8600 years ago. A Neolithic needle bones were also discovered in Turkey in the Dezi Province. But copper wires and metal wires were first found in Naqua Egypt, ranging from 44,000 BC to 3000 BC. The history of needles really is the history of metallurgy and eye needles were found in Bavaria in Germany dating back to the third century BC. So the advancement of the needles and their use has been a, a result of the ability to form iron to steel and two alloys enabling the needle to become thinner and finer. With concomitant improvement in manufacturing and laser technology, we now get down to 7080 needles and the surgical needle is there to allow placement of the suture within the tissue, carrying the suture with it with a minimal amount of residual trauma. We have previously said that all needles are made in the circle. When you carry the needle through the tissue, a tangent slice at any point should render a perfect circle in which the needle sits. Any skid or rotation leads to a gap which is bleeding or microabscess. The swage which is the back end of the needle and we'll go into the anatomy in a moment is the thickest part and has been the thickest part for a long time. The swage began when MRSA was doing catgut sutures and started embedding it in the end of the needle in a hole and crimping it. Those holes are now made by laser and the suture is inserted in the end. And eon have now produced a needle where the suede, the end bit with the thread goes in is no bigger than the rest of the needle. So the ideal needle needs to be rigid and resist distortion. Another is d flexible enough to bend without breaking, slim to pass through the tissue with minimal trauma and sharp enough to penetrate the tissue with minimal trauma to the surrounding tissue. And also needs to be made of a stable material that is resistant to corrosion. And they are commonly made of stainless steel and alloys. And many of these are actually covered with a silicon coat to actually help them blind through the tissue hycon, make their own steel. And the steel that they use to make the sutures every year is the same amount of steel to make 100 and six cars. They came to me with a kryptonite needle for cardiac surgery to try and this was a tungsten, I think radium alloy that was extremely fine and very thin. What's interesting that the Visy black needle that I commonly use to put the lemur to led I felt on some occasions what had changed. And I brought this up with a rep and he came back and said nothing's changed. Three months later, he came back and apologized to say that the manufacturing team had changed the shape of the tip of the needle and that's why I noticed the difference but they hadn't passed it on to the sales team. So even with the 70 needle, I was able to pick up that difference, what I'd also found with the Visy black, the same needle one was made in Munich one was made in, in America, but I think one was better than the other. I couldn't say which was American, which was German, but they behaved differently. So the idea of a suage needle is not really foreign because the native Americans were known to use sewing needles from natural resources. And one such resource is the algarve plant. The leaf would be soaked for an extended period of time leaving a pulp and long stringy fibers and a sharp tip connecting the ends of the fibers. And this was the needle. So the sharp tip was a needle but it continued on to the fiber. And I suppose that was the first natural needle. We're just going to revisit how to hold the needle holder and the needle driver. Now there are many eponymous names to needle drivers and the metallurgy enabled needles to become curved and why they became curved because that was therefore possible to take a needle and operate it at depth if I take a straight needle like this and I take it in depth, you see, I haven't got so much space there and I can't move it around. However, if I take a needle of similar length, this is much shorter but round, I can take it in in depth and move it around and manipulate it in dark cavities. Exactly when the curved needle came about. I'm not quite sure I did ask the last CEO of econ about the history of it because HYCON was originally based in Edinburgh. And I also asked why the curve which we will describe at the moment that was not clear. And if anybody out there has an answer to it, I'd be very grateful if you could share it with the Black Belt Academy. So let's come over to the top and look up what the principles of the needle entail. Now, all needles and here is one are effectively made on the circle. And our duty is to take the needle cleanly on the circle through the tissue, minimizing the damage that is to the tissue. At one end, you have the swage where the suture is attached to the needle. The needle is on a curve, it has a body and it has a point. Now, the degree of the curve interestingly enough is in a s and again, this is a question that I do not have an answer to and why it has ended up in a s nobody can tell me. And if you can find out again, please share it with the Blackb Academy. So if I take the wage here at 100 and 80 degrees, you have a quarter length needle which is 90 degrees, 3/8 needle, which is 100 and 35 degrees, half a length, which is 48 needle. And then another needle that goes to five eights. And the reason that we have these different length of needle, it really depends on the depth of the tissues. We are stitching him. There are specialist composite needles, part curve, part straight for specialist functions found in, um, maxillofacial surgery and sometimes found in gynecological surgery. But this quarter three eights, half and five eights doesn't really come into play unless we start thinking of this five eights. Because what we've got