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Hello, good evening. Good afternoon. Good day. Wherever you 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 and now working as a professor in the Medical Education Research and Development Unit of the University of Malaya. And we're coming to you from Kuala Lumpur at 23 30 100 hours, we supported by Gabriel of Medal in Lithuania and my fellow colleague, Chris Caddy is in the UK. What is wonderful about the med platform is that we are able to reach 4234 followers across 100 and 19 countries. Indeed, this evening, we have 26 countries from A to Z Australia to Zambia with Latvia and Sweden in between. If this is your first time. Welcome. And I do encourage you to look at the first three parts of the series because we are on part four for those of you who are returning. Thank you very much indeed. And please continue to spread the word. The whole thing about stitching and anastomoses is joining things together and the thing is joining things together. Usually comes in the form of tubes and they found at all sorts of places in the body and in very inconvenient places. So this is where you having control of your needle and having a framework to think in three dimensions is important to attend to the basic surgical skills of stitching. No, the history of anatomizing blood vessels is full of famous names, but it wasn't until the microscope came along in mass production. In the 18 100s, the people started to understand exactly what the endothelium of the vessel did and begin to understand the vascular physiology and thrombosis because many people had tried to join blood vessels together. But as soon as blood leaves, the blood vessel exposed to tissue factor in the air, it clots and in fact, it reminds me, I think we should as surgeons do a session on blood and clotting, the groundwork for vascular anastomosis was done by Carol and Guthrie and they reported some of the first successful anastomosis, but it didn't last long. It was in 1916 that mclean discovered Heparin. And 24 years later, Gordon Murray found that it could prevent thrombosis and voila vascular surgery was born and he was able to do end to side anastomoses. And this paved the way for all sorts of things including the first human kidney transplant. In 1954 it was otologists, Niland and Hren were the first to bring the laboratory microscope into the operating theater, but it was Jacobson who used the microscope to apply it to microvascular anastomosis. And we'll talk about that later this evening. The first attempt at a microanastomosis was actually in 1960. But tools and sutures, as we've previously explained, have improved, significantly, enabling people to do more and more complex procedures. See, the future of surgery will always be inextricably tied to creativity and the innovators out there. And as future surgeons don't stop questioning and don't stop your curiosity. It was in the first few years of the 20th century that Alexis Carroll one in 1873 and lived to 1944 introduced the three point technique. In essence, he placed sutures around a lumen at quiescent spaces of 120 degrees and found when he put tension on that effectively changed the circle into a triangle. And in doing so, was therefore able to stitch in a straight line down each sides of an otherwise equilateral triangle. Funny that geometry comes in again. But his work on vascular anastomosis earned him the Nobel Prize in 1912 for physiology. And he is to be regarded the father of anastomosis. Now, vascular anastomosis really only became successful because of heparin and coral. But the art of bow and masis dates back to the 19th century. And then Nicholas Sen did the first review in 1893 and described 60 different techniques for intestinal suture which he attributed to ancient and modern methods within the past 200 years, gastrointestinal anatom has formed the life of everybody with potential obstruction. And the most important factor of bowel anastomosis was discovering that it's serosa apposition introduced by Antoine Lambert in 1802 to 1855. And this was helped, of course, with the introduction of as ESIs by Lister, it was only in the 19 seventies that bowel anastomosis and the advent of stapling devices came in. Indeed, I was a trainee in bath surgical rotation in 1987. And staples were being introduced at that stage. To my mind, it took as long to set up the bowel in the right position to apply the staples as it did to actually stitch it. We'll come on to that in a moment, but the principles of anastomosis applied and despite the perfect patient, a healthy bowel meticulous technique, anastomoses do leak. And when they do the mortality is up to 23%. I find this horrifying because as a cardiac surgeon, the mortality for elective coronary artery bypass grafts in the UK was less than 0.8%. Interesting. Now, approximately 4% of all anastomoses done in general surgery is for bowel cancer and it is debated whether staples are better than sutures. And there are a number of trials that have been done. One of the biggest was actually done in Scotland in the West Scotland, Highland anastomosis study in 1991 where they looked at 8004 patients in the care of 13 surgeons and concluded that overall, there was no difference between staples and suturing. Subsequently, there have been a few other meta analysis that have decided that in a case of a colic anastomosis for right hemicolectomy for cancer, particularly in men. One, a evidence recommends the uses of staples. I think this is a difficult subject to debate and the conclusion of that meta analysis suggested that it should be down to the surgeon to decide. But the principle of all these things is that for ANAs mosis to work for b you need blood and you need oxygen. That is why as a surgeon, you should do a cardiac examination and a respiratory examination and an E CG and a chest X ray as part of your pre op. Of