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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon. The immediate past directive, the Faculty of Surgical trainees for Royal College of Surgeons of Edinburgh who accredit this program. I'm currently a professor in the Medical Education and Research Development Unit in the Faculty of Medicine. It's a and I'm delighted that I joined this evening in production by who is 1/4 year medical student at the university, aspiring to be a pediatric cardiac surgeon. Thank you very much. The information the Black Belt Academy would not be possible without the internet reach provided by the platform on me. We now have over 3800 viewers. Tonight, we have 57 registrations from 25 countries including Australia, Bulgaria, Georgia, Iraq and for the first time, Japan Kenya Nepal, Saudi Arabia, Uganda and Zimbabwe with countries in between. If this is your first time. Thank you and you're welcome. We are starting at the very beginning and the foundations and if you're returning again. Thank you very much. Indeed, especially because we have shifted the time to our nine o'clock here in Kuala Lumpur, it's lunch time in the UK. But hopefully people will get used to new time and we will see more people joining tonight. We are focusing on the very basics of surgery that is poorly taught, poorly explained. But is there in every single sport that you do in the, has just been playing? I mean, this evening and has won his game and through to the next round tomorrow. When did man begin to stand? Well, that was at least 3 to 6 million years ago. And the early humans combined apelike and human like ways of moving. And the fossil records really determine how this gradual transition went from climbing trees to walking upright. So 7 million years ago, uh cyanopus may have walked in two legs, but we actually had evidence of 6 million years ago when we became bipedal. And that was because the angle of the neck of the femur to the pelvis started changing. Obviously, each time you walk from one leg to another, you briefly stand on one leg and this puts stress on your leg bones. The result is that the knee becomes bigger and australopithecus and amens is an example of a larger, more solid mean, providing evidence that this primitive human walked upright. The curve spine came in 2.5 million years ago. And the curve of your spine acts as a shock absorber when you walk and it is uniquely human. And you can see a similar curve spine and a who walked upright in a very similar way. It's interesting in martial arts, the curve of the spine is there to absorb contact and protect your growing area from injury and being hit. The hip bone similarly changed about 1.95 million years ago. With Ect having a pelvis, very similar to modern human homo sapiens, the pelvis and the thigh bones of this early human enable them to walk long distances. And this was a big advantage at the time on the plains of Africa because of the seasonal changes and following the rains fluctuating between moist and dry, open grasslands and abundance of food. Then again, in the fossil records, we have 1.89 million years ago, the long five bones of her rectus enable us to take longer strides and therefore farther and faster than any other earlier humans. It's interesting that the femur is increasing in its length and osteotomies are not uncommon in the Nordic and Netherlands countries where the height of is increasing with the length of the femur. So the connection between the upper thigh and the hip bones getting longer and longer in early humans is an evidence of our ability to walk and the hip muscles provided that support and the connection between your upper leg and hip bones being long provides a base and able to withstand the stresses of walking and running. Well the environment changed. We walked in two legs, we could pick fruits now and other fruits, low frying bouncers because our hands were free. It enabled humans to appear larger and more intimidating and we could cover the landscape more quickly and efficiently hand, we're free to forage and carry babies. And I think of the evolution of the surgeon and we used to joke as trainees that the orthopedic surgeons used to walk with their knuckles on the ground and the other surgeons had their hands free. No offense to my orthopedic colleagues who are extremely talented. But that was a joke at the time as part of the evolution of surgeons. So, have you ever wondered why the kitchen countertop is the height? It is. Now, I remember this because Professor Anderson taught us anatomy of the upper level back in 1980 at Southampton Medical School. And he explained that this was because it mimicked the median height of the population to enable the upper limb to function easily and comfortably. So just try this for a moment. I want you to stand there and lift your hands out to the side and keep them up in this position. We can appreciate the functional movement of the upper limb is compromised. And you quite rightly name the 27 muscles that bring the scapular up into this position that enables your humans to be abducted and lift up. But even for the short period of time, you're probably now feeling a degree of fatigue. But imagine holding this for a few hours, uncomfortable, more uncomfortable. How long would you like to go? I've had my workout in the gym today, but no, drop it arms to the side. And as soon as you do that, you feel totally relaxed, your shoulders are down and your elbows are tucked in. Think about it a daily activity that you do. Thank you. It's iron, You wouldn't iron up there and you wouldn't iron down there. You'd iron at a comfortable functional height and you do that naturally because you take an I board and you adjusted to the height that you require, such as by the side and your hands, I touch on the table. The interesting thing is when I asked you to describes how we address the height of the table. You said the waste of belly button or some of us have a more generous waste and the belly button is somewhat displaced. And in