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Hello, good evening. Good afternoon. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a professor in the Medical Education Research and Development Unit in the Faculty of Medicine at the University of Malaya, the immediate path director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And they accredit this program. Welcome if this is your first time. And thank you very much indeed for returning. If it's your second or fourth or fifth, we have a following now of 4338 people in 100 and 29 countries. And tonight 64 people are registered and thanks to me, we are reaching 30 countries including Afghanistan, Cyprus, Georgia, Jordan, Kuwait, Mauritius, Ne Pale Malaya. Of course, Oman, Qatar, Romania, South Africa, United Arab Emirates and the UK. Thank you very much indeed. And thank you for joining the Black Belt Academy. I read the answers to your questions with interest and I hope to answer them as we go through this evening's lesson. What is interesting that everybody seems to favor a forehand stitch rather than a backhand and the alignment of needles in various situations is poorly understood and explained. And I hope by the end of this evening that you'll have a better idea. But first I would like to go back to a little bit more of the history of needles. I said to you that I'll try and find out a little bit more why needles are straight. Because I demonstrated last week you take a straight needle in a short space and you can't rotate it. Well, I've done some further research and there's a nice paper called the History and Evolution of Surgical Instruments by John Kirk up who is a consultant orthopedic surgeon in bath. And indeed, I did some of my training in Bath in UK and he was the assistant honorary curator in historic instrument collection at the Royal College of Surgeons of England. So as we said, that needles have been around for a long time in the form of bones and only became possible as far as manufacturing is concerned with the age of metals, with bronze and iron and steel forging the way the earliest ones perhaps happened 4000 BC with the smelting of copper. But the application to actually surgical procedures as we know today probably didn't happen to 600 BC needle making in itself became a specialist craft in the 14th century. And the Cian Monks Bosley Abby in near Reddit in the UK and Worcestershire converted drawn steel Hamid one and two flat punched a hole and created eyed needles in stages which are still the basis of making needles today. And about 1655 needle manufacturers were sufficiently independent to establish a guild, the guild of needle makers in Thread Needle Street in London. Although Ridd became the principal center for manufacturing in Britain and it continues to be so before Lister and we said before that the sterilization that Lister brought into surgery changed everything because it made surgery inside the body cavities, relatively safe suture needles till then were straight and principally used for the skin closure. And the variety and range was rather small and it was not unheard of for surgeons to request glovers straight. Sakr curved on appropriate needle tooth stitch the skin. And in fact, Druitt wrote in 1859 the straight Glover's needle is a very convenient way to stitch the skin and can be procured from any Cutler. Interesting at those times, in 1497 another person pointed out Brunswick pointed out that the lance and the round pointed needles were beneficial. And in 1575 Parre demonstrated that the three cornered or trocar needle was actually sharper and better for piercing tissue and it was cit in 1275 pointed out that the triangular point was better than the round point. Now, in 1320 a de Mon Deville remarked that the suture wounds inside the mouth or the eyelids a curved needle was best. So I don't know if he actually came up with a curve needle, but they found as soon as you left the skin and went inside the orifice that you had to curve the needle to enable you to manipulate it in that space. It's uncertain when we actually ended up with a half circle needle or 5/8 needle. And they are certainly part of the 19th century innovations. Now, why it ended up as half, 3/8 or five eights, et cetera? Why? And eights at all is a bit of a mystery. And again, it's something that I've done some research into whether it is related to the four cardinal winds of heaven or the intercardinal winds that would be at, at eight points on a compass rose that forms part of all uh compasses. Now, I don't know, but there is the history of the needle from a quarter to 3/8 a half to five eights. Why? Eight? I really don't know. And I can only assume it's due to this compass thing following the introduction of antiseptic techniques. Of course, I know with increased knowledge in metals, we found an explosion in different types of needles. And even today, the innovation and manufacturing of needles is becoming