course, if you don't have enough blood, don't have the oxygen or you've got a dirty field, your risk of anastomosis is high, low hemoglobin, steroids, diabetes, cachexia, cancer, and apparently males in particular, with chronic surgery are at risk. And that's perhaps because the pelvis is small, but I've always thought about it this way and wondered if you had all the money in the world. Would you go and buy a handmade suit or dress? Would you want one of the peg cut and stapled by a machine? Because indeed the best suits are done by the best tailors with incredible skill. And even if the stapler fails you still need to actually understand some principles and how to stitch, hence the hands and appreciation of the anatomy and the control of your needle that will determine the success. So let's just revise a couple of things we have said to date. One, we suggested you hold the hand in the palm of your hand, the needle holder in the palm of your hand, such that the angle of rotation is aligned with pronation and super. And you can complete a full pronation and super. And that is the rotation of the needle. And I can complete 270 degrees. And that rotation is maintained no matter the position of my upper arm or humerus. And you can imagine exactly that with a screwdriver because we will be getting our arm in all sorts of positions to get to the 3D dimensions. I hope that you have remembered the simple rules of picking up your needle one. It has got to be at the tip. There's no space between the tip of your needle holder and the shaft. It's just on the halfway and note that it's angled out and that angle out is related to the angle between the horizontal and the forearm. In other words, the displacement of the wrist, as I demonstrated previously, that angle allows you to piro with the needle over the tip to backhand and forehand without delivering the needle with the forceps. The forceps is very simply there to retract and very occasionally hold. So when we talk about anastomosis, it's important that you have some idea of thinking of the geometry and how it works. And I'm going to bring you over the top to the table and take you through some models. In essence, we talk about a clock and I am standing here at six o'clock, top 12 o'clock to my right three o'clock and nine o'clock. What I did think to myself as I was drawing this out, my accuracy in drawing the hours is not as good as it ought. And I wondered if that's because I'm not wearing a watch. And we're in a digital era because as I previously described, 90 degrees is easy for us to spot is we are surrounded by an that being said, no matter what the size we can gear it down to 12 o'clock, six o'clock, three o'clock, nine o'clock. And we also determined last time as we were stitching around the banana, you found on this axis between four and five, my alignment of the needle will bring as a right handed surgeon, the needle towards my shoulder. And that is the most difficult stitch to achieve. I therefore to continue, the anastomosis have to swap to backhand and swab my leg and weight distribution to stand on my left foot. And now I can continue round to 11 o'clock and I find myself continue now forehand. So that side was backhand, that side's forehand and it is useful to remember to peru at your needle and practice doing that without needing to hold it with the forceps. Now, when you're bringing two edges together, we got one lumen in there and one lube in there. OK? And now we're gonna bring it together. What we got to do is bring it six o'clock to six o'clock. But now this is an isomer, the three o'clock is the nine o'clock on the other side. But the color is the same because what we want to be able to do is fold the two together like that. Ok. So that is the isomer of that, but 6 to 6, 12 to 12. All right. And we folded over. This becomes more apparent if we think of it in three dimensions. And what I've done here is taken some tiling right angle plastic things. I found these are very useful for the banana and potato models to stick in the potato and banana. It helps you align simple little trick. And what I've got here is 12 o'clock, six o'clock, three o'clock, nine o'clock. And the important thing is that the alignment of the needle is 90 degrees into the tissue at every stage. The other thing is that your bites are even from the edge. Ok, all on the same plane and regularly spaced. But you got to remember that a continuous suture is potentially strangulation. And therefore, as you ask your assistant to follow, it's a lateral hold and not a pool. If you can imagine, I'm gonna move this down into this plane. There you go. Now, you can see the sort of angles that you're going to have to get your needle in. Now, in this sort of plane, I can come in as long as I come in at 90 degrees, I'm going to enter the tissue correctly. Now, do you come from inside or outside? Well, effectively, whether you evert and invert depends on how accurate your stitching is. If there even bites and evenly spaced all the way round. If you pull the come through and finish your rotation and take the suture from the inside, you'll find it naturally inverts. When you take the suture from the outside, it will naturally e of course, there are fancy little stitches you can do in bowel surgery to get round the corner, the Cornell stitches. But the advantage is with a bow with a Mesenteric stitch and an anti mesenteric stitch. You can just pass it under and literally flip it over. It's a little more difficult if you're stitching in aorta because the posterior wall will be fixed. And we need to think how will I A needle? It won't always be place 90 degrees across what you want to stitch in these circumstances, but you have to 0.90 degrees into the tissue and your rotation has got to be clean. So, what we need are some models that will help us think about this rotation and placement to allow you to play with the