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Hello, good evening. Good afternoon. Good day. Wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon, the immediate past director of the Faculty of Surgical Trainers, the Royal College of Surgeons of Edinburgh. And I'm coming to you from Kuala Lumpur. I'm a professor in the Medical Education Research and Development Unit of the Faculty of Medicine of the University of Malaya. Tonight is a special night. Thanks to Medrol. We have reached the 100th anniversary of live broadcasts. We have also passed 3000 registrations and over 30,000 minutes of viewing of the videos. We have over 100 videos on catch up now, thanks to med, all we are reaching every continent, South America America, Europe, Eastern Europe, the Middle East, China, Russia, Australia, and all the islands in between New Zealand, Indonesia, Philippines, Seychelles, Maldives, Ireland, and of course, the UK. Thank you very much indeed for following and spreading the word. We hope we are making a difference. This is the second part of a four part series trying to deconstruct stitching. So you understand why and how to make and take a batter stitch. We previously said that all needles were made on a circle. And the role of stitching is to take the needle on the cycle, take it in and take it out in and out on the curve to 360 degrees. And why we need to do that is because if you take a tangential section of the path of the needle through the tissue, one should see that the suture sits cleanly in the middle. If you drag it in or drag it out, you are going to end up with a space as indicated by the red pen. And that space is bleeding in a vascular anastomosis or spurting in a car anastomosis or a micro abscess, which will lead to breakdown of the bowel anesthesis. So it's vital that we understand how we rotate the needle. And previously, we said we start by holding the needle properly on the access of pronation and Super Nation. Such that pronation cation almost gives me 270 degrees. This simple action you're familiar with using a screwdriver and with the beauty of the upper limb is that the pronation Super Nation action is maintained no matter the position of my shoulder, humerus and elbow. And you know that too, because he use a screwdriver in the most awkward of places. The next important principle is the pick up of the needle. And you remember we need to pick it up just beyond the halfway that there's no space between the tip of the needle and the shaft and the of the needle and the needle is angled out. So the perfect mounting as we described last week is that there's no space between the tip of the needle holder and the shaft. I'm just beyond the halfway and we'll talk about this again in a moment and the needle is angled out. The reason for that is that angle. Remember is the displacement of the wrist below the elbow and effectively the horizontal of my forearm. And mathematically parallel lines, you can work this out yourself. It means that the needle comes down onto the tissues in a perfect plane of 90 degrees and will explain that further. You see what is the history of 90 degrees and what is the history of 360 degrees is what we need to take the needle on in its passage of the tissue. Now, the Ancient Astromen, the Persians and the caps noticed it took 365 days for the sun to orbit and re return to exactly the same position. In other words, the sun advanced one degree every day on the sylleptical audit and the patients had a leap year every six years to compensate for the extra five days. The Luna Canada had a total of 355 dates and what number sits in between 360. But that's not a very good explanation. And I much prefer the one embedded in mathematics. You see, the circle was divided into 360 degrees during the reign of Nezar in 605 to 562 BC in the Chaldean dynasty of Babylon. And they observed a complete year of 360 days. Now, the Babylonians used a number based system based on sex, a sex aal system and they related it to the number of 360. In fact, you can take the radius of a circle and draw out an equilateral triangle and put the vertices together and six equilateral triangles would sit within the circle with a base angle of 60 degrees. So the early s reckoned the year consisted of 360 days during which the sun made a complete circle around the earth. And that's what led to the division into 360 degrees. And that's been carried forward to geometry, but they also had different ways of counting as well. And why they're like 60. Ideally, you might want to take 100 because we've got five fingers on both hands, but they took 12 and counted literally the pins on the hand, 123456789, 1011, 12. And after one iteration, that's 12 2nd in 24 36 48 60. So their system of counting enable them to count to 360 not just to 100. Now, why 360 is an interesting number? Because this can be divided by every number between one and 10 except for seven. In fact, it has 24 numbers that can be divided into the number of 36 contrast that to 100 which only has nine devices. So this property of 360 makes it a very strongly composite number. And these make it possible to perform complex calculations, but very simply 360 can be divided into 23 and four parts. And the resulting number 80 120 90 a whole numbers. So the Babylonians use this number based system on sixes. And as I said, the six triangles within circle gave you six space values of the angles. Now, although we say the Babylonians were clever at the 360 working that out, the oldest known text come from the indus valley in the northwest of India. And the RDA is the oldest known text and they've been transmit and handing over stories since 2000 years BC. And the reader is the cortex and collection of 10 books consisting of 1000 and 28 hymns and 10,600 versus much of it is yet to be translated. But there's evidence in the rig reader and this is almost 1900 years BC of the year being divided into 360 parts. In the simple verse from book, one was 12 spokes. One will naval three who can comprehend this honor to a place together. 