to be able to do is to rotate the needle all the way back and point it into the tissue at 90 degrees. Because if I don't come at 90 degrees to the tissue, the needle will bend and deflect off. And the principle of using the round needle is to rotate it back such that you can point it into the tissue. If I come in at a funny angle, it deflects and bends. Now, most people when they are pronating and supernate are able to take the hand from 90 degrees, pronate 90 degrees and supernate 90 degrees. And that is not a problem. And that is the principle on why we want and encourage you to palm your needle holder because that pronation and super nations between the index finger, middle finger and the common flexor origin. So if I just demonstrate that for the moment, pronation super, I almost get 270 degrees in that movement and the tip of the needle holder remains steady. The beauty about the upper limb is that pronation Super Nation action that is not too dissimilar to using a screwdriver can be performed no matter what position the upper limbs put in with respect to the shoulder girdle and scapula. As I said, you do want to be able to bring the needle in 90 degrees into the tissue because you're coming at an angle. That's where you start bending and it starts getting as well. So let's come back over the top and look further at the anatomy of the needle. Firstly, you got three parts and the three parts of the swage, as we have described, the body of the needle, which is the working part and the tip and the no go areas for holding a needle would be that bit and that bit one because you're gonna damage the needle point in tip and two this area, you are going to damage the swage and the suture itself. The body of the needle is not exactly round, although there are perfectly round atraumatic needles, most of them are sort of oblong shape. If I do a cross section at that point, the tip is fashioned in all sorts of different ways. And the most common is a blunt indicated with a single point in a hole. The blunt is actually like that, a taper point which is a conical point going to a sharp little bit is indicated by a small point like that. So those are, that's the basic round tip to the needle. Then you've got the cutting point where the tip of the needle. If I take a cross section through here is triangular shape and in big triangular shape, this is the cutting needle, it's cutting that direction on the concave surface and cutting in those directions as well. The reverse cutting is opposite to that. It cuts both ways. But now cuts to the outside, this sharp point and that sharp point are cutting the tissues. And that's why you're using it for thick tenderness material. And with that cutting, you're potentially damaging. As I said, with improving alloys e spatulate and where it's flat there and flat there, not damaging. And it's in fact cutting laterally out each side. Now, with improving technology, the point has actually moved such that they can now sculpt this end bit. So we end up with a taper cut needle or partly taper cut needle at the end. And all of these are to actually improve the ability of the needle to pierce the tissue. As I said, as manufacturing's got better and more complicated. Some of these designs on the end are now getting quite special and we're ending up with diamond cuts or even smaller diamond cuts and curved cuts at the end. And if you look at the tip or any packet, you'll see that the description of the tip is indicated by a circle. Half is that half circumference. And that is a conical tape account, the length of the needle is a cord length between the swage and the point, wherever that is, the whole length is on the circumference from the swage to the point and the radius is from the center of that circle to the body. And that is how the geometry of the needle is described and recorded on the needle packet. And do have a look at all of these to get some idea. No, the bigger the suture, the bigger the needle. And we won't go into different type of sutures today because we've covered that before. But obviously the finer the suture, the smaller the needle, the blunt needles that have a large blunt tip here are used to separate the tissues and used on fibro tissues to reduce the risk of damage. And they best suture for inserting deep sutures and wounds. The taper point or sharp needles pierced like two cars and spread to tissues with minimal cutting and then used in areas where leakage must be prevented because it's not cutting out sideways like these. So this would be used in soft tissues, subcutaneous tissues. Jura Gi muscles, mucosa, the cutting points and the pacing points have sharp edges that are used to cut connected tissues, tendons and the spatulate ones for separating layers and particularly helpful in ophthalmic surgery. The thing about the cutting needles here, cutting the directions on the inside, on the outside of the curve, predicates on the inside of the curve to actually cutting your suture itself. So do be careful the interesting thing about the cutting needles. I was teaching on an aortic valve course two years ago. And Martin who used to be my trainee said to me, have you ever looked at the instructions for putting in the valves? I confess, I hadn't. He said, well, it's useful because if you look at that, they recommend you do not use a cutting needle through the cuff or the valve because it might indeed damage the material. And the valve itself. I had known that fact and he, he pointed out on a training course. But when you next look at your needles, look at the packet and think of the tissue that you're using and, and stitching and what the function is for cos that will determine how you're going to use a needle and why. So I'm gonna move this out the way for a