BBASS continues needle control and alignment by applying the principles described in parts 1 and 2 to three dimensions. We demonstrate how to control the needle, angles and vectors as well as how to stitch without getting in a tangle. At the end of the session, you will be able to confidently organise yourself to stitch two lumens together even if they are of different sizes. We re-emphasise the rotation of the needle, the 1-2-3 pick up and need for adjustment according to the wrist and elbow displacement but at all times maintain the ninety-degree principles of point and place.
Part 3 - Alignment in 3D
Summary
In this on-demand session from the Black Belt Academy of Surgical Skills, Professor David O'regan provides expert instruction on the practice of anastomosis, the process of joining bowel and blood vessels together in surgery. This is the third part of the Stitching series, with the basic techniques discussed in the previous sessions. He discusses the history of the gastrointestinal anastomosis, various techniques, suture types, and the important factors that influence its success. This comprehensive session is an invaluable resource for medical students and practicing surgeons alike, aiming to offer in-depth insights into this complex procedure, increase confidence, and improve surgical skills. Attendees are advised to view the previous sessions for a deeper understanding of the principles referred to.
Description
Learning objectives
- Understand the history and evolution of gastrointestinal anastomosis and vascular anastomosis as well as the contribution of key figures in their development.
- Differentiate between various techniques of anastomosis such as hand-sewn and stapling and identify factors that determine the success or failure of an anastomosis.
- Grasp the importance and role of meticulous surgical technique and handling of tissues in performing anastomosis and identify potential complications such as leaks.
- Recognize the significance of needle control and alignment in conducting anastomosis and learn how to correctly mount and position a needle.
- Apply knowledge of anatomical and physiological differences in bodily tissues and vascular supply to the successful performance of anastomosis and understand challenges associated with different lumen sizes and vascular supply watershed areas.
Similar communities
Similar events and on demand videos
Computer generated transcript
Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.
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 o'regan. I'm a professor in the Medical Education Research and Development Unit here in the Faculty of Medicine, the University of Melia Kuala Lumpur. And we're coming to you live from Kuala Lumpur tonight, supported by Metal with Vanish who is 1/4 year medical student in the Faculty of Medicine in production. If this is your first time, welcome. If you're returning. Thank you very much. Indeed, we are now reaching 4403 people in 100 and 30 countries. And last week Afghanistan was a new country to add to the list. Tonight, we have 39 registrations from 17 countries from Bangladesh, Bulgaria, Egypt, India, Libya, Nepal, Pakistan, Saudi Arabia, Sri Lanka, United Arab Emirates, UK and USA. Thank you very much indeed for joining us. This is part three of our Stitching series and if you've missed parts one and two, they are available free on catch up and it would be worthwhile going back to them because I'll be referring to those principles. This evening, we are now taking our stitching that we have learned the basics of needle control and alignment and we're now applying it to the three dimensional problem of anastomosis and joining bowel and blood vessels together. I found this when I first started surgery extremely difficult to think about the orientation and where to start the anastomosis and how to organize my sutures. So these evenings, presentation is ready to help you think about how you go about the anastomosis, paying attention to how you organize the sutures and how you orientate the needle, the art of the Baron. After basis goes back into the 19th century and that famous surgeon Nicholas S from Chicago, who died in 1908. He did a a review in 1893 and found that there are approximately 60 different techniques of interstim suture, which he attributed some to ancient modern methods and also described 33 different methods of the suture. So within the past 200 years, gastrointestinal anastomosis has transformed lifethreatening conditions into safe and usually routine procedures. And this is chiefly based on the knowledge that the CSA apposition introduced by Antoine Lambert who was a surgeon between 1802 and 1855. But the whole thing became impossible. Of course, again to list and the antiseptic techniques, it was Murphy Button who introduced a described a stapling suture technique in 1892. But it wasn't until the 19 sixties that the experimental apparatus and instruments in Moscow developed a group of instruments capable of stapling gastrointestinal anastomosis. But these initial instruments were cumbersome. And after further engineering feats, Rage introduced a modified form of the Russian stapling device which in 1985 led to the resurgence of sutureless anastomosis around the world. I had started my surgery in 1987 and remember going on these courses, thinking to myself it took longer in my opinion, to set up these stapling devices accurately and meticulously as it did stitching them. So even today, intestinal