360 like pegs they shake not in the least. So perhaps that is where it came from. So when we consider 160 degrees, 1 360 degrees, we also consider Euclid who described 90 degrees, 90 degrees meaning from the Latin Rectus or orthos being Greek. And he didn't describe it in numbers. He simply meant that if you took a line or ray and place it on another line such that two angles, either side, we're equal by definition, you would have a perpendicular line. And if you're familiar with IG CSE geometry, you can construct perpendicular lines and bicep lines simply using a compass and drawing out and connecting the dots. So how does this all fit in? And what we discussed last week with the needle, we said that was the switch at this end and we had a quarter, 3/8 half and 58 needle. And they did ask if anybody could come up with the answer when I looked at this and thought, mm. Is this not related to the classical compass or wins? See the Ancient Greeks had two separate descriptions. One cosmology that the North Arctic, the bear the center and fought against the lipid spearman, East Anatoli sunrise, the city in the South Mesembria and juices, the setting sun, but they correlated all this to the winds as well to navigation and they were obviously sailors so boreus in the north and not in the east and in the south and Rys in the west. And these eventually came to be coalesced and completed cosmology and winds into the four point compass, north, east, south and west. And these as we know, are the four cardinal directions, but there are four intercain directions or ordinal directions described as northeast, southeast, southwest in northwest. What's interesting reading? This is that we are familiar with the two names of the winds in the Southeast AA wins in the northwest is the Mistral wins. Now, I haven't read the actual explanation. But if you think that you're tracing a circle, a quarter circle is 45 plus 45 two eights, 45 plus 45 plus 45 is 100 and 35 degrees. Three eights, a half circle of 48 will be 100 and 80 degrees and you add another 45 degrees to that and you get of 5/8 there. You have it. No, we talked last week about rotating the needle back. Such the point is 90 degrees. So if that's the point, I don't have to rotate a quarter needle very far for the point to point into the tissue. Nor do I have to rotate it very far for 3/8 needle. But for half a needle, my pronation super Nation really is going to use the maximum of the functional anatomy of my hand being able to rotate P pronate, calm down, supernate P and most people can actually do the 180. The thing is that if you hold it exactly at that point on the shaft of the needle, you'll then be able to rotate it back. But on a 5/8 needle there and becomes a problem because the whole idea is to align your needle. So it points into what you wanna stitch because we said before the war and we of tissues is such that you have to go at 90 degrees through the tissues. You know this because stitching a button to a shirt is impossible if you do not enter 90 degrees. So this nautical map or the compass rose divided into eight paths is now part of the omnidirectional range systems and global positioning systems and or some of the equipment and you'll find the nautical map or compass rose based on the four cardinal wins and the intercardinal wins on every single map that you look at there, you have it. So we need to learn how to actually rotate the needle into and out the tissue cleanly and properly. And a model that will give us feedback if we do it wrong. And what I have here is a microwave potato and the microwave potato is a fabulous substrate to work on. It is part of what I call the splash models and I call them a splash model. Because if you can imagine a Olympic diver diving into a pool, the perfect dive does not give any splash whatsoever. And the diver enters the pool with no falling over or falling back. So to enable you to understand how to actually align your needle to achieve rotation, you need to think about alignment at 90 degrees. You are 90 degrees across what you want to stitch and 90 degrees into what you want to stitch. And I now considered that in three extra rules. So once you've got your needle lined properly, the sagittal plane is aligned because the needle can bounce on the surface and now pronate back, uh pronate back until the needle is pointing into the tissue and now rotate the needle forward. I should come out exactly opposite. Now, the important thing to note and I've tilted slightly is that the needle is held by the tissue. So I don't need forceps to deliver this needle. I need to deliver it iterative and continue my rotation round and pick it up and I can use it again. OK. You can see that the angles angled out and that enables me my balance. So at all stages in this, I am 90 degrees into the tissue coming down, I'll put that into there and 90 degrees across the tissue and I called it place point, rotate. Now to enable your action to be smooth and the place point rotate II will show my hand, I'm placing my needle down, I'm pronating and rotating the needle back to point. And as I'm doing that, I can naturally unlock the needle holder. And that is important because I can, then when I initiate the rotation of the needle, continue the rotation of the needle through without interference. Think about it, you don't stop your hand. When you throw a ball, you're throwing a ball and you open your hand as you throw the ball in the same way your needle hold it opens and allows your needle to go through the tissue. So well, that was a place point, rotate, place