position. Remember, the principle of alignment is absolute but how you stand and how you position your arm will really depend on your own body habitus provided you're standing at the proper height. What is interesting in my training in martial arts and with the sword, it's the principle that counts and how you stand and the position and the spread of your feet and the distance between your heels and toes of either leg really depends on your body shape. The principle being you have to be stable. So there you go. As you think of it, we've taken a clock which we've tried in two dimensions before and we have now made it a three dimensional picture and the principles I hope you appreciate are exactly the same. So if we are joining one tube with another and that's the top and that's the bottom. OK. What we did say is that you need to change direction as we're going through and around the clock. But it's a little bit more subtle with an anastomosis. Very simply with all suturing principles. Whether you're doing a skin, a blood vessel or a bowel, you should always be stitching to yourself because a continuous stitch to yourself will not become tangled. Whereas if you're stitching away from yourself, the likelihood of you tripping up and tangling is huge. So if you look at this simulated bow or vessel, the distance furthest away from me down there, funnily enough, turns out to be the four o'clock position. It is diagonal across the vessel that's 12 o'clock, 11 o'clock, four o'clock. And that's the furthest point. So when stitching at depth, you start the furthest away from you and you start with a back wall and you come to yourself and at this point you'll find you're starting to move away. That is where you stop. Then you take the back wall up and towards yourself again. Here and again, you're not tripping over your stitch. So how do we actually practice these and think about it? Well, another little model I've just put together here. I got some baby socks. Now, the baby socks are kind of fun. You'll remember that I said to take a needle through the t uh a shirt, you have to be perfectly perpendicular into the shirt. You know that when stitching a button on now, this floppy sock, I've got one sock inside the other and you can think of it as endothelium adventitia mucosa cirrhosa. OK. You've got two layers. And I've always said as the master, you can take your needle through two layers provided they sit together. But if they're part or slipped, you have to do them separately, there's no shortcut whatsoever. So what I like about this so is the natural ribs and I can actually see the rib and practice aligning my suture through 90 degrees in and I'm going to rotate it out and all this exercise is doing is helping me align. Now, I'm not gonna try and force it through that bit at all. I could bring my Forceps to hold it up, but I'm not going to be able to do that because it's not going to sit properly. So therefore I would again, same position and take it through so you can do it on the top and practice your alignment. What I found where the sock was that if I wasn't perfectly 90 degrees to the to the soft tissue, it wouldn't go through. So, although it might look clumsy, it might look silly. It is actually teaching me some very important things. Now, I did it in 22 there because it, there's a gap between the inner layer and the outer layer here, the two layers are together. So it's quite in order for me to take them together. Now, what often happens with the forceps when stitching is so focused on stitching that the forceps as I previously shown will be grabbing the mucosa and think of that damage and force of 5 million newtons millimeter squared that are being generated because you're not working the forceps independent of your stitching. Now here, yeah, 90 degrees across, but I gotta make sure I'm 90 degrees into the tissue and I can align it and all this exercise is simply doing for me is giving me an opportunity to think about my arm position, which leg I'm standing on and how I'm going to get my needle round. And sometimes you do actually have to think deliberately about your position. But the principle of needle alignment is absolute. And the best thing to do is to practice and play with a simple model because if you're not perfectly 90 degrees, it's not gonna go through the tissue very well. We go through the sock. As I said, I'm not going to be using a suture this evening because a monofilament would get awfully tangled. And that's where I do need an excellent assistant will hold the suture on a lateral hold in the direction it comes out of the tissue. And that's, it's literally is a lateral hole between finger and thumb. And I think your assistant is incredibly, I critically important when doing an anastomosis. The other thing is I need to say is you need to be aware and feel the tissue. Now, I stood up and said, Samia as he did a beautiful aortic valve replacement. And I was very pleased and he closed the aorta four millimeters by four millimeters deep 40 proline 40 by 404 by four by four. And he did a beautiful job and I was bone dry when we closed on bypass. And as we came off blinds, the order started to unzip and it started to unzip a bit like postage damp tearing. So I immediately went back on bypass and I said I better come around and have a look at this. And I picked up the needle holder, I made for a stitch. And what happened? I did not feel the needle go through there or a water at all. I asked for some Teflon and, um, in essence, put Teflon down both sides to buttress the water. But I also took a little bit to send for histology. And yes, it came back that this gentleman had severe cystic medial necrosis. Now, the thing is though SIA did a beautiful operation and it looked very good. He could not feel the tissue and he could not feel the tissue because he was holding his needle holder really, really in a grip. When holding an