fact, the rule in surgery, you should remember that all landmarks should be two bony landmarks. So that is my anterior superior. I there, that is the height of the table, ok? And for me, 100 and 78 centimeters, 94 centimeters and height of the table is just perfect. This is perhaps one centimeter too low because this ironing board only goes up to 92 centimeters. And those of you who watched last week with my son operating who is 183 centimeters. We needed a table of 100 and four centimeters such that he too could stand the elbows by the side and slightly extended to the elbows and pole. And this is of critical importance, I believe because not only is it reducing the fatigue of those 27 muscles that you described, but it has done something very important that will come back to you later on it. In this position, you will not be able to grip anything and your plans are relaxed and you have maximized the function of the intrinsic muscles of the hand. So the great thing about the shoulder girdle is it literally is suspended, isn't it suspended on the petrol girdle between the clavicle, the maneuvering clavicle and the scapular are being held to the side. And as you move the scapular and moves the humeral joint, so you can get the humerus a position, but no matter what the position of the humerus, you are able to pronate and supernate at any angle at the top bottom and at the side and there that ability of pronating from your hand up to your hand down, that makes us uniquely human. And that is part of the process of operating ation to 180 degrees. And that is part of our rotation that we describe when we discuss how to stitch. So the thing is that as soon as we start moving the scapular from the side of the chest, we start having to use those 27 muscles to do that. And as soon as you abduct the arm, you're adding even more and no wonder you're starting to get tired. Why? This is a significant problem is because 92% of surgeons during their career will have musculoskeletal degeneration. Indeed, it is predominant among plastic surgeons and cardiac surgeons and I too have had fusion of C five C six with a metal plate and a screw. You could say I've got radiological evidence that my head is screwed on. Some of you might say, you don't know if the screwed up, right or not. The longest operation that I've done was standing at the table for 23 hours. And how do you stand for 23 hours at any one time? The important thing to remember in standing there should be a right between the top of your head, elbow, your shoulder, your elbow, your hip and knee and your ankle. And as soon as you start leaning forward, that's where the problems start curry before we go into that, let's talk how you can stand perpend. And for a long period of time, the first thing to remember is do not block your needs as you stand, give your knees a slight bend, the arm straight up and down and with a slight bend, move 1 ft slightly more forward than the other. And therefore, as you're standing, you can actually move your knees back and forth like a swagger, but maintain unusual position. Locking your knees actually can lead to lightheadedness and even fainting. But it certainly increases the tension across your back, pelvis and Elvi tilt and causes a lot of strain with your knees flexed. You can walk back and forth and this helps with your calf pump and circulation periodically lift your heels off the ground, then lift your toes as well. And this is very important for long periods of time. And to facilitate this, it is recommended that you stand on a mat that reduces the stress of standing on a hard floor that will enable you to rock back and forth. The squishing map also has the added benefit if there's lost some water above you're above the flood waters, so to speak, all these stays dry for most of the day, but it cushions your feet, the heels and the ball of your feet as well. Of course, what you need to also consider are your shoes. Now, I personally preferred clocks because the wooden clogs one, I felt more comfortable for my feet but provided a very good arch support and they didn't get sweaty or smelly. I do recommend as a surgeon that you take responsibility for cleaning your own clocks. And the idea of borrowing other people's clocks from this, a mass of clocks that are dumped in the theater, quite frankly, does not appeal the other thing you can do is occasionally put your foot up on a stool to stand on one leg at a time. And this reminds me of my time in the registrar at the London Chess Hospital on the Friday, I'd fallen off a horse and thought I'd sprained my ankle but found walking extremely difficult. And by the end of the week decided I better get an X ray because I could feel bone crepitus as I walked. Indeed, I had a spiral fracture of the fibula and a slight displacement. But by then my toes were like purple pork sausages and I was put in the back giving crutches and it was Easter weekend. Nobody offered to do the weekend on C for me. So I hired a second car and automatic because it was my left foot so I could drive on the right and I actually did more operating in the following three weeks standing on one leg than I did previous to that. That was my one leg standing story. The important thing is is that you need to keep gently moving occasionally. Just lift your heels up to your butt in between a break. Do not ever bring your hands behind your back because of course, you're a sterile if necessary. Just take a gentle walk around theater to string your legs as well and do this whenever you think your legs are falling asleep. The important thing is after a long day. Of operating, you need to decompress your spine. So literally holding on to the edge of the door, if you can reach and just hanging off the edge of the door or against the countertop, leaning back against the counter to stretch your back, pressing your arm against the door frame and pressing the back and the door this side, pressing your back. But you'll find that after a long day operating all your neck and shoulders become extremely