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Hello. Good evening. Good morning. Good afternoon, 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 retired cardiac surgeon currently in Kuala Lumpur in Malaysia and it's one o'clock in the morning. I'm a visiting professor at Imperial College, London and the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. The Blackburn Academy is accredited by the Royal College of Surgeons of Edinburgh and we are powered by metal. That means that this evening we have delegates registered from Canada, Brazil, Egypt, Pakistan, Myanmar, and the UK and others. I'd like to think all of you for following 4242 on Facebook 705 on Instagram and 1263. On Twitter. Last week, we introduced the first principles of stitching and we're talking about the needle being made on the circumference of a circle. Now, early man looked up into the sky to see the disc of the sun and the disc of the moon and for a long time, appreciated circles and the sun and moon as two D and was in 1700 BC that right, the area of a circle. The father of mathematics Euclid 300 BC in his duties on the elements described all aspects of the circle that to radii joining a chord form an isosceles triangle and a radius dissecting a cord forms 90 degrees that tangents from one spot to a circle touching the radia at 90 degrees of equal length. The tangents two the diameter on either side by definition of parallel and the angle subtended by the circumference at the center equals four right angles or 490 degrees. It's interesting that Archimedes derived pi as an approximation as a calculation of increasing number of polygons with increasing number of sizes. But it wasn't until 1880 that a mathematician in Germany Lindman proved pi is a transcendental number. In other words, a fraction that is got an increasing number of dec decimal places. Interestingly, it was a Japanese engineer in 2006. AKI Haraguchi who remembered pi to 100,000 decimal places. It took him 16.5 hours to recite it. Starting at nine o'clock in the morning and finishing at about this time in the evening, Kuala Lumpur 120 he actually felt a pie was a symbol of the religion of the universe and a sacred number, a computer. Recently at the University of Applied Sciences, calculated pi to 62.8 trillion places. Why on earth did they do that? Well, simply because they can, what I love about euc in geometry just to digress a little bit is the relationship of circles and 90 degrees. So you might remember from your gcs E how to construct 90 degrees with a compass. So I'm gonna put it down on the end of the line here and I get to draw a semicircle. I'm then going to put it on end of ac circle here and draw another mark. And from there, draw another mark and using the same radius on that point, draw mark and on that point there for a mark. Now, if I actually take a rule for that to the end of that, actually, I should have 90 degrees. My pen was slipping at the time. What was, what was interesting though is that the first mark that we made not 16 degrees that is 100 and 20 degrees and the radius there bisected that to 90 degrees. But using that diameter, I can now make a mark out here and then using this cord length, putting it over on here, make a mark and simply with a compass, we are now ending up with an angle here of 70 degrees. Personally, I find it fascinating that with a simple string and compass, you can work out all the degrees and bisect all of these and work everything out in five degrees with a compass. But we've diverted a little because what we want to talk about is the needle. And then last week, we stressed that the needle is made on the circle. We pick it up three important points. One, there was no space between the tip and the shaft. Two, you're just on halfway and three, it is angled out. But I want you to notice something about the shaft of the needle as I pick this up, I'm gently picking it up and you see it flips into place. And that's because as I said last week, the anatomy of the shaft is in fact cuboidal and allows you to pick it up. One, two and three is the angles we also demonstrated last week that control of the needle and unlocking is using your abductor policies and that analogs it so you can still hold and control the needle unlocked. And this is what we wanted you to practice is flipping it over, cross the point forehand and backhand, a note, flipping it over forehand and backhand. I'm maintaining the angles for forehand and backhand. And that angle to re I remind you is the angle between the horizontal and the forearm because I am standing up and my wrist is displaced lower than my elbow. And I'm doing this slowly because the feedback from last week was simply slow it down and do it more deliberately, which I'm trying to do for you now. But this means that I can control the needle forehand and backhand in the space. My focus of attention without having to bring forceps into play. My needle now starts working for me. So, how do we practice? And now we're gonna go through the potato model and what we've got here is a microwave potato and I've drawn some lines on it and anybody doing any sport or golf or artery would put sticks down or draw lines to align the needle for the needle to pass cleanly through a tissue is gonna be aligned 90 degrees across what you want to stitch. And it's got to go 90 degrees into what you want to stitch. And you've quite rightly said, 90 degrees is everywhere. It offers stability, but it passes easily through tissue because it goes to the war in the left straight through at 90 degrees. And hence, I've come up with this simple mantra to enable you to think about your stitching all the time, you place it at 90 degrees across what you want to stitch. And as we've demonstrated before that angle, there is the belly of the needle is pushing the tissue away. And that means that I am at 90 degrees two, the