anastomosis can be performed in many different ways. And really, there is no randomized prospective trial showing benefit of staple versus suture. Suffice. To say for my personal opinion, if you are buying a suit, a handmade suit tailored perfectly for your shape, I think it's better than buying something off the shelf and machine cut. So it's really the factors, local and systemic factors that determine whether an anastomosis is successful or not. And in bowel anastomosis, the reports of leaks range from 1% to 24% depending on general conditions of sepsis, hemorrhagic shock and local factors as well. Predominantly tension, vascular supply and tissue handling. What is quite clear in all these randomized trials is the word meticulous attention to detail and surgical technique, mindful of what your forceps are doing. So the other thing is factors have not demonstrated any difference in either single layer or two layer anastomosis. And again, this comes down to adequate exposure, access, gentle tissue handling, absence of tension and distal obstruction and hemodynamic stability. It was in 1882 that ha was already drawing attention to the idea that the collagen content in the submucosal layer was the main factor responsible for maintaining an assis because anastomotic healing goes through the same stages of inflammation with a lag phase, a proliferative phase remodeling of maturation and then stability of the tissues. The bursting pressures of an anastomosis is often used to gauge the strength and it reached about 60% in 3 to 4 days in about 100% in about a week. But for the purposes of a bowel ANAs sis, it's important to think that the cirrhosa is vital because it holds the tissue better, but the absence and that's the peritoneal layer, which you can imagine that the thoracic esophagus and the pelvic rectum below the peritoneal reflection are technically more difficult because you do not have the strength of that serosal layer. We also know of course, that the stomach and small bowel are particularly vascular and heal very well. And you've got to be mindful of the vascular supply of a bowel. And when looking at an anastomosis, I remember the days of general surgery, holding the bone up and looking at the arcades of the vessels and choosing my resection margins wisely be mindful of those watershed areas of vascular supply. Of course, the anastomotic leak can be fatal, but it also increases length of stay. And the symptoms could be mild from vague abdominal pain, a mild fever, leukocytosis, tachycardia, and in elderly people, even a rhythm disturbance. As I said, whether you use hand sewn or staples, there's no difference in papers and it turns out that it really, it is down to the surgeons preference preference and technical ability. The ideal suture as we've already described in previous sections causes minimal inflammation and minimal tissue reaction. And the po popular choices are uh Polycin or Polydioxanone. In my day when I started surgery, it was asthma in two layers, one in a layer with a rapidly absorbable cat gut, which of course is no longer available. And the CSA layer of interrupted silk, whether you do continuous or interrupted, performing anastomosis, again, that does not show any difference in outcome, suffice to say that a continuous anastomosis is potentially constricting and reducing the vascular supply. So a double layer usually consists of an inner layer of continuous or interrupted absorbable sutures and an outer serosal layer again in interrupted or continuous. Sometimes a Singulair can be done as well. At 2006 meta analysis. Looking at 670 patients didn't show any difference. But the principles of a well nourished patient with no systemic illness, no contamination, adequate exposure, gentle tissue handling, well, vascularized tissues, meticulous surgical technique, then then no problems. Sometimes we encounter two different lumen sizes. So that's where people suggest and decide to compensate that side to side. Or if one is very small, doing a Cheetah slit on the mes anti mesenteric border to actually make sure the two sizes sit together. Surgical technique and technology has evolved over time and nothing could be more demonstrable than vascular surgery. And the history of vascular surgery and anastomosis is full of famous names. The first years of the 20th century Alexis Carrell, who was the surgeon between 1873 and 1944 introduced the three point anastomosis, basically equi descent stitches around a tube with tension pulls it into a triangle, making it much easier. And he actually went on in 1912 to win the Nobel Prize in Physiology and Medicine. And he's called the father of vascular anastomosis. And he was the youngest person to be awarded the Nobel Prize and the first winner, his work was primarily performed in the United States. Although he was a native Frenchman, he immigrated from Lyon in France. But his inspiration for that came from reading about the assassination of the French president Sadie who was stabbed in the abdomen in 1894. And Carl was quite vitreon and condemned the surgeons who tied off the portal vein because at that stage, joining vessels together was unheard of. And it was that apparently spurred on to think about how to actually successfully join vessels together. But of course, this was much improved with the advent of Heparin. In 1916 and 24 years later, Gordon Murray found that he could prevent thrombosis by performing enter end anastomosis. And this