instrument, it should be able to be lifted out of your hand. And the funny thing is that the same thing in karate or in I on Sunday said lighten your grip. So there's a sword that weighs 950 g and you need to hold it as a light such as somebody could literally take it out of your hand, but it's the lightness of grip that will determine your response to somebody attacking you and you can feel the sword. Now, I have to teach that in surgery that you need to be able to feel you might perceiver are coming around here that I am swapping from right leg to left leg, moving my elbow in the air. But at all times, focusing on trying to get this needle 90 degrees through the sock. And I can assure you, and I'll demonstrate this side. If I do not take it 90 degrees through, it doesn't glide through and I can feel the difference. So the SAR does actually help you align the vectors. And if you're doing it continuous, I would have done the posterior wall to there and pick up the other end and come over the top. But if that's helping with the alignment, we cannot actually forget a banana. And what I've done here is taken a banana, cut it in half and just use the teaspoon to scoop out the inside. So I've got a lumen and the thing is as you've seen with the banana, this shows your entry and exit points. So same again. No, and some of this is awkward. What and depth and in real life stitching is awkward. So the thing is that you need to be deliberate. And as we've seen before that if your entry and exit is poor, it will show up as a skid mark on the banana. What we really want to see is some nice even spaces for this and to be able to see. So if I go across, I might be sticking it into the other side. Now, the only other thing to point out with a vascular anastomosis, it always is from inside out downstream. And why we say is it has to be inside out downstream because you need to be able to bring the intima onto the adventitia. If it goes the other way round, there's a potential that you could lift the intima off the edge and titia downstream and that and potentially could dissect. So the exception or rule for vascular anastomosis is downstream, make sure you're from inside out because that is ensuring that the intima and adventitia are not separated a bit like the so model, I'm having to move around and change the weight distribution, the train, the right foot and left foot, depending on which hot of the circumference of this vessel. I'm stitching and I'm sure you'll see now that the banana is starting to show me one, my spacing and two is a even. So in fact, to practice this, you don't really need a stitch and I can look there and say that's good. That's better. That's a bit of a skid. That's, that's OK. But I'm getting feedback from all the tissues and I can see if my rotation is good. That's what happens if I'm rough. OK. It literally does tear out and we've put the banana and a suture pad in a CT scan and measured the hans field units. That paper is going to come out shortly. I hope that is why I do not abide by suture pads because organic material, particularly the banana is giving you feedback. There's one other element two, this, that's a tube. We've got a 12 o'clock, six o'clock, three o'clock, nine o'clock. Now, let's take the shape and squeeze it. And if we squeeze it, that effectively is a fusiform shape and what you'd see with an end to side anastomosis or a patch in vascular surgery. Now, as we have said before, the vector for this are very different because I, one hand upstream, you have what's called a heel. All right. And at the other end, downstream, we call the to all right heel and toe. So that's the vascular way of talking about 12 o'clock and six o'clock, we call it heel and toe. All right. Now, if you're doing it correctly and joining something together, it's better to put the heel down at the toe down and then the heel because you can cut back up the vessel to fit. Now, I've got a patch here and the principle of patches is that it's got to be bigger than the incision in the vessel and really needs to be twice the width or at least twice the width. That's the width there and that's twice the width and all this patch is going to go into there. But note that I haven't cut it as a point. This is important in all end to side anastomosis, especially in cardiac surgery in small vessels. Because if I cut this into a point, my sutures will squeeze and crimp the end because of the vectors there. Ok. So I need to cut it rounded and this will then ensure that I'm not squeezing the toe. I stitch it all the way. And only when I get towards the heel, do I complete this patch? Tailoring it to exactly the length I require. But I only do that once I've secured the toe. Ok. And that's stitched down. Now, previously with an assistant here, I have actually stitched cloth to a banana and as an exercise it works. Ok. Remember I need to go inside out. So it's outside in on the patch and bit like all material. There's a whoop and we, and your needle has to be 90 degrees through that place, point, rotate live the needle and that would be the next ditch there. Now, I'm starting two stitches from the end because only two stitches away from me and I stand there and I come around anticlockwise on the ANAs sis because it means it's 12 or heel and then it's forehand down the side. Ok. So I'm stitching towards myself all the time. Remember it's 90 degrees at that vector and that's what's giving you the tr education. And this is a bit like the 11 o'clock forehand to backhand conundrum and depending on your body habits, you might have changed foot and done that beforehand. Remember, I'm gonna try and do a backhand day, but that's not gonna work. So I need to fl my needle hold needle, forehand. Note that I'm not using forceps. I lined my needle now with a vessel. It's parallel to the two walls. All I've got a curve banana parallel to the two walls. And I can use the belly