a real specialist science with increasing use of alloys and particularly refining the tips and the sw where the thread goes in. And by 1961 the diversities of sizes and shapes of needles described by Shrimpton and Fletcher. They had 5000 different needles on purpose purchase on their list. And it increased ever since we'll address the eye of the needle next week in our next part of our exploration of the needle. But surgeons have forgotten they development and the importance of the eyeless needle because quite frankly, they have become disposable. So what it comes down to now is how we think about stitching. And as we owed to last week, when we follow a curve incision, as you see here on a banana to reiterate the point, pick up the needle is 1231 just beyond halfway, two, no space between the tip and the shaft in, three angled out in doing so that enables you to align the needle 90 degrees to the tissue. All right. And as I pointed out last week, I can press safely into the palp of my finger because I'm using the belly 90 degrees in that plane and now can rotate the needle back point at 90 degrees into what I want to stitch. And I can de determine that I can point because I can pinprick the banana skin. And now I simply need to rotate at this point. Here, I've, before I came on air, I was taking the needle in and out of the tissue and I'd done that 12 times take through, deliver it iterative and pick it up. What happened when I start my alignment here, as I described last week to minimize the abduction of my arm. I've turned my weight onto my right leg and almost turned into my elbow. So I'm not abducting my arm. Now, place point rotate and I rotate the needle through the tissue, pick it up and do it again. But to go from there at 90 degrees across 1 to 1 to stitch to here, I cannot stand in the same position. There's no way. And to come to this position, the place point rotate principle maintains, but I'm now standing on my left leg and my left leg and I rotate the needle through the tissue. So to get from that position to this position, I need to change the weight distribution on my legs from my right leg to my left leg and I go through effectively 90 degrees. I'll just turn the camera around the other way cos it makes it easier for me to see the screen as well. Ok. As we go from there, right leg to there left leg. So what does this mean as far as stitching is concerned? Because a lot of what we do is going to be stitching around in 360 degrees around a circle. And I'd like you to look if I put a needle on my needle holder and I'm just simply gonna rehearse where I am. So as a surgeon, I am standing here at six o'clock away from me at 12 o'clock, three o'clock, nine o'clock and much of what we do in surgery, whether it's an aortic valve or bowel anastomosis or a vascular anastomosis. We are looking at clocks 6, 12, 3 and nine. And we need to orientate ourselves. The exercise is to think about how you're standing. So, in this position, I'm fairly neutral at nine o'clock, perhaps more my left leg eight, seven, six. And as I come from 7 to 6, I'm now finding I'm standing more on my right leg, five on my right leg. And then I get to four o'clock and I'm almost leaning into the table and have abducted my arm. But in this position, I'm trying to stitch into my shoulder, I'm right handed and this stitch is coming into my right shoulder. It is in this position that trying to affect a rotation and stitch. You see how my arm is bent? And we talked about a rotation previously is actually pronation ation. See how my wrist is bent that I'm not going to be able to rotate or anything like that. In this position, I have to do something different. This is where we now have to go backhand. The principles amounting are the same just beyond halfway, no space between the tip and the shaft and angled out. And now I'm standing on my left foot and by rotation, is it easier pronation? I'm on my left foot, pronating, pronating, pronating. And as I'm coming around here, I'm moving from my left foot to my right foot. I'm always standing on both feet and in this position to affect this stitch, I'm standing on my right foot. But now I've got a problem here almost diagonally opposite. Uh And it'll be different for you because of different shape, but you'll find diagonally opposite in that position to affect, look at the position of my wrist. Again, I cannot rotate. I therefore, in this position now have to change. And I'm now forehand and I'm standing on my left foot. So just to reiterate here, I was backhand on my right foot. And in this position, I am forehand on my left foot and I continue round the circle, forehand on my right foot. And this is where practicing your petting of your needle over the tip. And now I'm back hand on my left foot. So you can see how I can maintain my 90 degrees to the circle at each of these points by using a combination of forehand and backhand. But what I've actually done is