paved the way for kidney transplantations. Then, of course, we had the microscope and my line and were the first to bring the microscope into the operating room. And Jacobson applied this to micro anastomosis. And as we heard last week from my fellow colleague in one reaches a small vessel and he put less sutures in interrupted because of continuous sutures could cause constriction. So the future of surgery is always going to be inextricably linked to technology, size of needles in size of sutures. But fundamentally, the success of all of this is going to come down to your ability to handle the tissues that is not only thinking about your needle. And we said needles are made in a circle. We recommend that you hold it like a benediction sign such that rotation or pronation and super afforded by the radius folding over the owner gives you a smooth rotation of the needle. The ability to take the ne needle holder on and off as we've pointed out is just that ability to unlock the ratchet. So very little movements required to actually unlock the Roche and put it on. But that requires practice to reiterate are three important principles of mounting the needle. This is to achieve the perfect 90 degrees because all anastomosis, whether it is bowel or vascular, your needle got to enter the tissue at 90 degrees and come out at 90 degrees. Such that the, if I do a transection or the path of the needle through the tissue, we have a circle and the suture sits clearly there. So we showed previously, if you skid the needle in and out, then this space you've got here is a micro abscess that will reduce the function of your bowel anastomosis and that space is bleeding, which is quite obvious to all vascular surgeons. So the first thing to remember is to pick up the needle correctly and to reiterate, there's a 123 principle that I can spot whether a needle will work simply by looking how well it is mounted before it comes into the field. First, it is mounted just on the halfway. But remember the body of the needle is your working length and it depends on what you're stitching to and whether you can pronate back to get the needle 90 degrees into the tissue. So you move the needle accordingly. That being said, it's usually mounted to start just beyond the halfway two, there's no space between your needle and the shaft and three to remind you of that angle. Now, that angle is important such that your needle is 90 degrees to the tissue. You then need to line your needle up 90 degrees across what you want to stitch and then point it 90 degrees into what you want to stitch. So taking you further from our thinking of the protractor and going around in a cycle. If I am standing here at six o'clock, we noted as we went from nine o'clock, 8765. When I got to half past four, I was stitching into my shoulder and in that position, I had to change my needle to backhand and move my weight distribution to my left leg to continue stitching around the clock until I reach a point diagonally opposite. And at that point, I find myself having to go back to forehand. But each and every time I make a stitch, I need to make sure that my needle alignment is correct. No, that's all very well in a two dimensional plane. But what if we going to now join it to something else? So if I take that as a bit of bow or an anastomosis, six o'clock, nine o'clock, 12 o'clock, three o'clock, what I need to do is join two together and you note that this is an isomer that this nine and three is the opposite. They swap places and you need to think about folding it together like this. And as I do that, I also think to myself right now, the principle of surgery is always been stitching stitch towards yourself. So to stitch towards myself, I need to stitch, start my stitching the furthest point away. So it's usually the deepest point or the furthest point away and if I'm looking at that, you'll see, my furthest point away is going to be around six o'clock on around four o'clock on this anastomosis. So there it is four o'clock, four o'clock and it's the furthest point away. That means that I'm stitching towards myself along the back wall and stitching towards myself over the top and the back wall. Therefore, is, as you quite rightly have answered in the questions is the one you need to take most care of, particularly in vascular anastomosis because that is often the spot you are not going to see or come back to at all. Whereas the anterior you could perhaps put an extra stitch in. So what does that mean in three dimensions? So if I take here a toilet roll and I've put my 90 degrees in there, there's my clock, six o'clock, three o'clock and I turn it on its side. You can see that the 90 degrees into and out does mean that I now have to start moving around and moving my elbow in the air, turning to my right leg and to my left leg to ensure that my needle rotation in and out is correct all the time. And although I said 90 degrees there, if I turn that around this way, it is still 90 degrees if my rotation is in the horizontal plane or the vertical plane. So now we need to think what is easier to do horizontal plane to go 90 degrees in or a vertical plane as well. But the 90 degrees still is important. So how can we practice these and practice this rotation and practice needle position? Well, the first instance I thought I'd come back to the potato model and the potato model. I am now going to try taking my needle in and out of the potato and practice going around in different