surface and 90 degrees is a perfect angle according to Euclid because each, every opposite orthogonal angle is 90 degrees as well. So 90 degrees and that's what I refer to as the belly B. So I'm just gonna zoom in a bit further. So you can see the belly of the needle pushing down. And in fact, that particular element is very useful in vascular surgery at heel and toe and cardiac surgery that I use the belly to push the posterior wall away and almost allow the recoil to bounce a needle up through the anterior surface. But we'll come to that in the later sessions as an advanced element, 90 degrees across what we want to stitch. I'm rotating it backwards, 90 degrees into what I want to stage, pointing it in. And I am rotating iterative through and it should come out on the line. I take the needle through the tissue and I'm gonna zoom in further through the tissue and I deliver it it iterative until I'm just beyond that halfway point. I can then apply the needle holder and take it out on the curve. And in doing so, I've maintained that angle to the needle. So we'll just do that again and practice makes perfect. But this alignment and the soft microwave potato gives you feedback because if you do it incorrectly, you start tearing the potato. So as you can see the needle's rotating cleanly out of the potato there, and I'm picking it up before it comes out at the tips, continuing the rotation and delivering. Now there's one element to this that's important to now talk about because what I've been saying there is place point and then rotate, place point, rotate. But what I've done as I have placed and rotating back in a pronation movement and in pronation, my thenar eminence is now going to unlock the needle. And at this point, I have actually got the needle holder unlocked. I can now point it into what I want to stitch and continue my rotation without having to worry about unlocking the needle holder. Because I've often found that people not unlocking the needle holder and taking it needle into the tissue. When it's in the tissue, they unlock and there's an inadvertent dropping of the arm which causes tearing and a problem. So place I'm pronating back and I'm pronating back, I'm unlocking point and rotating through. So let's try again. There you go 90 degrees across what I want a stench and you should say this to yourself out loud each time you're stitching every time you're stitching place point. Now, the other thing about pointing is that if you're pointing at something, you're saying it's there, you're not saying it's there point is specific. So the pointing element of this is giving you the exact distance from the edge that you want to be. It's not roundabout, it's pointed there. And that pointing is focusing and reinforcing the accuracy of your stitching. Rotate it through. Note that I'm delivering a part of the way through the tissue. It's just beyond the halfway, pick it up and I continue the rotation. I don't pull it and drag it out. Now, this is where we can start having fun because we need to do that backhand. Now. So I've just down the back hand and again, without using the forceps align a needle place, rotated back and in the back hand, I'm sating now point and rotating again. Same principle applies. Just be on the halfway and if you don't grab it, but just nudge it because of the cuboidal shape of the needle, it'll drop into place and I'm ready to do that again. On the back hand, the potato is very friable and is not going to tolerate poor rotation or dragging it out. And what you're doing is practicing your needle skills, not the forceps on a surface. And even if I drop it, I should be able to pick the needle up to use again without the forceps. So that's on top of the potato. And at Greenbelt in the Blackburn Academy, we would like to see you pass this needle forehand and backhand across the potato, non dominant hand behind the back, maintaining your posture and maintaining the al alignment. And without touching the needle with your forceps. See what happens if you pull it out too much, you get potato and you start mashing it two. That's the first exercise and practice to do. But of course, when we're operating, not everything is in a convenient plane. And as we discussed last week, that is why needles are around. They round such, you can use a driver to take them through the tissue at 90 degrees in confined spaces. So, let's just have a look at this a little more closely. I'm going to zoom right out because I gotta get my arm up in the air. So that's on top, that's away from me. That's my side, that's my stitching arm side. And that's to my left side and the same applies in the alignment. There you go. 90 degrees, 90 degrees, 90 degrees, 90 degrees. Now, the thing is, is that in this position of the top, I've now got my elbow in the uh in the air. And when my elbow ends up in the air, the displacement between my wrist and my elbow diminishes. So therefore, I do not have to angle the needle out very much. Imagine I'm using a screwdriver. I've abducted my shoulder and imagine from my shoulder or elbow to my wrist is a straight line. So 90 degrees across what we want to stitch. And here you can see it more clearly and I'll zoom in to demonstrate that that the needle is coming out of the tissue at 90 degrees. And I'm delivering iterative just just beyond the halfway, applying the needle holder and continuing out. And my angle preserved for me to do that again. So pointed in 90 degrees into what I want to do. Oh, it's coming out at 90 degrees and delivering it iterative, picking up just on the halfway and rotating it out. Now, just as on top, I'm gonna do that backhand. And it's for you in these circumstances to work out the most comfortable body position for you because stitching is really dictated by the alignment of the needle, which I agree. So with your arms up in the air or if you're in your right