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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 Dave Regan. I'm a retired cardiac surgeon, the immediate pass directive, the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh. And I'm now a professor in the Medical Education Research and Development Unit or the Faculty of Medicine at the University of Malaya. Thanks to med, all, we are now reaching 100 and nine countries and we've got 41 registrations this evening. So welcome. And thank you. This is from Egypt, Germany, Maldives, Romania, South Africa, United Arab Emirates, UK USA Zimbabwe. In no way. Thank you very much. Indeed. If this is your first time? Welcome. This is part three of a four part series looking at stitching. And I do recommend that you look at the other elements, although we'll do a brief recapitulation if you're returning. Thank you very much. Indeed, I did ask in the questions, do you know how to align a needle? And many replied, I have no idea. I then asked, do change your position with the alignment and many of you said yes, but couldn't answer why. And lastly, I asked, do you practice at home? And only 2.5 out five of you answered. Yes. Which left me wondering why don't you practice at home? And is that because you don't understand how to practice? Don't have the tools. I'm not so sure. I would love to see all trainee surgeons given a set of instruments. And I'm trying hard to persuade the system to actually get everybody a set of instruments like this. So you can practice at home while I have it on my hand, we've had 10 entries for the global competition for the most innovative practice. And we're looking at those at the moment to decide the top three and they will get a set of instruments that decision will be made in September when we got the instrument packs available and we'll send them out to the winners and announce them on social media. So just to recapitulate of the principles of the first two lessons. First of all, we said we'd like to see you hold the needle holder along the line of access of Pronation Super Nation, which is between the index finger and the thumb and the commonplace, the origin. So we're holding it like a benediction sign and the rings are there supported by the palps of the fingers. 4th and 5th folded over one and the other is left open, the index finger is extended down the needle holder to give you direction, appropri perception to take it on and off was simply an abduction of the thumb to unlock the ratchet. And the reason for putting it in your hand this way is to affect the axis of rotation, pronation, supination a bit like a screwdriver. And you'll see that is giving me about 270 degrees, the shoulder and the flexion of the elbow enable you to work this pronation super nation in every angle you can conceive. And you know that because using a screwdriver in a flat pack on a car engine on an awkward place, you need to get your lower arm in a position such that you can affect that quotation. The second thing was is the way you mount the needle. And we've got here a needle mounted and we said it's got to be just beyond the halfway. Number one, number two, there is no space between the shaft of the needle and the tip of the needle holder. And number three, it is angled out and that angle we said was equal to the angle between the horizontal from the elbow and my forearm. And it represents the displacement of the wrist from the elbow. Of course, if my elbows in the air, my wrist is not displaced and that angle is rendered null and void. So the 123 of picking up the needle enabled you to bring the needle down and I come over to the top, to show you bring your needle down onto the tissue, such that the belly of the needle is pressing on the tissue. And in that respect, you're ensuring that you're 90 degrees into the tissue, ok? 90 degrees into tissue. And we said the alignment was 90 degrees across what you want to stitch and 90 degrees into what you want to stitch. OK. The other advantage of the needle being angled in this way was simply enabling you now to practice manipulating your needle forehand and backhand on the tip without using forceps at all. So I can control this needle forehand and backhand, forehand there and back. And uh and at all stages is just on the halfway and there's no space between the tip of the needle holder and the shaft. So the next part of your alignment was as we practiced on the potato. And I hope you've tried that 90 degrees across what you want to stitch and you pronate back such you 90 degrees pointing into what you want to stitch. An imp pronating bag. I've actually unlocked the needle. I now can rotate it forward in super in my forearm and the needle comes out of the tissue and the rotation if that's the swage and the red dot hears the point. And we said that's a quarter 38, half, 58 and eight with the compas star which had this position here. Southeast Suco Northeast mistrial. The Wins the cardinal wins or the intercardinal wins. And if you think of rotating the needle into a plane, if it's a quarter needle to rotate it back, you don't have to be very far to rotate it. So that point is pointing to the tissue. I'm just going to take this back. So