directions. And occasionally my hand will actually be in the way because I'm having to take my elbow in the, the uh, so the idea with this is for you to practice and be familiar with the different angles that are required, the potato, this is microwaved and soft. If I'm rough, you can see I'm gonna tear it out. We don't want to be doing that. We want to let the needle rotate cleanly through the tissue and start thinking to yourself the alignment. So you've noticed I've drawn some lines on here really to represent the lines that I had here. So that's the 12 o'clock position. That was the three o'clock position. So my practice is in and out on the line and this is holding the needle for me. But my alignment each and every time has to be cleaned and you can see how easily it tears. This will be the same for any vascular anastomosis. It will be the same for any bowel anastomosis. So the idea behind this exercise is to get you thinking of having to change your angles each time, which requires not only a needle alignment but also change in your posture as well. Of course, coming over the top is relatively easy because all of these are familiar forehand angles, which one can see in this exercise. And if you go back to our first potato exercise, we had some difficult positions, namely the most difficult b down here at the nine o'clock position. You see, I've got my green line there in the nine o'clock position. I've now got my arm in the air. My wrist is not displaced with respect to my elbow. So therefore the angle I've got my needle is slightly reduced. I'm standing on my right leg and I am going to sort of do a screwdriver stitch through the tissue and this in these positions, these angles end up extremely awkward and extremely difficult and is the idea behind the potato model is to get you thinking and practicing how you're going to stand and how you're going to rotate the needle through the tissue. So that's an easy way of looking at it, but we can actually continue our stitching by using the banana. Again. What I've done here has scooped out the inside of the banana with a spoon. So it's maintaining its shape. And you see, I've now just got the skin either side, but the skin is also going to tell me whether I rotate the needle in the tissue cleanly. There you go and take it out cleanly and you can look at this afterwards and see if you've got a good needle alignment coming in and out of the same there. But are you also test if you equidistant from the edge? Certainly in aortic surgery or large vessels? I like for a proline and II talk about four proline, four millimeters apart four millimeters from the edge and four millimeters deep and the banana. Remember will show you if your exit wound is poor and you can have a look at the banana afterwards. I haven't tried actually stitching this together. I'm just using this, the needle only. Sometimes I hold the needle but I don't use the forceps to deliver. I deliver with a needle holder as often the case when you're going round. Now, you very often need to attend and think about your needle position and sometimes you indeed have to reposition your needle by hand, right? And certainly if I'm picking that up, I'm having to reposition it by hand to ensure that I my needle alignment. This side is good. So how can we translate that into a vascular anastomosis and something practical? Well, I've got some baby socks here. So the important thing about a vascular anastomosis is that if the blood is flowing this way, you want to ensure that the intima there is actually held down to the adventitia as you go round. So simple thing with a vascular anastomosis is. And if we say this is downstream, then I need to be going inside out on this side. Because if I come outside in the potential for lifting that off and creating a dissection is pretty significant. Now, the other thing to point out about the sock and I'll go down a little bit closer because it will give you an idea of why these baby socks are quite useful. In the very beginning. We said 90 degrees to the tissue. Because if you take your needle through, not at 90 degrees, you see there's resistance. If you take a needle through at 90 degrees, there's less resistance to the tissue. But also if you look at the sock, the ribs, so you can see your alignment of your needle with the ribs. So let's see if we can do anastomose this pair of socks together. I am going to be using a three year proline here. It's a bigger needle than I usually use. But I'm doing this for the purposes of demonstration. So the furthest point away from me would be four o'clock. So I'm taking that as about four o'clock on there and I'm going to go through both layers at that point and the inside out on that side. So I'm going to be, I've got a double ended as in vascular anastomosis. Many of these are double ended. So I'm going to, I'm gonna put a li a clip on that side and I do have an assistant this evening reaching across from the table. So I'm just gonna hold that out the way and I'm going to be using the suture of this side. So, so I'm going to remember I'm coming outside in and I need to be looking at right anastomosis. And remember I am doing this in two all the time. I am doing it in tear and I'm going to, your assistant is holding this as electoral hold and not a pool. Where am I am outside there? I'm gonna come inside out again. I need to always think to myself, where am I can you take that across the other side, please? Thank you. Where