tense. I've always thought it would be wonderful to have a physiotherapist come down and do some work on your neck and back. Of course, if you prone to edema and swelling and vital pain, it is recommended that you wear support stockings as well. One of the things that I introduced to my training matrix to, yeah, part of my power, excellence and the metaphor of power and golfing metaphor of deliberate. The first box in the top left hand corner of the matrix was posture and standing correctly. I call on consulting Christopher Lincoln and one day chastised me for not standing correctly and asked the sister for a bandage for and he took a bandage and asked the sister to bring in a drip stand and then proceeded to bandage me to a drip stand. So I remained upright throughout the operation a little bit extreme, you might say, but it did work and it did use J Timothy who's now a neurosurgeon who who operated on my neck and I did the same to him when he was badly. But what's interesting if you look at all the pictures that are out there of surgeons operating and you look at how they standing. As soon as you start leaning forward, the shoulders move forward, the pelvis tilt the hamstring shorten and you look like a crane that added to that difficulty as soon as the chin move off the midline by every two centimeters, you are adding 2.5 kg a week. So imagine getting to five centimeters, your temperature. That's how much weight is now being held in your head. About eight centimeters, your neck and back are supporting the equivalent of 26 kg for weight. Now, I just got these out of the kitchen code, floor cleaner and soap powder with a combined weight of 5.5 kg. Imagine standing there all day with that 5.5 kg and the strain that's gonna put on the muscles, the other kind of mastoids, the muscles is going to be extreme. So getting the table at the right height is extremely important for your physical and muscle and skeletal health to take wear and tear out. Because what will happen is not only get neck pain but every time osteophyte formation around the neuro canals. And when I had my surgery, I had a 95% stenosis at C five C six and no wonder had neuropathic tingling and pain down my hands. It is important because the hunting of the shoulders with internal rotation, elevation of the elbows and fixing of them for total power. And I've often wondered if that is the reason not standing. The fact that I had to yoga meant that I could only get my kicks to this height or my son could get his kicks to that height. It is very important. It's interesting to note the formula one drug spend a long time conditioning their neck and upper to of muscles because when they go around the corner at 3 to 5 g, the central f forces mean that the head and how can weigh as much as 70 kg. I was also interested to know there's one circuit where the drivers drive around anticlockwise rather than most of them being clockwise, which is adding extra weight and force to the neck. So this hunching of the thoracic spine, the ring of the shoulders, the internal irit of the, you can imagine you can lose your doses and the thoracic vertebrae themselves become a problem. So it's important to keep fit. And some of the best things you can do to keep fit apart from general fitness is to work on squats. And one of the stress positions that we have used often is called, keep it up with your back straight, your need at 90 degrees, your feet at 90 degrees, that's called the horse riding stance. And in the back that you're holding this for two minutes, you back straight all the time, try yourself but simple sws and going down deep squat is very good for your hip flexion and standing up again. It's interesting doing the e and number of the moves require standing from a kneeling position. And what's interesting, I always thought you raised your weight up on your front knee and leg. On the contrary, the position you wait, such your back knee is pushing you up. So the body comes up in a vertical position and not leaning forward and posture is critically important in for drawing the sword. And it's something that the watch and fail you are right. The other thing is the plank. Now, the tank is very good for the core and I'm up to 4.5 minutes every second day with a plank and it's very good for maintaining your back and core muscles as well. So, supposed to say, with all these exercises, if you're getting any tingling or discomfort, please see a fitness coach or physiotherapist. Not a simple exercise to do is stand up against the wall, throw it straight head against the wall, keep your chin in and just hold yourself forward a little bit to keep your shoulders back and your chin in to main stretch and decompensate for that stress you're putting on your neck. Of course, this now all comes into play when we're thinking of surgeons who wear headlines and wear loose and these, the los that I wore in, they are lightweight. Yeah, but it means chin in and I cli my head down two aspects of this one. For those of you who are wanting loops, I would suggest that you put your lips on and you put your hands in the functional position with your shoulders, down elbows by your side and look at your thumbs and then that depends the distance. So my loops, I focus to that and I'm in focused today and that's the depth I focused than I've got with my loops and I wore them for most cardiac operations including aortic valve and mitral valve repair because it enabled me to see the clarity, the junction between the leaflets and the fibrous skeleton of the heart. But imagine if you're not standing properly with the weight of this and some people got headlights and cameras and other lights, how that is adding to this incredible force that you supporting or operating. No wonder we get fatigued and no wonder our next end up. Probably what's interesting. This is now recognized by many of the new companies and new companies have brought up blue that with the prison that enables you to look forward with prison enables you to look down. I haven't tried it, but it's