moment and we're gonna focus on the needle itself. So the pickup and I am going to focus down on the needle. So we have a good view and I think I might have to use the bigger needle here and focus. So the working part of the needle is the middle third and I suggest that you put it just beyond the halfway. This will change, this position will change depending on what you want to do. Firstly, to pronate the needle, it's got a pronate it back enough. So it points into the tissue. So I don't know if you can see that, but that is not 90 degrees into the tissue there. And therefore, I am limited in my pronation to point the needle into the tissue. And I should come closer to the midline because that is the limiting factor is pronating it back so that I can point it into the tissue. That is the start of your rotation at 90 degrees. The other reason you might want to move closer to the point is if you're piercing something hard and calcified, and you want to push it directly into the tissue like that rather than coming at an angle and it bends and deflects and even on a coronary artery that is calcified on a small needle, I would pick the needle up closer to the point. And indeed, if it's very, very calcified, put a pair of forceps on the other side and support the wall and push it slowly and deliberately through in 90 degrees because I can actually then control the tip and it knock and the scar as soon as you start trying to push something through and you're too far back, it is actually going to fall out. So your position on the needle really depends on what you're stitching, but also limited to your pronation super nation. Now, there's, that explains the position on the shaft. The second important thing is there should be no space between the tip of the needle and your finger. All right. And this is actually useful because it's act maximizing the sweet spot. If, if you think of any tennis racket golf club, there's a sweet spot to pick up the needle and that is at the very tip. And I'll explain another advantage for that at the moment. So rule number one is to pick it up just beyond halfway or pick it up, such as you can rotate it back and point it 90 degrees into what you want to stitch or you bring it closer to the tip. So as you point it and push it through something really hard. And certainly when I'm using the reverse cutting needles, the sternal wires, and I'm pushing it through the sternum, even with a big needle, I'm mounting it on a heavy needle holder and I'm pushing it 90 degrees through this 10 that way. But now there's an another important element we have said. One is just beyond halfway. Two, there is no space between the tip and the sharp. So I can, should be able to run my fingers along there. And if you're wanting to mount the needle, we'll come to that in a moment. Hold the needle on the palp of your finger and you will not give yourself a needle stick injury. Indeed. Yes. Needle stick injuries are common in theater, particularly if you look at gloves and studies have shown holes in the gloves afterwards. You certainly know you've got a hole when you're using your forceps to conduct the diathermy and you feel the burn through your glove. The fact that it is not a hyp needle, the fact that you're wearing gloves and you've got alcohol between your glove and the skin. And as soon as you feel a sharp point, and if you're holding your needles lightly, you're not gonna penetrate the tissue very far. And the risk of transmission of disease is therefore very low compared to hypodermic needles. So the next important element of this and this is where I have a B and my bonnet because I do not believe we are actually teaching the ergonomics of stitching properly if my wrist and my elbow and I just come up, most surgeons are actually standing. Ok. So if I'm standing and I'm at a comfortable height with my elbows by the side of my shoulders down, am I elbows are slightly extended and my hands are palma flexed, but like a puppet. We've described this before. You'll see that my wrist is displaced from the horizontal from my elbow and that displacement between the retractor and the elbow, you see that angle there. Well, that is the angle that we need to change the needle and I'll come back over and show you this. So if I'm sitting down, if I'm sitting down my needle ankle is appropriate, if it's 90 degrees across the tip, and most of the time your needles pass, pass to you like that and not at the tip and not angled out. But this is me sitting down and look at my needle and I actually presented and rotated round. That's fine. And I put the belly down, you can see the body of the needle is pushing the tissue away. Let's focus a bit further. The body is pushing the table away. What happens then if I'm in a sitting position and I now stand up and if I stand up, you can see that this 90 degrees in the sagittal plane is lost. OK. There's no longer 90 degrees and it's tilted out. And that just because my wrist is now lower than my elbow and to correct that that angle I've just demonstrated, I need to put on my mo and that's the third principle of your needle pick up. Now, you can see that the Sagal plane is 90 degrees to the surface and you can try it yourself. I take a box, you can audible. That's the belly. I don't angle it out. Can you hear the difference? That's the belly hitting the surface. In other words of aligned in this, in this plane where that is not aligned and that alignment angled out is vitally important because now you've got the 90 degrees and because all angles, 90 degrees is a perfect angle. It's fourth part of the circle. I need to know, bring my needle 90 degrees into what I want to stitch and I can rotate it around because I've got the 90 degree plane here and every angle is equal and