leg or left leg, you have to work it out such that you can pronate and supernate clean, cleanly without interference or the needle. And again, we want you to be able to do forehand and backhand on that side, this side to the right, same again again, my elbows up in the air and because the displacement between my wrist and my elbow is not so much, the angle is not aligned, but the principle is 90 degrees. And really to help you think about that, you can use a simple thing like a bracket and I'm gonna put a bracket into the potato. You wonder why you had these earlier and there's a bracket that's 90 degrees. Ok. So when I take this needle out, my needle should be flat against that bracket and my arm's in the way looking at it, but my needle should be flat on their bracket to give me that 90 degrees rotation precision. All right. So that's what you're gonna be thinking about. You're 90 degrees to the edge. So there you go, needle in the air, take it out again, just be on the halfway and I'm picking it up with the tips. And if I pick it up gently, it will flip into the right position ready to use again and make sure you come out on the line again. We want to be able to see you flip your needle forehand and backhand. If you drop it, pick it up. But if you pick it up, remember to hold it against the palp of your finger. That's this way you feel blind. So ordering the bodies that your finger, you're not going to stab yourself. So five on that side as well, please to my right side, something similar. Again, I gotta think about how I'm going to stitch this and I want you to play around yourself with your body position and the alignment, the alignment is absolute, it's 90 degrees. So you have to work yourself around into position that it's comfortable for you to rotate that needle. It's not for me to stand the principles of the need and plus needles of all sizes and what's interesting aligned. I've only seen described in two journals. One, I understand that cornea transplant surgeons put perfectly radio stitches through at 90 degrees. And if it wasn't at 98 degrees, the cornea would crinkle i plastic upsetting the vision. The only other was surgery by describe of now, if you got dissection before I can assure you that the tissues are like wet blotting paper and blank poto do not to it. Poor rotation of the needle and less than 90 degrees in go home. And since most dissection patients are coagulopathic that could take you hours POSTOP to satisfy not least the amount of transfusion on this angle. Here, the fifth side is really a brown belt and this angle is as the cardiac surgeon would recognize is a junction between the aorta the roof of the left atrium and it's the lower end of the aortotomy. You do for surgical aortic valve replacement. And it's called the angle of sorrow for a good reason because if you don't stitch it accurately or if your incision is too close to the left atrium, you could end up in very thin and nasty aorta to do the stitch. I've mounted a back hand because my wrist and elbow are not displaced. It's almost at 90 degrees. I've displaced it in this case to get my hand out of the way of the camera. But my elbows up in the air and I check is at 90 degrees and I rotate back and rotator forwards. Same principle applies is to gently deliver the needle just beyond the halfway, take it out. And for that angle, I'm ready to use it again. I am not using forceps. I'm simply using the curve of the needle and I would commend you to try it yourself and practice and experiment your body position to get the perfect rotation just beyond halfway and I can pick it up. So the place point rotate applies in every angle. The place is always 90 degrees, 90 degrees across what you want to stitch and 90 degrees into what you want to stitch. The point is a bit like many lumens. People drop the needle holder into the lumen and put it across. Using something like this reinforces you to stick it 90 degrees into the hole and rotated out. You have to be accurate to put it into the hole and take it out. But the alignment is always always 90 degrees across what water stitch and into what you want to stitch. No, to demonstrate the curve of the needle in the shaft being cuboidal. If I come to pick up this needle from the table and I come gently watch this because it's actually slightly cube oil, it flips into place. I think I am covered in a lot of potato and starch those out to another needle. There you go and the flips into place to reinforce the pointing of the needle into tissue. We're going to introduce a another model for you to play around with. This is a po deck and an eye circle of the yolk with the white. Now this is going to reinforce the pointing in because I want to take the needle and put it accurately between the yolk. So place it across between the yolk and the white. The thing about also this is soft tissue, but what it's going to do is also reinforce your lightness of touch and your delivery of the needle. Because what we don't want you to see is pushing the needle into the yolk like that zoom in a bit closer. So you can see, I don't want to see the yolk and the egg being scrambled. So we want to be able to take the needle back in pronating I've unlocked and pointing into that space and delivering the needle as carefully as I can on the rotation without scrambling the yolk, the banana model that we'll see. Next week, it demonstrates exit of the needle on his passage, the tissue. This is an exercise and demonstrate reinforcing entry of the needle into the tissue. I'm very happy to take questions or observations Gabrielle if there are any, not at the moment. But if anyone do has any, please pop them in the chart. So I'm being very careful to see that I'm going to into the space between the yolk and the white. And this exercise is teaching me to rotate the needle back properly. And these, all these models give you