of my needle if it's a small vessel to point, push the posterior wall away and therefore avoid any chance of picking up the post war and using the anatomy of the needle to aid my stitching. So all of these would come around this side. And in fact, I can use the patch ones down and you see it'll e naturally as eye stitch because it's aligned, I can do the two together. So I hope that's given you a framework of thinking and how to stitch and how to actually practice some skills at home. We have therefore progressed from a simple deconstruction of how to hold the needle holder, how to mount the needle 1231 just beyond halfway, two, no space between the tip and the shaft three angled out. Such that when you push the needle down on the surface, it's the belly of the needle that is pushing the surface down, we then went place at 90 degrees cross, we want to stitch rotate back. Remember as we rotated back, that pronation enabled me to unlock the needle. So it's 90 degrees into what I want to stitch rotated round. And I had tissues holding the needle for me, I can deliver it if you don't grab the needle but gently apply a needle holder because of the cuboidal shape of the shaft, it'll flip into position and you'll find as you're going around anastomosis, there's a slight change each time and you can nudge the needle into position ready for the next stitch because it's not quick stitching. That is required but accurate stitching and appreciating the vectors and the set up, this reduces your diastolic time and means that you got economy of movement and flow. Remember when holding your instruments to use the lightest of touches forceps as previously determined is not used unless exceptional circumstances to mount the needle but to retract tissue. So I'd like to invite my colleague and fellow Sensei Mr Ca to join us in the discussion. He does a lot of plastic work and microsurgery and wax at a finer level than a 1.5 millimeter coronary artery. So hats off to you Mr Caddy and I'd like your observations and comments and how these principles apply to even smaller vessels. Yeah. Well, the first thing is that the principles are applicable to every situation. Um So we tend to do small vessels, micro vessels and they're now doing what's called super microsurgery, which is lymphaticovenous. So, lymph vessels into veins or lymph vessels into lymph vessels. So we're using much finer sutures sort of 10 or 11 0, which is finer than your 67 and 80 in, in heart vessels. Uh But it's all about distributing the, the tension about ensuring that the room is kept open, that you don't pick up the back wall. And it's about isolating the movement. So it's just between your thumb and the index finger with the instrument lying in your first web space. Um But no, II say it's, it's all about accuracy and setting yourself up for success and that's it. It, it's the set up. And I think my conclusion, looking at the teaching of skills turing in particular is that we don't think about or drill the set up. What's interesting with all martial arts and you're not going to be able to do any cars a combinations unless you have set yourself up properly. And it's interesting chatting to the sensei and I hoped to interview him on Blackard Academy. He's passed me on to his, his sensei who's fifth man in London. And I'm intrigued at the level of detail and nuance they put in their instruction in 15 years of surgical training. Only three consultants ever sit, hinted at any direction on how to hold a needle and how to align the needle as well. So I think we've got a lot to learn what is clear though is only with practice. Will you hardwire your recognition of these vectors and angles that will enable you to stitch more accurately? I think it's also about being open to learning. Uh So most of our, our students are at the beginning of their journey and they're like sponges, they're open to learning. I think as people become more senior, they become more resistant to change. And that's where you and I need to think about how do we get people to change when they're set in their ways? Uh If it's been good enough for the last 20 years, why do you want to change? It is about continuous improvement is about continuous improvement. And that's what I like about martial arts because you're improving all the time. It's a journey. The thing is it always, always comes back to drilling the basics and it cannot be arrogant to think that you got the basics, right, as I said to you before, although I've got second hand in the, I do, I'm not training with 1/4 hand sensor and realize I know very little and got a lot to learn still. And I think it's true with surgery and takes a lot more work to undo bad habits than it does to actually correct them earlier. So if you're starting your journey and surgery, I do recommend that you look through the series and start practicing usually between part one and part four of the series. I'm looking at 6 to 8 months with regular 3 to 4 times a week practice to ensure that the needle is working for you, think about it. But II think the caveat to that though is I if you can find a do, if you can find a sense who will look at what you're doing and give you feedback. And it needs to be honest feedback, self self regulation and tuition does need expert feedback. And that's why in karate you go to dojo because the s they will correct you. And that's what we're trying to do with the black part academy. So if you'd like instruction, uh please introduce us to a la local consultant. We'll be very happy to instruct them and show them how to help you become better surgeons. Thank you very much for joining the Black Part Academy. I haven't quite decided on the talk next week because I'm waiting to hear if we've got a guest speaker, but thank you for joining us. Do pass the word around and be safe Gabrielle. Thank you very much indeed for the production and say ak for your wise words.