moved from my right leg, backhand in that position to my left leg, forehand in that position. And you'll find that one half of anastomosis here is forehand and that hand is back hand. Now, what I've done here also, I've from blue to red. That's a half circle. That's a three eights, that's a quarter, 38, half and that's a five eights needle and we said the eighth is how much of the circumference goes round. But you notice that that is 90 degrees rotation, 4545 plus another 45 degrees. Those mark the winds, 4545. And you need to remember when rotating the needle, it is the point that is going to give you the precision and accuracy. You want to be able to point the needle into the tissue. Ok. Left leg pinprick it that pointing ensures accuracy of entry. But you can say I want to put it there. You're not using the belly, you're pointing into the tissue. And that point action is limited by your pronation super and also the length of the needle. So this is a half needle. So I can pronate, see I'm too far back and I am not pointing into the tissue too far back and that is not pointing into the tissue. So I need to come forward and now that's pointing into the tissue. So where hold it in the shaft is determined by how easy it is to pronate the needle back, to point it into the tissue. So it's not in a fixed position. Ok. That's easier. Certainly with a smaller needle is not an issue. It's easy to rotate and point in. But you use the smaller curve needle on something a little bit more superficial. So bring that to the exercise of point place, rotate on a banana. And what I've done is literally taken an apple cora and called out a section of banana. And the aim of this exercise is for you to go round. And I suggest you start out by literally marking out vectors for yourself. So you rehearse it, place it 90 degrees. Remember your circle theorem that 90. When a line hits the circle at the point, it hits the circle to the radius will be 90 degrees. So 90 degrees and you point it into the banana and you rotated out, OK, pick the needle up and you move to the next part 90 degrees across what you want to stitch, point it into the lumen and rotate the needle out. Note that I'm actually using the full cord length or diameter or code length of this needle. The code length in diameter for a half length needle is the same place, point, rotate, place point, rotate the thing about stitching. It's not stitch, stitch, stitch. Whenever you stitch, you need to actually set yourself up properly. As I'm coming around here, I'm now finding that I'm on my right foot predominantly and I'm continuing my place point, rotate, place point, rotate the pointing bit is going into the needle into the lumen. And I'm not actually touching the flesh of this banana with a needle holder. Remember on this, the tractor I showed you in this position, I am now stitching in to my right shoulder. I therefore need to turn my needle backhand. I need to move to my left foot and continue I exercise and place point rotate backhand. Now, what I note in this exercise is between there and there from the change from forehand to backhand, the spacing goes awry. And to be honest, when people do this exercise, I can see somebody who's right handed and that's too deep from the edge or left handed because of the space demonstrated. So I'm changing the angle of the needle at the moment to actually ensure that I'm standing in the right position, right angle to place point rotate. And as I come around here, I'm moving more to my right foot, I've almost stepped into my elbow that was slightly abducted. And I'm using a big needle in this circumstance to actually demonstrate. And you can see, but you can also see as the needles were rotating backwards, it does actually damaging a banana. So for the purposes of stitching the skin, this would be too big a needle. But what I'm using it for is to practice my rotation. So from there to there, I went from my right foot to my left foot between 1011 and 10 o'clock on this banana. And I continue the rotation by drawing it out. We'll use a smaller needle by drawing it out. This is helping me in thinking on my body position and thinking of my needle alignment, making sure that I'm entering the tissue properly. And what I'm trying to do here is literally come perpendicularly out of the banana. So the secret here is to go in and rotate it some perpendicularly coming out of the banana. You can see now the smaller needle, it is actually a little bit easier. You don't need a thread for this exercise. What I want you to do is just practice and rehearsed your alignment and rehearsed your body position. So here we go, five o'clock, my next ditch will be way into my shoulder. So therefore, I need to flip my needle to back hand, turn to my left foot and continue my stitching. All right. Now, the important thing is as I flipped it from forehand to back hand. As we described previously, we're doing that without the use of