I'm rotating this around the needle. Imagine that's it curve. I'm rotating the needle round. So the point there is pointing into the tissue. If it was a three eights needle, I'd have to rotate it a bit further around. So that point is down a halfway needle a bit further and even further still for five eights needle. And this is dictated by your ability to sate and pronate for most people that will be 100 and 80 degrees. But you can imagine with a five eights needle, you're not going to be able to rotate it completely around five eights. And therefore you're holding it on the halfway such that you can point into the tissue. No, the whole thing about stitching is this very simple alignment of 90 degrees. And we put you through the test last week and you did extremely well in spotting 90 degrees in almost everything we did. But now we understand 90 degrees. We got to think how we gonna apply this. Now that 90 degree alignment is the alignment that you need. Then placing the needle across what you want to stitch and into what you want to stitch and why is 90 degrees? Because as we demonstrated last week, the geometry of the circle and 90 degrees means that 90 degrees is fourth part of the circle. And as Euclid said, each and every angle opposite is also 90 degrees. And we hardwired to recognize that. But now we're gonna talk about direction and not any of that, the alignment and direction and magnitude. And this is where the term vectors come in. And I'm gonna use vectors, simple mathematics, a vector has magnitude and direction. The length of the line shows its magnitude and the arrow shows its direction. And the parallelogram is intuitive to vectors and bear with me all will be explained. So the parallelogram appeared, the work of Aristotle back in about 350 BC and then appeared in the mechanics of Harem in the first century ad in Alexandria. And was also the first corollary of Isaac Newton's Principia Mathematica. And He Newton, as we know, he dealt extensively with vectors. Although he didn't coin the term vector or name the vector, he applied it to forces and velocity. And the thing about a parallel is you've got two equal sites. And if you were to go from A to C, you can go A B to C or you use the vector W plus V to indicate you've gone to A to C. But the arrows open like one way streets. If I wanted to go B to CI would go V or minus WV, because you're going against the traffic. So that is V minus W and that's V plus W and reverse. And then the first two decades of the 19th century mathematicians like vessel and Argan and particularly Carl Friedrich Gauss conceive the concept of taking complex numbers as points in two dimensional planes, effectively treating them the two dimensional factors. And he, he gals used this concept to prove the fundamental theorems of algebra was in 1827 that Morbius donated these direct lines and gave each of these lines an alphabetical number. And he developed an arithmetic as I've described of adding and subtracting these vectors and multiplying them with scale at multiplication. He didn't turn vectors either and didn't explore it any further. But then came along William Rome Hamilton or in 1805 in Ireland died 1865. And he showed that complex numbers could be considered abstractly as ordered pairs of real numbers. And this was part of an idea that mathematicians had trying to extend two dimension into three dimension as as shown here. And it was frustration for many. And Hamilton was finally inspired when walking to a meeting on the Council day of the Royal Irish Academy and is walking past the Royal Canal. And he quickly realized that vectors were in three planes, Xy and Z each at 90 degrees. And the first part of it was scalar and the XY and Z were the vector components. And he introduced this sort of trinomial and call it a coion in his mathematics. And he felt compelled to call this a vector for his work. He was actually knighted in 1835. And he had done a lot of fundamental work on optics and theoretical physics. But this was then used by Gibbs and Oliver. Hi Riverside to develop ve analysis to describe the electromagnetism developed by James Clark Maxwell. And factors now are the ideal language for describing forces, physics, applied mathematics. And of course, we recognize this as global pos positioning as well. So why do I actually think this applies to surgery, the positioning and direction of our instruments, our needles and our knives carry a vector and do carry a degree of magnitude. And what's interesting in the learning of martial arts which has been going for a similar time ass for 600 years for the samurai for the sword. And the Edinburgh College got his constitution in 1505, that martial arts has described everything in angles and what I would think of as vectors of force. By way of example, I'm second done in here. I do. But having come to Kuala Lumpur and joined the Japan Club, I'm being trained by 1/4 DSI who specializes in, I conclude I know nothing. I have to learn again. For example, if I take the sword and this is a, a wooden bamboo sword and they've done a cut to do shy. He explained, I need to turn the blade 60 degrees out to the side and then take my arm in a wide circle. And I'm pointing