and forever orientating yourself and thinking where the needle is coming out. Let's see. OK, I've actually go, we got that, see that easily done. I've actually gone, lived it around. I've lived to myself on that one. There you go. So even though right? OK. Oh dear, I've looked myself around, excuse me a moment and I can see the needle is not coming out. That's the thing about doing these things. Life is sometimes it doesn't work as you want it to work. So there I am cause I went for. So thank you. Take that there please cause I had to came went around the outside there. So OK. Yeah, careful not to try and hold the endothelium. I'm holding the adventitia or the red part of the sock to be honest, this is very much like a vascular anastomosis and stitching, descending thoracic aorta. It does need good assistance. My son Hanna is here standing opposite and holding thank you. So you can see along the backward here, I am actually going downstream inside out, maintaining the tension on the suture as we go. But along the back wall, I am actually stitching towards myself. What? Thank you and this separation of the two socks, to be honest, is not uncommon in the dissection where the layers have been profoundly separated. In vascular surgery. We resulted in aortic surgery. We sometimes use a tissue glue just to hold those two together, but nothing to be honest, beats accurate stitching. So as I'm coming around this, I'm actually thinking to myself, which are the better, better ways I can stand to orientate the my needle through the tissue. So I've now moved to my back hand and I'm having to think all the time about my needle, my body position, my needle position. Now, the thing is about the sock. It's not forgiving for poor needle position. My needle will not go through the sock if I'm not 90 degrees to it. And you know that from stitching a button on a shirt, so we've almost done the back wall. And this is the the one wall I will not see in a bowel anastomosis, one could put a stay suture on the Mesenteric side and the anti mesenteric side of a, the, the bowel and you can put a mosquito on that and literally turn it upside down by passing your mosquito from one side to another. So the back wall in a bowel anastomosis and most bowel anastomosis is not problematic. Obviously, it is problematic in fixed retroperitoneal positions and deep down in the pelvis and a rectal rectal anastomosis that becomes problematic. Now, although I'm actually holding the, the bow with my forceps, I am not squeezing it and not grabbing it at any stage. As we demonstrated previously, the problem with forceps is that it actually causes significant damage to the tissue. Thank you. So now I'm starting to finish the back wall. I'm now coming up towards myself and you can imagine that in a moment as my stitch continues here that I'm now going to start stitching away from myself. Just hold, reach over there, hold that. And this is probably that point. If I continue, I, I'll put one more stitch in. I actually feel that I'm now starting to stitch away from myself. So that's the point that my posterior anastomosis, I was actually going to finish. And I think I've just in talking that I've come see that I came from outside in because I wasn't thinking there's a good player point to actually stop that. So I'm going to just take the needle off that not thinking I came from inside to outside that that is going to posterior wall sorted. OK. On the back, there you go. So now I can take my other suture and come in. Same applies. I'm now again, coming over the top towards me. So I'm coming over the top that's coming towards me and wherever you are. And I've done some big anastomosis for the arch in the head and neck vessels and some of it is very, very distal and the important thing is is that you start away from yourself. Always any questions from the audience anish no questions at the moment, no questions. OK. So I'm doing this. What I'm really want to emphasize is the fact that the stitching now has become a very dynamic process that I'm actually having to think of my 90 degrees and I'm having to think of my needle angles and I'm changing the posture. I take that through. Thank you. I'm having to change the weight distribution on my right and left leg accordingly as I take the stitches and as long as I'm coming 90 degrees into the tissue, whether I'm coming in a horizontal plane or a vertical plane, as you've seen coming around these circles, it's necessary you don't have to use a suture to do this. I would like you just with a needle practice doing this and aligning your needle accordingly. My forceps on is are not delivering the needle but holding it in position such as I can pick it up and I can complete the delivery with bye. So I'd continue that around posterior and continued across towards myself and there you have a vascular anastomosis. So the principles come back to this tree damage this three dimensional oh appreciation here. Now, lastly, there's one other thing I want to do is demonstrate what is necessary for putting a patch and this will sum up a vascular anastomosis. So I am going to use a four here if I actually demonstrate on here. A this is essentially an end to side if I'm using this patch coming in from the side, if you could hold that there and you'll be following. So again, in all vascular anastomosis and patches, you do not want to actually put a thin end into there, you need to cut a round end. So all end to side anastomosis and