forceps. I find it quite an engaging exercise and it's interesting and my son just pointed out in a book that is reading the atomic habits. When something becomes automatic, you stop thinking about it. And when you're stitching in this place, point, rotate, I don't want to, it should not become automatic. You should be quietly saying to yourself place point, rotate to reinforce positions. Now, you can see as I'm going round, you do this a few times. The banana actually starts showing you the holes. So you can see, have you come out cleanly nice, clean hole, bit of a drag, clean hole, clean hole, clean hole. Ok. But the same thing applies on even smaller holes and I'd like to just show you how to use the castros and smaller needle. Now, the castros uh round bodied like a pen and they sit in your hand like a forcep and the rotation of the castros is literally a rolling of it. A rolling of the barrel. They are used for, I use it for seven os 50607 ohs and most microinstruments are on the same principle. But the mounting of the needle, the position and the line is exactly the same, bring you back over. And what we've got here is a smaller hole that I've made. You can use the barrow or pen. But I use this for practicing top ends, which is the top end being the colloquial term for a vein graft has been sewn to the coronary artery. And the top end is the vein graft being ANAs directly to the aorta. So imagine the aorta is not too different to the thickness of the banana and your rotation of the needle a 50 through this needle and your placement of the sutures is exactly the same, the pickup and the rotation of the needle is exactly the same rotation is achieved with rolling of the barrel of the needle. I've lost under control of the needle there and rotating it in and out and picking it up in the same way. Same principle applies and what you need to be able to do and if I look at the distance from there to there, it's not a distance. And to be honest, I'd say I'm a little bit out of practice of top ends of con. And if I wanted to practice doing, I certainly said myself this exercise to do to get it regular. So there you go. I'm at five o'clock position. Even with a small needle, I now need to turn to my left hand, left foot and back, hand, left foot, back and place point, rotate. You can see even a 50 needle. He is making holes in this banana and giving me feedback, place in a note. So the exercise on the banana and I've got more than 12 sutures here. I think they're fairly scent. It's interesting that the pap surgeons are trained to actually do tw eight stitches on the top end. So when they think of a top end, they do eight stitches. But I hope you can realize now that the principles of alignment apply equally two small needles and big needles. I'm good. A good, I didn't rotate the needle and my alignment. There was poor and I need to set up the angle better. The thing is about surgery. You must not accept anything that is ok, is a dirty for two letter word in my book says the word fine, fine as a dirty four letter word. So that's more than 12 sutures. But I think fairly equidistant. But as I went round. The principles of moving between my right foot and my left foot remained when it comes to arteriotomy, small or large. The principles of alignment are the same, exactly the same. It's 90 degrees across what you want to stitch. Ok, 90 degrees into what you want to stitch and then out and what I need to do, particularly when stitching skin is you need to be able to lift the skin up, edge up and make sure that you come 90 degrees underneath it and you threw at 90 degrees, it comes out at 90 degrees. So, although I use the skin retractor there, we often given forceps, but I hope you appreciate now that the tooth forceps that severe damage. So the 90 degree principle applies at every point. So this is not a circle, but it still applies all the way along. So even at this point and this point, the angle subtended between there and there are not too dissimilar to the angles that I demonstrated on this banana earlier and you're moving your body from there to there was 90 degrees from this vector here, that vector there to that vector, there is probably 80 degrees. Now, the thing is we get to a point where we talk about a heel and a toe, we'll call that the heel and the toe, the heel is always proximal with the blood flow going that way. OK. So the heel is proximal in the vascular anastomosis, the blood flow is there to the toe. You can imagine that it's quite easy to crimp the heel and the toe. So when it comes to the heel and toe, 90 degrees is at that point and is angled out along that line. What is 90 degrees actually at the toe, mean at that point or 90 degrees at that point is actually parallel to the two walls of the vessel parallel to the two wars and you take the needle. Sure. Now you can see the same thing applies. I have to go backhand to get to that angle. Cos that was the angle at 11 o'clock