the sword backwards as if to stab somebody. I bring the sword in to my temple just to my left eye with a blade. Now focused at 11 o'clock. And from there, I continue the movement down from 11 o'clock to four o'clock stopping just outside my knee and no further that level of description and how to execute a cut and actually limit the movement to what is needed. I have not seen applied to any description whatsoever in the lining of surgery and I'm baffled to be honest. So to help you with your development and practice, I'm introducing in this part, the concept of vectors, direction and magnitude and I'll explain as we go along. So what I have here is a banana and I've made an incision along the length of the banana and with a triangle measured equal spaces along at each time I am 90 degrees across this incision. And to practice, I need to line my needle 90 degrees across water. Want to stitch. I rotated back pointed 90 degrees into what I want to stitch and I rotate it out and, and deliver the needle on the curve it until I'm just beyond the halfway and I can pick the needle up again and delivered out and ready to do the next stitch each time I am aligning my needle 90 degrees across what I want to stitch. And for your practice, I'd strongly recommend that you too. You too align your needle with pen across the banana and degrees into what I want to stitch. I'm just gonna swap the needle round. That's too big a needle. So, 90 degrees into what I want to stitch, rotate it back and I can take it around and use the curve the needle and take it out. And I should come out on the line equidistant from the edge, taking it out. You can see the needle is held in the tissue and I've moved it to just beyond the halfway and I gently apply the riders and then lock it once delivered. And I continue down. Now when somebody is doing a continuous suture, I see people focused on the stitching bit, but I never see them focusing on the set up of the needle and I never see them deliberately align the needle across the tissues. Now, as I'm going round, you will note that these vectors that I've drawn or changing angles and because they're changing angles, I cannot stand in the same position at any one time. And I have to adjust my body position, my body position changes very simply by changing my weight distribution between my right leg and my left leg. So when it comes around to this side of the banana, I'm standing on my right leg, I'm standing on my left leg here, but I have to move because if I extrapolated that vector to that vector, the angle subtended between the two is 85 degrees. So I can't, by definition remain standing in the single spot at this end. Although I'm on my right foot, I'm now getting into position where I'm about to get to the most difficult stitch you can possibly do. And for a right handed person that is stitching into your right shoulder and it's in this position that I have to think about how I'm going to continue stitching. So if I took a stitch there, that would be probably at the limit of my forehand stitching from there to there. Now, this comes into play when we're talking about elliptical incisions. So the difference here is that it's quite all right to take a needle across both edges. If they are aligned, as you see here, that side is aligned to that and my needle can go across. It becomes a different matter when you've got an irregular or elliptical incision. And you'll see here now that the vectors are different, let's start across the middle, they are more or less aligned. But as soon as you go across from left to right, the vector is pointing in a different direction. And that means that you have to align your needle across this way, take it out and then you have to change body position and change your needle position and a line at 90 degrees across the side. And there are no shortcuts for doing this. None whatsoever. What people often do. And I sadly see is get the needle through there and with a needle in there, they try and, uh, twist it round, uh, and tear it out. And you can see immediately that it's torn the banana and you are inflicting a lot of damage. The other thing to see is this, you will conceive as part of a venotomy or arteriotomy. And well, we're talking and the last part of our series about anastomosis at one end would be called the toe on the other end would be called the heel in vascular surgery. And the toe is downstream in the heel is upstream, proximal. Ok. No, you can see the arrangement of the vectors is almost a tr application. And if your spacing of sutures is too far apart, you'll end up crimping that end. So daily at the heel and toe, you take smaller bites to ensure that you're not constricting the end. Now, as I've come to this end, which is directed towards my shoulder, I cannot take the next ditch going round without having to effect a change in the position of the needle. And it's in this position that I swap the needle over check it is aligned. Yeah, and I've changed my body position. So I was in my right leg and I've now gone across to my left leg. Also, without thinking about it, I've now aligned, it's a needle perpendicular at the point and the point is perpendicular, either end or it can draw a