opposite at 90 degrees. So I can put 90 degrees across what I want to stitch, rotate it back, 90 degrees into what I want to stitch. And that is critical to maintain the perfect rotation through the tissue. Now, there's another wonderful thing about the fact that I got angled out. Now, I've previously demonstrated that I'm holding the needle holder in the palm of my hand and I'm unlocking the needle holder with abduction like that. But what I want you to learn and practice in this exercise is to hold the needle holder without the ratchet on. I haven't got the ratchet on. And if I got the needle holder without the ratchet on, I should now be able to move the needle around just gonna pick up the other and flip it over and per it it over the top, forehand and backhand. That's the angle I want to stitch. I'm just focusing again and I can pro it over the oop seat. So what I'm trying to do and demonstrate is you can get the needle to move for you without bringing your forceps into play. And if you relax the needle, hold it and relax on your grip, the cuboidal shape of the needle holder of the needle body will enable you to flick from forehand to back hand to forehand tobacco. Now, you're gonna say, well, I'm doing that on a solid surface. Well, yep, I am. So as part of our teasing exercise this evening, what I am going to do this is a slice of mango is see if I can practice my needle maneuvering. I pro my needle over the top without damaging a manga. So you don't have to use force. And I'm not making a smoothie out of the mango and I'm using the anatomy of the needle to flip it over forehand and backhand to me to continue stitching. And this will become apparent and important in part four of our stitching series, you can use any type of material to practice this because you don't want to be sticking it in and pulling it around. That's not the point because you're gonna damage the surface. You're working on. What I'm doing is pi wetting the needle over the point, forehand and backhand. So I thought to myself, OK, Mango is kind of soft or what could be softer and more challenging than a watermelon. And the watermelon season is out at the present moment. And again, I am going to practice picking my needle up and positioning it on a watermelon without making a mess of the watermelon. So I'm learning lightness of touch and learning con control a bit like my sensei said in karate, I should not be chopping with a blade. I should be slicing with the braid and I should be using less strength and more technique and relaxing and letting the instrument and the needle do the work for me. So there you go pirouetting over the top on a watermelon and I hope you agree that I am not mushing the watermelon up when I'm practicing simple needle control without mounting it with the forceps and I can get it into any position that I require. My forceps are used for retracting and holding tissues and not for positioning or delivering a needle in majority of circumstances because the tissue would hold the needle in position for you to continue the rotation. And we demonstrate that with different models next week. And I hope you can appreciate this is what is referred to by a cardiac surgeon at hospital. And he called this sexy moves by fellow Carrera was demonstrating the sexy moves on Twitter, but I don't think he was doing it on a watermelon. So that's big needles for you. But what about really, really small needles and here at the tip of this and we will focus down even further. That is a seven or needle. OK. And the seven eye needle is used in cardiac surgery for most anastomoses. But I want want to demonstrate to you the rotation of a castros before we go any further. And if you look at that, you will immediately see that I'm holding my castros in a manner, not too dissimilar to the way I hold forceps, my distal interphalangeal joints are extended and the palps on my fingers are applied, enabling me to use and la likewise, the castros here around body and the movement of pronation and super of the of the needle is literally a small little twist like that. And let's see if we can focus down onto the tip and have a look at these principles as well because the principles of needle pick up and rotation are exactly the same no matter the size of the needle, I'm going to put this, I think against the white plate. And you can see that I'm holding it, it's probably a bit too far. The same mounting. Yes. No space between the tip of my finger and the pulp. Yeah, is mounted just beyond the halfway and angled out. And that is what I need to look for. I need to practice with even in the current circumstances, one way of practicing these moves with a seven hour needle is, can you move your needle forehand or backhand of the top on a poach deck? Now, it's a little while since I've been playing with seven o'neills. So just bear with me a moment. The principle of doing it on a peg is exactly the same as doing it up on. There you go. You see, it does not take much of a movement and then you go back hand. Ok? But it's a little learning to hold a needle with the lightness of touch and try not to pierce and practice picking it up and moving your needle without and getting the alignment each time the practice, you should be able to move it forehand and backhand and pick it up. Why? Use a poached egg? Because that's not too dissimilar to a wet, sticky surface. Now, if I look at that, I'm not happy with that position because it's too near the w and it's not at the very tip of the castros. So if I was going to reposition it, I put it on the tip of my finger, ensure the alignment and do it again. But with practice and I haven't practiced this for a while. I thought I practiced it live with you this evening to demonstrate that this is a very sensitive