hand and the back hand there and come out the same applies at the hill. The hill 90 degrees is parallel to the two walls. OK? But if we're going around the hill, we got one stitch here angled out because what you want to do is form a sort of tr application. And now you can see that I'm gonna be stitching into my right shoulder. This is where my alignment and body changes. The alignment is the same 90 degrees which is parallel to the two walls, lined it up. And I take my needle through, I'm now standing on my left foot and I can, can continue mysis. So the principles are moving around an anastomosis is a dynamic one guided by the alignment of the needle and simply changing your weight distribution between your right foot and left foot. And this is something that I think you need to work out yourself on a model like this. Practicing at. What stage on that clock is it? Five o'clock, four o'clock could be half past five. It could be half past three that you're having to switch between forehand and backhand. To be honest, I had a cardiac surgeon who joined me excellent training. Very neat with his hands. But when I put him through his paces, he actually didn't have a back hand stitch at all. He did everything beforehand and got himself into very comported positions to get some of the forehand stitches there. They were accurate enough. But actually, that's like asking Roger Federer to win a game of tennis without having a backhand stroke in his repertoire. So what we actually focused on was a backhand stroke and the back hand is effectively pronation. The pronation is somewhat easier. So as you look at the banana, you can see where the needle has come out, but there's something else to add to the use of the needle, particularly with a vascular anastomosis. And I'll demonstrate here essentially when doing a vasal anastomosis, we're taking a needle into a vessel. And the thing that begin a surgeon's fear the most and most surgeons fear the not is the needle picking up the posterior wall. Imagine that's a two millimeter coronary vessel. If you don't angle the needle in properly, you're likely to pick up the posterior wall and cause damage. Here. There is a trick. The trick is now to mount a needle further towards the switch is where my needle is there. I then used the belly of the needle here to push the posterior wall away. That means I can gently slide the needle into the lumen. And it means then my needle can on a recoil almost perpendicularly come out the front by presenting the curve of the needle to the posterior wall. I'm never going to run into this problem here of the needle hitting the posterior wall at all. So use the belly, push the posterior wall away, slide it along and allow the recall to bring it up. So let me see if I can demonstrate that to you on a model that I have here, I'll just get out the model. What I've got is some macaroni pasta. All right, and go where a bit are cut earlier. Um Inhale AAP got a bit of macaroni pasta here, focus down and indeed pasta is actually a quite a nice material to use. So if that, if you imagine, and this is far bigger than any coronary vessel, if I'm actually taking this in at that level and at an angle, the chances are that I'm gonna hit the posterior wall. Ok. What I need to be able to do is hold the needle further back as I'm showing you there, I'm holding it much further back and now, I can use the posterior, the belly to push the posterior wall away and come up to the end to your wall. It's quite fragile. This, it's been water. Yeah, it's breaking. But I hope you can see that I can push the post of your wall away. Let me just find another piece here and I'll make a little incision in it. So I'm going to use my needle to actually push the posterior wall away. OK. I don't want to, to pick it up. I can push the posterior wall away and I can bounce my needle through the anterior wall like that. You can see the force is down. It's out of the picture at the moment. I've used the belly of the needle to push the posterior wall away down there, enable it to bounce up to the surface and I'm not going to break it. Now, the other thing to practice with the needle, especially on small needles and small things. You can use your needle gently to separate. Yeah, to define the edges. So I'm using it. And when stitching, you need to be able to lift, you gotta be able to lift this tissue up. Rotate the needle, don't push down and push it across. The easiest and safest thing to do is use a rotation to lift the edge. You can appreciate my needle going into the lumen and I'm lifting the edge. OK? See if we can get closer or without moving my hand. So fine coronary vessels I can use, I can walk my way along and anastomosis get to the tip and lift the edge and rotate, you know, through and you can use pasta. This has become quite sluggy, but you can use pasta practicing that's becoming a little on the wet side. Let me find another piece here. What I'm trying