point, rotate. In fact, its place p pronate, unlock point and rotate and pick up again. And the great thing is about the potato is if you are clumsy with your needle rotation and this is deliberately well microwaved. And I do have to give a warning that microwave potatoes are very hot, but you can see that poor rotation and you start mashing the potato. Now, the first advanced skill in the Black Belt Academy is as we said last week to be able to flick your needle over forehand and backhand as we described, pirouetted over the top and align it properly and come back. The other way same thing applies, which is a reverse action. The needle is held by the tissue, pick it up. And you can see now I've deliberately and I can now come back the other way. So this exercise in the first instance, is on the top of the potato. But of course, there are five other aspects away from me. It's the same. So how do I get my needle aligned down there? Well, this is now starting to bring in the fact that your elbow to get to that position needs to leave your side and you know that putting a screwdriver into a flat pack cupboard. So the alignment, despite the awkward angle is the same as 90 degrees. And the reason to do this 90 degrees is to enable you to effect a perfect rotation in every single position. There you go, the needle is actually held in the tissue for you. I can continue the needle delivery. Note that I'm just teasing it out iterative till I'm just beyond the halfway and I should be able to then continue the rotation, pick it up and use it again. Note that the angle now of the needle is more 90 degrees and that is obvious because think about it with my elbow in the air, my wrist is directly below my elbow and there's no displacement and therefore, I do not need to angle the needle out. So when my elbow goes up, the displacement between my elbow and the wrist is not, is m very minimal and therefore, you reduce the angle. So again, you practice, take your needle out flipping it over, get the needle angle right and a line at 90 degrees the other way. Now, fine, you can see for me to get in the perfect position. You can't see that. Now, that's because my hand is overhead, my elbows in the air and I'm rotating the needle back through the other way. And I've drawn these lines on the potato because this has given me the reinforcement of the direction and alignment that I require. See that and I'm rotating the needle out. You can do this on every part of the potato and for you now to work out. And these are the awkward angles that require stitching. How do you actually stitch there? Which is to my right side. Well, I have to think about it a little bit but it is dictated by the position of the needle being 90 degrees across what I want to stitch and our elbows in the air again and I'm gonna rotate back. So I'm pointing and rotating the needle around and I'm delivering it on the curve. OK. And now I gotta come back the other way. So without touching the needle, I re remounted, I do a screwdriver to drive, drive the other way. So these are exercises that are getting you to think about your needle control. How are you placing your shoulder and using a pronation super nation? Now, you can imagine trying to actually do this with your fingers through the rings of the needle holder and I put it to you that now becomes extremely difficult. OK. So we can try this the other side this is using for demonstration. I'm using these little plastic things that are called spaces if you're into tiling in the bathroom. And that is a lovely way. Again, I demonstrating now this is awkward for me because the cameras immediately had and I want to come in around the camera and as soon as I start doing that, I am going to be obstructing the view, but I am not going to get the perfect rotation of the needle. And I am very likely therefore to uh the tissues, OK. Without touching the needle, I flipped it over the other direction and taking it through. And I'm compromised in this because my elbow is not in the air and I'm trying to keep it out the way so you can see. So that's four angles and then you got this angle here. And this perhaps again is the most difficult of the five and being a hemisphere of the potato. This is now challenging your arm position and your abduction on the shoulder. But at every stage, my alignment of the needle is 90 degrees, no matter where I'm stitching. What I'm doing is having to work out how to position my upper limb to ensure that this rotation is clean. And what we want you to do is practice this on each part of the potato and what you need to be able to demonstrate in the black beard Academy is control of your needle. And without the forceps, be able to move the needle backwards and forwards in and out of the tissues cleanly without tearing the potato. Nobody said this was easy. But the whole idea behind these models is to challenge you and challenge your thinking. Now, the thing about this is this is picking the needle up and taking it out even more challenging. Take a boiled egg. I will just focus now on taking the needle through the tissue and one I build egg. And this is what I call the second uh needle skills is I need to rotate the needle backwards and insinuated between the gap of the, the yolk and the white and rotate the needle through. And this is now teaching you to be very careful indeed and deliver the needle through the yolk. Uh You might think I'm nuking. I am not, but this is a useful exercise cos also it's teaching you to point the needle into the space between the white and the yolk. Now, the thing is that if I'm not careful, you end up scrambling the egg on that side. But this is a great exercise. I usually reserve this for the second D level of stitching, take your needle in and out of an egg, the gap between the white and the yolk. My third model