line between the two. And that's how I'm going to align the human toe of any anastomosis. But also note that I've just taken this needle bit further back on the shaft. And the reason I've done that is such that I can take this belly and I can push the posterior wall away of a vessel, such that the needle bounces up through the anterior wall. And I'm confident that I'm not going to pierce the back wall with a needle. So what I'm doing here in this alignment, there's a lining, my needle 90 degrees cross one stitch, in other words, down the middle. And it's usually parallel to the two edges of the wall of the vessel because you're in the middle of the vessel and a banana is not in the middle. Of course, because it's curved, but your arteriotomy would be down the middle and I'm now going to push the posterior wall away. So I'm pushing it the belly into the lumen, not the po point. And I'm going to rotate the needle up to the point and take it out. And that way I'm never ever, ever going to hit the posterior wall. And that's a little trick for all vascular surgeons for anastomosis. I now continue my anastomosis or continue the stitching along the vectors. But now I am doing this backhand, same thing applies each time I'm aligning it with a vector and you'll find yourself needing to change your weight distribution to get your arm into a functional position to rotate that needle. So remember place it 90 degrees across what you want to stitch, rotate it backwards and only the point of the needle is going into the lumen and rotated out. And I missed that one. And I felt my needle slip, but we practice until we can't get it wrong, rotating it back. I've unlocked the needle and I'm rotating a Ford as on the vector note that the banana itself here is not being mushed because I'm rotating the needle point in, I'm not pushing the needle down and then pushing it across. That is not rotation. See that that is not rotation and it, the backswing is very important to ensure that the needle is pointing into the lumen each time I'm taking care to align my needle exactly along the vector. It's a simple exercise that you can practice at home with a banana and a needle and a needle holder. So now I cannot do a backhand there. So I need to flip it over to forehand and well, uh I'm ready to continue beforehand and I'm now standing Amala for. So this simple model is getting you now to think about your alignment across the tissues. But it's also getting you to think about your weight distribution to enable you to rotate a needle. This is a simple model that you can set up at home. But it's actually getting you to think each time about how you, you use a needle. Once you practice. Of course, then I suggest that you take away the lines and focus on your spacing and stitch, regular stitching without the lines. And you'll see that as the banana develops, so to speak, you can see where the needles come out. And in essence, what we need to look at is a single punctum like that. I'd give that a good score. There's a bit of a shake there. That's a good score. That's a good score. That's a good score. That's a good score. That's not perfect. OK. So looking at it, you want to see a perfect exit mark. Now I'm doing this deliberately in aligning my needle deliberately. Each and every time, much like the Sensei Eneida is telling me all the time to relax, slow down, do it deliberately and focus on the angles. You can come the other direction if you want. But the principles are always the same and your alignment is always 90 degrees. What is changing is the shape that you're stitching? But as I've said to you, one of the most distressing things to see in surgery when people are trying to stitch two sides together with a needle in the tissue, they try and manipulate and force it around and force it together like that. The amount of talk and tension that's been inflicted at that point is beyond comprehension and that's what you're actually doing to the tissues. So to take this to the next stage and this is part of more complex thinking is stitching round in a circle. Now, the secret is stitching a continuous stitch. One should always be stitching towards yourself rather than stitching away. So wherever I am, I will start beforehand and I'll continue to stitch towards myself. Because if you're stitching away from yourself, you find that you're tripping over the suture and is getting in the way with or without an assistant. What was interesting in drawing these vectors on the banana and you can practice yourself is can you draw 12 o'clock, three o'clock, six o'clock, nine o'clock and the hours in between. So as I'm coming around here at six o'clock, and we will talk further about an and the clock and why we do 12 perfectly sutures in the i in next week's alignment or two weeks time alignment and anastomosis. So now I'm at four o'clock, OK, my or five o'clock and my next ditch is going to be into my right shoulder. That is the most difficult stitch to do in surgery. It is in this position. Therefore, I now have to change the needle and I'm standing on my right foot. I'm going to unwind. So to speak. I'm now standing on my left foot and I continue my stitching around the circle. Remember in the