to demonstrate to you is that you needn't be scared of the sharp needle on small things. On the contrary, the needle point will actually help you define anatomy. There you go. You see, I can lift the edges, lifted and rotated. Deliver it. Oh, there is a challenge. It's not tearing, but it's torn off the past of there, but deliver it without tearing. But you two can find all sorts of intriguing models at home to practice skills. In fact, the skill I use in cardiac surgery for practicing this is make a little arteriotomy in the white of the membrane of cooked over the yolk of a cooked poached egg at the point place, rotate it remains. So if that was yo, I'm not gonna come in at this angle and try and stitch it because I'm likely to hit the posterior wall. I'm holding the needle a little bit further back. I'm using it to push the posterior wall away and I'm bouncing up through the anterior wall. I'm never ever, ever gonna hit the posterior wall by doing that one more time. There you go. I can push the posterior wall safely, almost slide it under. And that's how I get my heel and toe itch each and every time safe and effective. So the alignment of the needle and your positioning is going to dictate exactly how you hold it. The position of the needle to the tissues is absolute. And that is the 90 degrees and the 90 degrees as we said before is and useful marker to be honest, because we are surrounded by 90 degrees. Because even Euclid described that the meaning of right angles refers to the adjective erectus or straight and right angles are fundamental to Euclid's elements. And he didn't use numbers. He defined them in book one definition, 10 as two straight lines intersecting to form two equal and adjacent angles and two angles which form right angles are called perpendicular. And you use these right angle definitions in 11 and 12 to define acute angles, those less than 90 degrees and obtuse angles, those more than 90 degrees and two angles are called complementary when they make up a right angle. And that became the determining factor of right angle triangles and the basis of trigonometry. As we know today, the thing is we are surrounded by right angles. Very simply the needle has got to go 90 degrees in this plane to the tissue, 90 degrees across the tissue and 0.90 degrees into the tissue. If the two edges are together, you can go through both at the same time. But if the two edges are separated, you can imagine the 90 degrees there and the 90 degrees there are two totally different vectors. As I've demonstrated almost 90 degrees in themselves, they should not be taken as one. What happens. And I'll just demonstrate on my model is when people attempt to do two, a stitch and two edges are not perfectly aligned. They go through this end halfway through or they don't even take it to, to go through that end and then turn their body and twist and try and force it to the other side. OK. And they literally think I'm being clever by dragging that through, pulling it and coming through the other side. Now, I hope you realize in doing that the other camera again from there, then try and drag it through the other vector and pull it through. Just look at the damage I'm doing to the banana and doing that. So my plea is very simple. It's a very simple play. If the two ages are separated like that, 90 degrees is there and 90 degrees is there, please don't try and force it through because you will damage the tissue. It's much better to go 90 degrees in into the lumen in 90 degrees out and on a banana like this, which would be a fusiform incision. You work from the outside to the center, deliberately equal spaces gently bring bringing it together and all being well. If it's on L lines, you'll end up with a perfectly closed incision. That is the fundamental principle. Almost as the eucalypt principles of stitching. It's not stitch, stitch, stitch. It's a set up. It starts with a 123 of your needle, pick up one just beyond the halfway. But remember, I've demonstrated that moves depending on the displacement of the wrist and elbow and whether you want to use the belly of the needle to push the posterior wall away. Two, there's no space between the tip and the shaft. That means that the tip of this needle holder is not mushing the banana. And you're actually maximizing the movement. Three, that angle out is the angle of displacement of the wrist and the elbow. But in recognizing that out angle, it ensures that you've got a sagittal plane. So I know whether the stitch is gonna be good or bad. Literally, by looking out the needle is held and how the needle is mounted before it enters the field. Then I want to say, please point, rotate, place it 90 degrees across what you want to do. You pronate to point. And as I demonstrated, as you pronate to point, you've unlocked the needle, you point because pointing gives you the precision and accuracy you wanted there, but it's 90 degrees into the tissue. And then