vascular surgery when you're cutting a vessel or cutting a vein, once you cut it with a lazy s such that you have got a round end. Now, again, similar principle to downstream, I am actually going to just all the issue for me. I'm actually going to come from outside in on the patch and inside out on the vessel. The important thing is it's inside out on the vessel because and I wouldn't put a, a house there on a proline. I don't have a rubber shot here, but you put a rubbish shot because the metal and proline would cause problem. So if you hold that up Now I'm going to come from inside out on the vessel. Remember it's inside out on the vessel because I do not want to lift, just hold it in there and follow that for me. Thank you. I do not want to lift up the intima or the vessel. Thank you. So it's inside out. I'm on, I was asked to test a new vascular conduit for a company and I felt it was a little bit on the stiff side. So I asked for a banana because I wanted to test, what do you feel like to like, go please to stitch this to a banana. And I had everybody watching as I stitched this vascular conduit tu banana. What I'm demonstrating here is what's common in vascular surgery is called a parachute technique. So it's usually four stitches. The observant of you would have noticed I had picked up the tooth forceps there. So now I've gone around the toe. I am going to hold that patch up and gently take it down and take this tension up on the stitches. And then the process technique you can use that actually pulled through Justin. So now it's down. Could you follow this side, please? I can continue my anastomosis, my patch on the banana. The important thing is that I've got to continue it into thinking of my vectors as I've previously demonstrated your note that the heel stitch pulled out. Thank you. And the thing is about these models as they are supposed to be difficult now because it's reverting. I can no use my needle to put that down and continue my suture in the banana, my needle rotating in is also taking the Dacron patch on this bit of material I've got here and is averting it for me as it takes down and note that the patch is much bigger. Um, the defect here, you don't want thin patches whatsoever. I'm running out of suture material here. But you've got the idea. It's only when you have come down to this hand and I've actually got the patch lined up that I can continue to no finish shaping the patch accordingly again, rounding the edges. So we have done a tour de force of some basic anastomosis principles and basic vascular principles. The important thing is is that the thread is gonna follow the needle. What I've tried to demonstrate is you now need to be a lot more fluid with your needle, the direction and your body position to ensure that you're 90 degrees going into the tissue and 90 degrees out of the tissue. Your forceps should never grab the tissue because that is going to damage it and certainly will crush the mucosa and damage and a healing, both of which would compromise an anastomosis if you got a great disparity in size, as I said, on a bowel, certainly a Cheetah slit on the antimesenteric side to join the two together on the vascular side. I always felt it was easier to do an end to side anastomosis rather than end to end. But arm and small coronary vessels, it reaches a diameter on very small vessels where a continuous suture is potentially hazardous because it'll actually pull through and cause a stricture. I use a continuous suture on coronary vessels with a 70 needle, I think as soon as you get smaller than that and certainly in micro vessels, it's approximation of the vessel with accuracy. Stage, sutures are extremely useful, interrupted sutures are recommended in very small vessels and interrupted sutures need to be used when closing veins because veins by definition need to dilate with increase venous return. And certainly I would not advocate doing a complete anastomosis with a continuous suture on a vein. I would certainly do interrupted sutures and use the old fashioned CRE technique. Remember with all anastomosis, you got to think of vectors, 90 degrees that side and 90 degrees that side are two different vectors. Therefore, as demonstrated here, when your two ages are separated, you got to change your body position. It's only when the two are together. Can you go through 90 degrees through both? I'm happy to take any questions from anybody or any observations. My fellowsi and colleague, Mr Caddy is actually on the line and welcome to join the discussion. I'm Vin, please throwing questions yourself. Do we have anybody in the chart answering questions anybody, any questions? Well, in which case, ladies and gentlemen, thank you very, very much. Indeed, for your support. Throughout the year, we are going to take a break and we're going to come back to you on the sixth of January in the new Year. I wish you all a Merry Christmas and a fun festive season and look forward to joining you again in the new Year, as you think of new models and new guest speakers are joining us as well. Again, thank you for your support. Do remind your colleagues that this is all free on catch up. You do get CPD points and certificates. We do appreciate your feedback. Please feedback a form that has gone in the chat room and also please let us know if there are any topics that you would like us to address in the New Year until then see you in the new year. And thank you for following the Black Belt Academy.