feedback, you mesh the potato, well, you scramble the egg and if you too hard it tears like that. I think the models that we use in surgery, I am need to give you feedback, but they also need to extend and push your skills to the limit. Such that when you come to stitching on in theater, you suddenly find having practiced on these sort of models that your stitching is more accurate and you've maintained a lightness of touch because it's only by attending to the basics that y you will master your stitching and exhibit lightness of touch. The thing about stitching, as I said before, that nobody focuses on the set up and the set up is of vital importance. The time it takes me and you to put a needle through the tissue is much the same. The time it takes you and me to do the next ditch is totally different. Why? Because I've reinforced and rehearsed the set up and understand the angles and the nuances of my needle changing on various factors. Two my needle moving without further interference or unnecessary movement and therefore the handling of the tissue and the flow of the operation ends up a lot smoother and I can maintain a rhythm. So to reinforce what I said, I want to share with you a couple of slides if I may. So as we said last week, rule number one, pick it up at the tip. And that means that the tip enables you to flip to forehand and backhand. But the tip is not actually pressing in to the lumen. And on my banana model, it's the tip that is mushing the banana itself. The needle has to point into the lumen as pointing through the screw hole on that bracket into the potato, hold it just beyond the halfway and angle it out according to the displacement of your wrist and elbow, the perfect angle, that's the 123 check before you even start stitching. We then need to think, place it 90 degrees across what you want to stitch point at 90 degrees into what you want to stitch and rotate. Now I'm gonna flick through the next five slides very quickly. And I want you to put in the chat room, which is 90 degrees. That is a, that is B let's see, that's D that's E and in the chart room, please, which is 90 degrees Gabriel answered and said maybe to one John, anybody else answering? OK. Do you want me to run through those again? Going backwards? Mm D C B A. OK. Good. Well, the answer actually is D and we did a study where we had these cards and asked surgical trainees to pick two of 20 cards out from angles of 86 to 94 degrees. And the accuracy was above 95%. And that's not surprising can as you've recognized in questions and answers, we're surrounded by 90 degrees. So simply aligning your needle place 90 degrees across what you want to stitch point at 90 degrees into what you want to stitch and rotate. You are satisfying all the geometry in Euclid's re from 300 BC. Not only doing that, the needle is starting to work for you and it's respecting the tissues and the Pronation Super Nation is doing exactly that because Pronation and Super Nation is 90 degrees either way at best or otherwise about 80 degrees. And you can see the needles as described last week for quarter, three, eights, half and five eights we described where on there to hold, to enable you to rotate back to point into the tissue to achieve 90 degrees. And I'm gonna stop showing my slides and invite comment to observation from you who are watching and ask you, have you been taught this in stitching? Is it something that you think that you can adopt and practice at home? And I would like to hear from you about your experience doing that. As you see, we need low fidelity bottles. All you need is a needle holder and a needle and your imagination. But I would salute the father of mathematics Euclid in 3000 BC. I'm not asking you to remember 100,000 digits of pi. All we are asking you to adhere to is the perfect angle which is 90 degrees. Next week, we are going to continue the story and apply this to vectors. And as you have already know, answered a vector has a direction and the magnitude of alluded to the fact any will explore this next week in further li fel models that will enable you to practice what I have noticed with people stitching, particularly if it's a continuous stitch that they start off with good intent with good alignment and good set up. But as the stitching progresses, the needle drops from the perfect angle to 90 degrees, the body itself contorts into really quite dramatic positions as people try and force the needle through the tissue. Remember, unless the two ages are together, you gotta do it in two all the time. The great thing as we'll come to later on in the series, if you go through at 90 degrees and come out at 90 degrees and you're accurate, you're inversion and e version that is required for vascular surgery and bowel surgery almost becomes automatic because you're stitching clearly. And Fuca said, I have not thought about it this way. And if it's not 90 degrees, you're quite right, you're going to cause tissue damage. You'll find when you start that your stitching slows up, but your stitching will improve in accuracy. But if you say to yourself, place unlock point, rotate, you are actually practicing the rhythm and flow that we're looking for, for accurate stitching. I'd also like to remember that we have advertised for competition and we will offer you a set of instruments for the most innovative practice at home. It requires that Gabrielle will put that in the forum describing what you're doing with your email and a photograph. The best three will win their own set of instruments, which is a basic pack including a scalpel bleed, scissors, needle holder, forceps, and a te everything to get you started. And that's what we're trying to do is literally hone our surgical skills Gabrielle. Thank you very much indeed for producing this evening. Thank you for joining us where you are in the world and I look forward to seeing you next week.