and very difficult exercise. They can be mastered that it gives you control of your needle and picking it up from a surface that is easily damaged. And what's like lovely is the poached egg is that surface? And it's not too dissimilar to many of the tissues. And the other thing is, is that because it's a wet, sticky surface, you can see that the needle itself becomes wet and sticky as well and is not behaving itself. So you can have hours of fun concentrating to move it, the needle around. And I am concluding with my, to myself that I've not practiced with my seven day needle for some time. And I'm not wearing my loops either, but I'm not making excuses for not OK, being able to do this, I'm just thinking to myself with the purge dig out. I am going to do some practice, to be honest. So give me immediate feedback and that's coming back to my sense being second done in I and starting to learn again and thinking actually, I've got a lot to learn. The thing is about all these models that we're introducing to the Black Belt Academy is to give you a model that's gonna give you immediate feedback and test your skills. So get you get black belt control of your needle. It doesn't take much time to start recognizing, I can change it forehand and backhand and gain control of the needle soup. Just as the sens a suggested some very basic exercises to help my sword skills to get the cut and slice properly. The models and the demonstration here today is there to try and instill confidence and practice in your needle skills and show that you don't need a power of forceps the majority of the time to take the needle out of the tissue or to repossession. It suffice to say when you take a needle out of the packet, it's normally mounted in the perfect position just beyond halfway and you can take your needle to that position on the packet and rotate it out and you're ready to use. I can tell whether any stitch is going to be effective just by looking at the needle mount in the angle before the needles actually entered the operative field. And a bit like the yoke of the, I've got the operative field when stitching is literally the two or three centimeters around the area. That is your focus of attention. When you're stitching, that is where you need to have the needle working for you and not coming out, remounted and refocusing all the time getting it in the right position, keeping it in that position enables the flow and rhythm of your operating. Now, we're joined this evening by my fellow colleague in sense, Mr Chris Caddy, who's a plastic surgeon who's quite used to using 7080 and 90 needles. And I would like to invite him for his reflection on needle use and needle skills. Mr Cady just to do your best. All right, David. Yeah, that was a masterclass in needles and there was a lot there which many of our audience weren't really comprehend the significance of what you're saying. Um when you were talking about the, the needle and the feel of the needle, um one of the things that happens certainly in the UK is that procurement comes along and changes the needles completely without talking to the surgeons. And uh you can say, what's this needle? Uh and it's all in the field. It's got the, so the, the nurse will say, well, it's a whatever it is. But you say, well, it's not the same as a normal one. So when you were talking about being made in Germany or the United States, you can feel the difference and the way it goes through the, the, the tissues is, is, is quite amazing. Um, so you're talking up to sort of 70, sutures in microsurgery, we use 89, 10, 0. And for microlymphatic anastomosis, you're using 11 and 12. 0. So they're much finer than here. So you, you need to get used to using it. But certainly demonstrating on larger needles gives you an idea of what's happening and how you adapt your technique to use them. Yeah, when and I'm sure you've found with the 10 or 11 0 needles, they're fine as a hair. You two are using your Castro Yvo type of needle holder. But your protein exudate in surfaces mean that they're very sticky and needles of that size do get lost easily but also do stick to the tissues. So having a good control and being comfortable and confident with a needle is very important and it comes back to demonstrating, I believe and this is the way I think surgical education could do a lot more is demonstrating these simple techniques with confidence on morals as we have demonstrated this evening that goes a long, long way to helping your surgical skills and you practice until you can't get it wrong. I know when I was practicing with that egg there, you'll hear that I go quiet and you, I feel I'm being drawn into the model and drawn into the practice to get it right. And I think models are not there just to do that, not only got to test the skill but need to absorb you in the concentration and the flow of doing it as well. And that is what I believe is missing in all the plastic models and skin suturing models that we have out there because I have not come across and I'm sure my fellow colleagues, Chris would say I have not come across any synthetic material at all that feels like organic material in human tissue in all my years of surgery. And that's why I think we should be practicing on organic materials. It gives you instant feedback and you immediately learn to lighten the touch and let the needle do the work for you while we're on the subject with small needles and getting stuck in tissues. A question that popped into my head and relevant. What do you do when you lose a needle on the count? And when does it matter? And when does it matter, Mr Cutty? Well, most hospitals will have a protocol for that uh and your scrub nurse. Uh uh and the, the runner will discuss that with you. So at the beginning of the procedure, you will discuss what happens if you lose needles. So, microneedles are a bit different to the larger needles, larger needles, you certainly have to recover and there are various ways of doing that. So they will have a magnetic sweeper. So, if you drop it on the floor, they can pick it up from there. Um, but the very fine needles, you know, if you think about shrapnel during, um, uh, military injuries, you can embed lots of metal within the body and it has no or minimal effect. Um, so I wouldn't lose a lot of sleep over leaving a microneedle behind. But what size is your cut off then? Uh, well, I, so I'm looking at 890 10. 