all you need to do is let the needle do the work for you. I've hoped I've demonstrated this evening that this place point rotate principle works on circles, ellipses irregular wounds and is the fundamental of all good stitching. What you need to work out now is where on the rotation, whether it is in the lis or circle, how the movement of your body changes from your right leg to left leg and where you go from forehand to backhand. Remember to practice your backhand as well as your forehand because we don't want to see on your banana stitching the tail tail gap and lack of spacing at the changeover point that I've demonstrated already and marked by my pencil. I hope this has made sense and invite any questions that you have or any observations. And my fellow Sensei Mr Caddy, who is a plastic surgeon in Sheffield is with us. These principles are part of all stitching and I'm introducing it to our Silent Mental Program here in Malaysia. But it's part of the what I call the indelible signature as I mentioned in the beginning because the patient will look at their scar and remember you for everything you did said and how you made them feel so past this should be Dente. Indeed Mr Caddy, it was Dente but it dried out with the air conditioning here and got really solid. So I put a little bit of water in it and now I end it up soft, but I hope you appreciate that you can use your needle even on soft tissue to lift the edges. And if you wanted to practice chorions, I do commend the post egg and you can use the point of the needle to actually feel your way down and to find a space in, in micro stitching. What we do is to inject fluid into the lumen of the vessel which brings the walls apart for very small vessels, very, very small vessels. Yeah, uh fluid or actually in cardiac surgery. Well, we use heparinized blood and in cardiac surgery, uh you can just dip your finger in a little bit of heparinized blood and dip it in and it gave, gives you contrast fluid. So do you put any contrast in the fluid that you use or you? No, no, you just use um heparinized saline because we don't want to clot the vessel that we're. So it's heparinized saline. So it flushes it out. It gives you a clearer view and balloons the walls apart. So you can see them. Indeed. I didn't realize you did that in cardiac surgery. I was doing that with heparinized blood because that was freely available. So there you go. And then, and then you can't see what you're doing. I I'm not, I'm not pouring it out. Carry, I'm just using a little dip with a little drop on it. Ok. But II need to be able to see the suture as it goes through the lumen. Sure. And and, and what size vessels are you stitching? Cos you, you do the same thing obviously on the very smaller vessels smaller than the two millimeter coronary vessel. Yeah. So what's the smallest vessel have you stitched? Uh Well, I'm not stitching now, but, but so we do lymphatics and lymphatics are very fine. So we're using sort of the 11 0 needles and suture material. So it, it's, it, it's the same thing. It's just a different scale. You're applying the principles. And when you're at that level, I presume you're using interrupted sutures rather than continuous. Absolutely. If, if you use a continuous suture, it tends to crimp the anastomosis and it can't expand. So the thing about vessel walls is they are flexible uh and you need to put them in, in interrupted. So when you get to a certain size and it's the same with veins as well. Never ever close a vein with a continuous stitch, veins are meant to actually dilate to accommodate the increase in cardiac return required for exercise. So never ever close a vein with a continuous suture. So in coronary vessels, we are using a continuous suture. In coronary vessels are probably two millimeters as as Chris said, when you go down to very small vessels that itself actually can strangulate, but that's also very important at the heel and toe. So in very small vessels, if you have this heel and toe stitch far apart, you can actually crimp the heel and toe as well. So the positioning of that really is dependent on the size of the vessel, the smaller the vessel, the closer those are together as we'll come to next week. When you're stitching a patch into that, or you're stitching a vein into that, you don't stitch a sharp end to a sharp end. So when we're cutting a vein or spatulated an internal mammary artery, in fact, what we want is a blunt end, a rounded end going into there to hold it open. If you try and cut, cut a patch or cut your vein or a end to side. ANAs sis as we talk about, if you have a point, you're not gonna get the accuracy and also the risk narrowing the heel and narrowing the toe. So on an end to side anastomosis, you need a round heel and round toe to sit in to that. Otherwise, the whole thing will be secreted and on a very small vessel, interrupted, sutures are better. How many sutures do you put in interrupted on a lymphatic