compass rose that I talked about last week, this is the southeast corner or the corner of the soo winds. But do you see that 11 o'clock to four o'clock was much like the instruction that I had in completing shivery as the last cut of the sword. And that in 11 o'clock to four o'clock instruction was a direction vector imparted to me by the sensor instructing me how to use the sword properly. I don't think I've ever had instruction on how to direct the needle through the tissue. And perhaps you can answer in the chat room if you've seen it yourself. Has anybody had instruction on how to do this themselves. So continue to go round and again, commend you to align your needle, consider what foot you're standing on and your weight distribution you are now coming to 11 o'clock. This is the cardinal wind, the mitra hour wind at 11 o'clock and is in that position, which is literally it is diagonally opposite. Yeah. So it was forehand, forehand, forehand across the diagonal, backhand, backhand, backhand. It will vary really depending on your own body habitus. But the one thing I've noticed with stitching in this is that the spacing and alignment of the needle is not as accurate at the soo maester change or the 11 o'clock four o'clock. And I want you to practice going round the banana deliberately in and out on the hour, every hour, placing your suture, pointing it into the lumen and getting to understand that movement. So, although I've actually said to you 123 place point rotate, 123 place point rotate, the interesting thing is that in the IO it is deconstructed in a similar form of 123 place point rotate in many of the waza, but you need to put them together. So the 123 place point rotate, which practice just becomes one that is when your focus or sunshine is now focused on the operative parts of the needle for stitching, which is the point, the belly and the shaft, the point, the belly and the shaft there I am. And I need to go back and I've changed direction again. So your task is to practice the skill at home. And if you noticed I've just taken that stitch and come out through exactly the same hole. So it's rather fun rather than putting 12 perfectly radial sutures in once you've gone around, once you can actually use your exit on the banana as inverter comma's target practice for where you want the next stitch to come out exactly in the same. I almost feel like sh shouting out 180 with like dots. But I hope that you now realize that this is not a case of stitch, stitch, stitch, stitch stitch far from it, it is a sequence of movements of the action of taking the needle through the tissue will be the same for you and me than the sist the time it takes to take the next ditch will be different between you and me. And that is what I call the diastole. The dale is this time between each ditch, the relaxed phase. And you remember the heart when it speeds up the rhythm and flow maintains. But it's the dale that shortens as the heart rocks in the chest. In sinus rhythm, you need to think about the diastole and I call it diastolic learning, relax. Don't try too hard. Focus on the setup. Focus on the correctness of your technique. The pickup of the needle just beyond halfway, no space between the tip and the shaft and angled out. But that angle is the displacement of the wrist and the elbow. Think about how you do that each and every time you might actually think this is laborious. No, you do this each and every time and focus on the set up, then the 123 place point rotate will become an automatic. So just as my sensei said, when holding this here, and as you said, it's similar to a Japanese salute with the out to the side and you're bringing it in that my blade is now angled to 11 o'clock and I can continue the sweep down in the shivery to four o'clock going no further than the outside of my knee. It is interesting in many of the instruction and this one I liked in particular with a ki cut across the horizontal, I needed to ensure that I held my wrist at the right ankle, not cocked because it can be locked out of my hand at this angle. I my full body is behind it. But also he had come along and just tip the tip down, saying from my shoulder to the tip, a drop of water should be able to run down the sword and off the tip because it's slightly inclined. It's that level of detail and instruction that I believe starts making it useful in practice. And that's why I believe martial arts and the learning of martial arts is very useful for the learning of surgery. I thought my colleague, Mr Keddy was going to a meeting but I see he has returned or is here and I'd like him to participate in a conversation. Hi David. Well, welcome. Sense. Well, so you, you were at first thing I wanted to ask you, you are a plastic surgeon, micro surgeon and you use the same alignment and I'll just show it here is I'll step out the way the same set up is on the tip of a cast. It's not gonna focus on that at this distance. Is it? I was going to say it's not very focused. It, no, it's not gonna focus. I'm gonna try and focus. But the alignment of the 70 needle on the Castro is exactly the same. Do you consciously align your needle each time you stitch? Um I do know because uh you've taught