0, so, II have lost 10 0 sutures or I haven't lost them. I just haven't been able to find them again. So they might be, they might have been uncovered. The thing is, you see, part of the protocol is, yes, either on the floor and you can pick it up on the floor and have magnetic pick up on the floor. But if you had lost it in the body, in a cavity, the chest or the abdomen, yeah, I would say anything smaller than even a 50, needle would be awfully difficult to find. So that is why part of your needle discipline is to keep it mounted on your needle holder and make sure that you counted in encounter out in your mind each time and get into that discipline. Radio x rays are not going to pick up. Don't have the resolution to pick up fine needles. And perhaps somebody could in the listening or a radio radiologist can tell me what is the smallest needle that you could possibly see on a, on an X ray, portable X ray in theater. Because effectively you stop the operation, check the count and search for the needle and don't close until you found it. But there has to be a cut off point of leaving a wound open in a patient anesthetized for a prolonged period of time where you hunt for a needle in a haystack. Yeah, a lot of that is about the amount of radiation you use in order to find it. If you're doing an X ray of a needle that's end on, you won't necessarily see it. Hm. But you have to take it from multiple angles to try and find it. And most patients are not gonna be on an X ray table either. It therefore presents a problem. And it is one of those situations where prevention is better than cure and being disciplined and how you use the needle counted in, counted out. So, a lot of that is about mindset and the culture within the operating theater. It's how you hand off the needles and how you receive them. So it can be, you can feel it's being irritating when the scrub nurse hands you the, uh, the needle holder with the needle mounted in a kidney dish or a receiver and you have to pick it up, but you need to develop that as part of the way that you handle all such material and they will count it in and count it out. So if they don't get the needle back, they want to know where it is. And that, that comes back to our discussion about teamwork in the operating theater. You're not alone, there's a whole team there watching what you're doing and keeping an eye on what you're doing. And I think if you're going to take a needle off a thread, that's fine, do it away from the wound itself and have somebody paying attention and a kidney dish at hand if you're doing that and take it and don't and leave it on a needle holder on a ratchet secure when you cut the thread, do not hold it, you know, fingers cut it because you never know you might drop it and lose it. We, we're getting instant feedback from Gabrielle about um the size of needle and radiograph. So, thank you Gabrielle. Much appreciated. So any other comments, ladies and gentlemen and any other questions from the audience? In which case, I one comment from just about uh realistic skin pads, but I think I know what you're going to react to that one. Yes. Yes, I II ask, ask her to try it out and report back to us. Yes. Then if you really want to test, test your closure, try testing a closing of a banana skin. It's easier to take the banana out and try stitching a banana skin. Uh That'll teach you lightness of touch when I look at what people are trying to do on suture pads, uh and the amount of talk and tension they're putting on and there was a comment on why the needles are actually rounded. Yes, I believe you can put a lot of talk on it because the simple movement of supernate like that is you can answer in the chat room, what is the most powerful supernate? You've got? What's the most powerful supernature? Anybody in the chat room? Straight it up? Any answers I have for you? No answers in chatter. The most powerful supernature you've got is actually the biceps. All that is why you've got screwdrivers that work in a clockwise direction such that you can use your biceps to tighten. So there Yasmina Ezra biceps, very good biceps are not needed in surgery. In fact, they're not needed with Kana. You need to let the blade do the work for you. Exactly. And that's what and, and relax and that's what my sense said to me. And that's what I hope to impart with you with the Black Part Academy. It's technique, not power or speed because the other one, Miu Masashi said one of these principles is do not do anything useless. Thank you very much for your attendance. We look forward to seeing you next week. Where we continue part two of our needle journey where we look at rotation, we're grateful if you take a moment to fill in the feedback form, do pass the word around. And next week is very special because it's our 1/100 podcast. And I think we need to celebrate it 100 broadcast on the Black Belt Academy of Surgical Skills. Look forward to seeing you next week do spread the word. And I'm also hoping after tomorrow's meeting that we can go live with an academy here at the Faculty of Medicine in Kuala Lumpur. Goodnight. Good day. See you next week.