and splash model which has now become synonymous with our competitions for the Black Belt Academy. And I have a scoring system for this and we'll be going on to this next week where we asked for 12 perfectly radial sutures, radial around the clock. Northeast, southwest, 12, 369. But the first part of the rotation of the banana model that I want to demonstrate it simply this people too often fail to rotate the needle back. And when they get a lumen like this, there's clean banana. What they do is push the needle underneath and then drag it through. What has it done to banana? You've got it. You've now got a banana split. OK. So people what they do not being lazy in the rotation is push it down and then push it through like that, spearing things, right? They're going across the use of a triangle. I'm trying to do badly, but also pull the needle out and you'll find in a few moments that this banana will start getting you f bad black marks. And I'm not gonna pay attention to my needle mounting. Now I'm gonna pretend I'm just focusing on the stitching uh because I have to be quick and I have to stitch very quickly and I have to cobble this together as I've often seen with staff and more junior level. And they're focusing so much on doing this for what they're forgetting is that the back end of the needle is also potentially doing damage. And if you look at the needle exit wounds on the banana here, dragged it out, dragged it out, dragged it out. But more importantly, I have not been rotating the needle into the tissue and rotating it out. When you have a lumen or a bowel or vessel, you stitching, you must point in two, the tissue and then rotated the tissue holds the needle for you. It enables you to pick it up and do it again. If you, yeah, deviation are the first principles of pick up the 1231 just beyond halfway, two, no space between the shaft and the finger. Three, no angle, do not do another stitch. Stop. Correct and then go through your alignment and rotation. There are many ways you can actually practice these skills. But to introduce us to the next stage of our four part series, it get you to think about this when I start here and I have used a pan on a banana and you can draw your marks to the banana, take it in, take it out and start with simple marks on the banana. I notice that I'm lining my needle up. I'm rotating back and rotating forwards. Ok. Oopsy. I'm right at the tip, correct place. We take back point and rotate forward slightly off there. Do it again. The thing is, is that between taking a stitch this side and taking a stitch this side, something has to have happened. I cannot actually stand in the same position to do this. I have to change the weight distribution or my body distribution. Because if I draw an angle from there to there, that 90 degrees across there to that 90 degrees across here are used with the two forceps, a tape, same amount the vector from there to there you can see is about 75 degrees. Absolutely impossible to continue stitching, standing in the same position. So this is an introduction to next week. Very simply as you go around something or the direction of your incision changes, you need to change your position. So from this side, I was on my right foot. When I came to this side, my weight was on my left foot and simply changing the weight distribution from my right foot to my left foot, changes the pelvis moves the shoulders and I therefore can continue stitching in a relaxed manner with the elbows by my side. Now, I've got a little test for you and the vague test is is why I believe thinking about stitching in this manner gives you a framework to practice. We has again and again and again, could be practiced until we can't get it wrong. Now, you will perceive as you look around you, you are surrounded by right angles. Look at the window, look at the door, look at everything you are surrounded in every direction by a right angle. Now, my test is of you. Yes. Spot the right angle please. Is it A is it be C D A F 0 g in the chat box? There were two right angles there, which were they anybody and call out the chat F ef mhm. Do you wanna see those again? The vinegar three ounces type the letter going back. Got quicker. This time you got the difference of plus and minus four degrees F if I told you there were two in there. OK. So everybody's picking up F and there's an age there as well. H as well. OK. Good. So you've spotted F easily the second one, your spotting age well done because we are surrounded by 90 degrees. If, and I ask you that was Jay, but that was a 90 degrees so far. I now ask you, can you spot 45 degrees in the lower case letters? Any ideas which was at 45 degrees? Not too easy is it, we are not hardwired to think about 45 degrees. Whereas you all identified the 90 degrees and that I think is significant when you're thinking of 90 degrees is the perfect angle. And the fourth part of the circle and every angle, orthogonal angle is 90 degrees, 90 degrees in that plane, 90 degrees in that plane, 90 degrees in that plane, that's all 90 degrees. So you, without any training has demonstrated to me, you should be able to put your needle 90 degrees sly to the tissue, 90 degrees across the tissue and rotated back 90 degrees into the tissue. I don't need to teach you 90 degrees. But what you need to practice on the splash models that I've demonstrated this evening. What is your needle position? What is the position of your upper arm and elbow and then start contemplating? Am I standing in the right position on the right foot or the left foot? Once you start understanding the angles then and practicing them, then you will understand how a needle works. This was reinforced to me at the weekend in my third lesson with a sensei with a samurai sword. As I said to you before I have the second down in the samurai