me to do that. So I pause every time I mount the needle until it's perfectly correct. And then I place it uh but that comes with time and with practice. So I can't claim to have always done this, but it's now part and parcel of what I do. Has it made a difference? Absolutely. What have you seen more than anything? It allows me to look at other people when they're suturing and think, what are they doing well? What are they not doing so well? And how can I get them to see that? It's interesting. Has anybody described it in that form before, to you before we started working with the Black Academy? Now, once again, why would they a a lot of this is unknown, unknowns to the vast majority of surgeons. You do it instinctively and not because you've been taught it. So that's what we do is probably wrong, but nobody has pointed it out to us. Hm. You, you do it because you can get away with it. Um You know, it, it's a bit like closing a wound. So one of the rules of closing a wound is thou shalt not create tension. But the caveat to that is unless you can get away with it. So it's about understanding how you're placing the tension across and within the wound. So you take the tension off by putting in the prestigious that engage with the fascia. Uh and you can then use different sorts of features in order to de dissipate that tension. Mm So it's tension but also lots of seizures called strangulation. But the, the, the thing is the harder you try, the worse your stitching gets. It's a bit like golf. If you start actually thinking about it, the swing goes out. And what's interesting with learning E AO is you do have to relax. You do have to focus on your breathing and you're holding even a 80 centimeter container with the lightest of touches that somebody could come along and just take it out of your hand. But the instruction is always around physics, pivots geometry and all this parity comes back to yoga and understanding body position and effectiveness of movement and it's that effectiveness of movement. And you understanding that you need to move and align your needle and when it's perfectly aligned, I'm sure you agree, Chris, the needle does the work for you. There's very little effort involved. Absolutely. It, it should, it should flow like water. Uh But you, you need to set yourself up for success every time. Yes. And if you don't just have a look at that banana now that's looking pretty manky at top end bottom. It, you know, the banana gives you the answer within 5 to 10 minutes. You won't see that in the tissues, but that is likely one to cause pain. Two to cause inflammation, three potential breakdown of the wound and for potential necrosis as well. Now, if that's happening to a banana in 5 to 10 minutes, you'll badly past sutures in a patient likewise is going to cause problems. You won't see it in 5 to 10 minutes, but your outcomes are not gonna be very good. So there's absolutely no point in doing this fast. And the lesson from the sense in the Japan Club, he said too quick, too quick. Do it slower, feel it, let it flow. It reminds me of Kung Fu panda finding your inner peace perhaps. But that's exactly what it is. That then is good surgery. I think what's important is that you have a feedback mechanism because you can't see what you can't see. And I think that's one of the benefits of the Black Belt Academy of Surgical skills is you can go and home your skills, but you then need to come back into the dojo and let you sensate see what you're doing and you're experiencing this on a weekly basis, you're going into the dojo, you think you're doing it correctly and he just looks at you and then gives you feedback. So you can't see what you can't see when you go into the dojo. But that's the difference between going on a basic surgical skills course and signing up to this sort of program, it, it, it doesn't stop at the end of the course. This is lifelong learning. Indeed. And uh, you and I have between us, probably got almost 90 years of surgery between us and still learning, still practicing. But the other thing is even when it comes down to complex situations and in my case, stitching soggy blotting paper of a dissection, aortic dissection, the accuracy of the passage of the needle to the tissue is of paramount importance because any tear as you see in the banana will mean that you're standing at the table for two or three hours trying to get it to stop when these people by de facto have got a significant coagulopathy. It doesn't pay to be quick, it pays to be accurate. Quick will come when you understand and practice your set up. It's called diastolic learning. So, II think you, you used the, the model there incredibly well. So, so that was AAA fusiform excision in the banana rather than an elliptical excision, correct? Um And guess what? Just to make you happy? I've got a skin hook here uh because I was actually going to demonstrate that you don't grab the skin with forceps. As plastic surgeons would do, you'd lift the skin up. All right, and you're lifting it up, then you can place your su suture underneath. If you're using tooth forceps, the tooth of the forcep can lift the skin up. But all too often as we demonstrated previously, when you're