vessel? Then Mister Caddy, it's all context dependent depends on the size of it where it is, but it, it can be very minimal three or four, three or four. And that's really just to hold it in position and let nature seal it together. But then there's a whole other area to discuss there about using um anastomotic couplers uh and uh using glues and lasers to, to weld uh wounds together. But that's for another day and that's into microsurgery, which you might be doing one day. But only once you've mastered the basics Venetia, you've been practicing Venetia is our producer. He's the fourth year medical student here at the University of Malay. He wants to do cardiac surgery, Venice. You've been practicing on the banana. How have you found your practice going? I think it has been improving lately. So I've been trying out over the weekend, but I think there is still much to improve, especially in terms of getting equal distance facing. And uh I think improving on the rotation as well to get it out evenly across the, the banana or across the incision actually. Have you seen an improvement yourself? Yeah. Yes, I have. I've been trying out for about two or three weeks now. So definitely some improvement. So the thing about the banana, as you can see in here, you can see all the holes made. All right. So it gives you an immediate and visible feedback. It doesn't come immediately, it doesn't come automatically and does require that you talk yourself through the place point, rotate. I sincerely hope that has made sense. We're going to continue this needle alignment and rotation next week. As we start thinking of taking our two dimensional objects into the three dimensional plane and get you to think about how you join things together like B or Ureter and how you orientate things as well. So I look forward to seeing you next week. We are going to break for New Year's Eve and then we'll be back in the New Year with a new cycle. Thank you very much for. There is one question, of course. Yeah. So Safia is asking, I'm asking about, for example, in exam setting, when the examiner thing, I hesitant by measuring my next move each time or I just do this in a practical setting, uh severe. If your examiner is thinking that I'd be delighted to talk to them because I am not teaching speed. II, as I previously said, when I first started cardiac surgery, the first instruction I had was just be quick on a two millimeter coronary vessel. You cannot be quick, you have to be accurate. The rest takes time as we said before, the set up in accuracy is of paramount importance. What we're rehearsing here is it a set up stitch, set up stitch? And when you get used to the set up, you'll find that the interval between your stitches reduces. And this is what I call the diastole. The dice is were reduced naturally because you're setting yourself up. So I have, I personally have no problems with anybody setting themselves up to do this ditch properly. I much prefer that than somebody just go stitch ditch ditch without thinking about it. So I'm afraid you do not need to worry about that feedback. Uh you might get from a trainer. I think it, to be honest, that's a bit of a wrong way of looking at it and continue deliberately setting yourself up properly each and every time. So, thank you very much. Indeed. Any other questions? I just have one last question. So on the fusiform incision, right? Do you actually close from one end to the center, then the other end to the center or one end to the other end? No, I a fusiform incision, I'll start from one end and the other end and walk to the center. What you're doing each time is actually taking up the tension but also ensuring the spacing. So I'd go from one end to the other. You cannot put a stitch across the middle of that. You can imagine the tension there would be too much. Whereas if I walk my incision across from the two edges, it'll come together, obviously, the length of the incision it needs to be appropriate for if you're excising a le a lesion, appropriate for the size of the lesion, you cannot close a circle. What's interesting, I had a lesion on the back of my hand taken out by a plastic surgeon and I was astounded that they made a small fusiform incision and I looked at it and I thought, hm, there's no way that's gonna end up as a fine line. And indeed, it didn't wounds heal from side to side, not end to end what you want is a wound to come together without tension preferably along Langer's lines. And you'll have a beautiful closure and choosing closing a fuse form of excision as Mr Keddy is saying, is context dependent. And just again, looking at and also it depends on the amount of tension in the skin. Important thing is you do not want any tension anywhere in your anastomosis. You don't want any tension in your arms and your upper body as you stitch either because that's not gonna help. All right. Thank you. Thank you very much, everybody. I'll see you next week.