sword from the UK. But stepping into this classroom with a proper sensei at the Japanese car in Kuala Lumpur, I conclude, I know nothing he picked up immediately that was putting too much force into the blade out, chopping, not slicing the other interesting thing in drawing the blade out of the scabbard. I draw the blade. He said, did you hear that? And I did hear it? And yes, it is a training one. It's a bamboo blade and a bamboo scabbard. But he said, I can hear the scabbard move if you hold it properly and draw it properly, you should not hear the blade touch the side of the scabbard and I put it to you if you hold your needle properly, rotate it properly. You are not going to do any damage to the tissue and your suture will sit perfectly within the hole created by the needle. Once you have mastered that your stitching is going to be really good. The outcome of your surgery is going to be significantly better, but we're going to practice until we can't get it wrong. My fellow sense also se done Taekwondo. Mr Catty joins us as usual to offer his insights into the ergonomics of stitching and comment. Thank you, Chris. Your thoughts. You are muted, sir. Wow. Wow. Wow. So as they say, every day is a school day. Uh So in the 1st 17 minutes there, you went into the history and philosophy of 360 degrees. That was all new to me. So thank you. Um That took me to places which no one else has done and I've been at this for a long time. So thank you. Um So as I say, II do a lot of, of microsurgery. We use different instruments, but the principles are the same. Um And so it's about controlling the tip of the needle, placement of the needle, rotation of the needle. And once again, David's been emphasizing that point place rotation. Uh and I particularly like the uh the boiled egg exercise, which is not easy. Um So you did it in a hard boiled egg. If you do it on a lightly boiled egg, it becomes even more difficult. Well, I think you'll have egg yolk everywhere to become messy. But what I will show you next week is Mr C has said these principles apply to every size needle. And I demonstrated the castros last week. Let me just get the castros out again. I've got the box here, you know, my box of goodies, I'll just look at my castros. Here we go. So the castros, the I demonstrated before that, I'm holding the castros like forceps. And remember our forceps exercise, we're extending the inter distal inter phalangeal joint. Uh because as sensors and surgeons of the Black Belt Academy, Mr Caddy, I'm gonna ask, what do we love? Well, it's all about attention to detail. So what we like, we love the lumbrical. That's what you're supposed to say. No, that's what we're doing. So if you look at the castros, my rotation is simply moving my fingers. There's not much movement there at all that the palps of my fingers are, are applied to the castros and the movement is as subtle as that. And I'll demonstrate that next week when we apply a 70 to the membrane over the yoke of a poached egg, a new try point place, rotate as if you're doing a coronary artery anastomosis. And I can promise you with 22 years of cardiac surgery, some of the coronary arteries you deal with are as viable and as soft as an egg at the other extreme, some of them are harder than golf balls that are used on the trade stands to demonstrate the exquisite alloys used to make the needles and some of them are like rock. And now you have to start appreciating in these difficult circumstances. How do you get the needle to work for you? Where do you move your needle holder to ensure that you're 90 degrees across what you want to stitch 90 degrees into what you want to stitch. Because you can imagine if something is rock hard, if you come in at angle, it'll skid off and we can't have that at all. So, microsurgery coronary surgery, any surgery, the principles of rotation are all defined. Thanks to Euclid, thanks to 360 degrees. Thank you to King Nebi K na. And there you have it. Any questions from anybody, please Gabrielle, any questions? Not at the moment. Maybe some people are just like any other observations since a cut. Now, it's just so you, you made a big play at the beginning about the, the linkage between the shoulder, the elbow, the wrist and then the lumbrical and the fingers. Um So a lot of these things, you isolate just the lumbrical by supporting your forearms and wrists. And so the movement is really just between the thumb and the, the middle finger. So that's where the rotation comes from. So you need to be very accurate in where you place the needle and how you rotate it. And certainly that's why microsurgery very often you're sitting down, such as your upper limbs are relaxed, but you can't sit down and operate like a pterodactyl. You do have to be in a functional position where your fingers can work and you can feel your instruments. Thank you very much for joining the Black Beard Academy. We'll continue with part three of our needle instruction next week. Please invite your friends. Please pass the message round and please will you actually take a moment to fill in the feedback form. We take this seriously and we will be very interested to know in any of your ideas. At the present moment. We are judging the 10 entries that were submitted for the Global Surgical Competition, some quite innovative ideas and we will be announcing those uh at the beginning of August with an idea of sending these out in September. It has to be September because I'm afraid I do not have the instrument packs with me here in Kuala Lumpur and I have to retrieve them once my wife gets back to the UK on the eighth of September. But for now, thank you for celebrating with us. The 1/100 broadcast for the Black Academy. Look forward to seeing you again and we'll say good night, good day, good morning, wherever you are in the world.