focusing on your stitching, the left hand is doing all sorts of wicked things or grabbing, dragging the tissues. But we covered that. So what, what was interesting there was showing it going um through the banana and then using this windscreen wiper process and the amount of damage that that does. So you have to take it out, reload the needle, reposition it and put it back through the other way. OK. Um And it was, it, it demonstrated that beautifully. My, my other comment is that the beginning of the session was um I, I'm not sure how many people kept up with you. Um So this was, it was about taking suturing to a completely different level looking at the vectors involved with that. So when you're being taught how to stitch, nobody thinks in vectors apart from you. Um But it allows people to stand back from it and think, what am I doing here? How do I describe that? And how do I describe it to the next generation of students that, that three dimensional vectors described by Hamilton? The three dimension will come in in the fourth part series when we're talking about anatomizing tubes because now you are not just dealing with the two dimension on the surface as we've got here, you need to think in three dimensions. So that's why Hamilton's work. I think is relevant there as well. Any questions from that's an iterative process. So you're getting people to think in two dimensions. But the next is it's a quantum three dimensions to dealing with three dimensional structures in a three dimensional, I mean the fourth dimension in this is time. So they need to understand healing of the wound. And once again what you can get away with and how the body's physiology and anatomy is on your side, but you need to work with it, not against it. Correct. We have two questions from the audience. So the first one is from John Rudd. Would you say that Bs and uh surgeons use the large double ended needle tension sutures if you know, you choose your needle and choose a suture depending on the anatomy and what you're trying to do. Um The, the double, the double ended cutting needles are used for fascia ligaments and literally for cutting tissues. Uh So you do need to know what you're teaching, how long it's gonna take to heal and that defines your needle and the type of suture as well. OK. And then the second question is from Rinko. So again, it, it relates to the tension. So to relieve tension in a wound, can you not add absorbable sutures as deep dermal dermal as of course they dissolve? Um Or don't you feel that it's better than a thin skin sutures? And yes, w when you're deep, uh you gotta remember whether it's absorbable or not absorbable, the suture will still cause tension. And you think of the pathophysiology of healing is that the edema of the healing tissue is gonna be maximum between three and five days. So the tension in the tissues and range of sutures are gonna be maximal then absorbable sutures are are not gonna are gonna stay in between seven and 12 days uh minimum. So whether it's absorbable or nonabsorbable, it's how you place them, the positioning and how you tie them. That is dictating the tension. Remember in all your deep sutures is particularly with nonabsorbable su sutures is to make sure you're not as buried in the deep tissues because if otherwise the monofilaments are gonna be standing out, particularly in pressure areas. So they, they might not be visible, they will certainly be felt. And the other thing you need to consider in all of this is tissue creep. Ok. So if you have a baby in your abdomen, slowly, the skin in your abdomen stretches and the same thing can happen on table, you can do on table tissue expansion, which is to get the, the collagen to relax and you then get some give in the tissues. But it's about understanding the wound and the time that you've got to close it in as well, it it's um once again, all of this comes with time and an appreciation of the tissues you're dealing with. Uh because for instance, skin on the back is very tense and you don't get the same amount of tissue creep in it. Whereas on the abdomen, it will give. So you can put tension sutures in to stretch the skin and then remove them before the end of the procedure so that you don't get that tissue necrosis or damage to it. But, but this is all up towards black belt rather than being at the beginning of your, this is advanced, advanced and thinking and it comes from experience and more often not you learn from bad experiences. And as long as you do, as long as you do as well as you do it. What, what am I learning from this? How can I do it differently? What am I? Exactly. Exactly. So thank you very much indeed for joining the blackboard Academy. Uh do send and post your pictures of your practice at home on bananas. We have got a feedback form. We do listen to your feedback and would be grateful if you take a moment to fill in the form and do pass the word around. If it's made sense to you, please invite somebody else to join the Black Beard Academy and when you join as a follower and then you'll get automatically updated on our latest events. Thank you. Good night. Good day and good afternoon. And thank you Gabrielle for the production and thank you Metal. So