interesting that you have introduced it to make sure that you're not inclining your head or causing neck problems. Now, let us come to this functional anatomy of the upper limb. The thing is that my arms either side, the shoulder down, this is a bit like a puppet, isn't it? In this position? I want you to try and grab something you can't, can you? It is very difficult. And in fact, to grip what you need to be able to grip is to be able to extend the hand a little bit that brings the long flexes into action enables you to exert a powerful grip. You know this and self-defense or try it on yourself, make a grip and flex your wrist. And as you flex your wrist, you feel your grip comes undone because you cannot grip inflection to grip, you need to be able to extend the rest and saying in this position, I'm flexed, I cannot grip. Now, the next important point of operation is very simply this next time you are holding an instrument or picking up the forceps, a pair of scissors or a needle holder, think on how you're holding them. And I would like you now to just pinch you for uh OK. Finger and thumb, pinch. That's actually the most uncomfortable. And the average force for ladies is about 25 mutants. For gentlemen, it's about 35 m of pinched pressure. OK. Now extend the D IP joints and extension of the D IP joints. The flexion of the metacarpal pharyngeal joints occurs. The Lumb grow and the Lumb course of the early muscles in the body without any burning origin or insertion. So try this on yourself. Now, with your fingers extended, try pinching yourself really, really hard as hard as you can. We call you can and is in that position with your hands flexed is the critical position to maximize the function of your had. An, there is a common saying in the world of strength sports that if you can't hold it, you can't lift it because Grip and Alice who is an Olympic weightlifter and a sense with the Black Academy talks about grip and position. If you can't hold it, you can't lift it. Well, I would say if you're not feeling it, you are not operating and to feel it, you need to deliberately extend the D IP joints by extending the D IP joint, the palp of one finger, it comes into contact with another and just do that with your fingers and feel. Remembering that you got more sensory input from the pulps of your fingers to your brain than you have from the eye to the brain. And as we discussed before, the principle of operating is to maximize the few on the instrument. If you're not feeling it, you're not operating. And therefore you can cares the tissues rather than being near the flesh as described by the white part pneumonia. So there's a lot more to operating that we need to get. And it's the surgeon who should dictate the height and remember the height is through a bony origin, not the belly button on the waist, the anterior superior spine is the height and I can look at that and that would be from there to there. And that's a comfortable position for me. And that all depends on your size and shape. There's another interesting thing about our posture and the way we walk upright. Simon S is a world leader management guru, really provocative speaker and thinker said good friendships mean we live longer and to have better friends, our quality of life is better as well. And that depends on good health and good health means you got to have good lungs, a good heart. But the most important element of all of this is having good th in quadriceps. And he was saying that having good thigh and crus means that you can walk around more and socialize more. So, one of the muscles that you need to focus on when operating is not in your core muscles, but your quadriceps as well. So holding those stances in those positions is actually extremely helpful and isometric exercises are actually very good if you cannot lift weights, do not lift weight if it is uncomfortable. So the is our producer this evening. He has been playing badminton. He is a sports person and would like him to make a comment on posture in sport and its importance in his thoughts and surgery. What are your thoughts on this? Mm high puff. Yeah. So I think, yeah, so I think that uh in sports, you know, most of the time we have to have good, good posture. And that's mainly because to generate energy, it doesn't matter in what sport we play to generate a good amount of momentum or energy when we are trying to, for example, since I play badminton, we swing a racket, for example. So good posture would maximize the energy that we get out of uh out of the swing, for example. So I think uh with that said that even in surgery, good posture would uh uh what they call minimize unnecessary movements and also improve the efficacy of our work. Indeed. And if your knees are just partly flexed and not locked out simply by changing the weight from one leg to another, changes the pelvic tilt, changes the angle of my shoulders and that couple of degrees. So I'm standing there that degrees can make all the difference to the angle and alignment of the needle. This angle is also very important and we will discuss when we talk about stitching the line between the horizontal and my forearm. And I know that if you draw out parallel lines down to the forceps and your needle, that is the same. And that is why we angle about because this angle is the angle of displacement of the wrist to the elbow. You can imagine there's no displacement where my elbow is up in the air and I'm pronating super. So my needles can be at 90 degrees when I'm sitting down right there and rest at the same level. So it's part of right for my needle to be at 90 degrees. But as soon as I stand up, this angle changes because my wrist is displaced from my elbow. And that angle there between my hand and my forearm is exactly equal to the angle that you got to displace the needle when you mounted. And when doing so, then you achieve the perfect 90 degrees and 90 degrees is the perfect angle because it's the fourth part of the circle and all needles are made in the circle and need to be delivered and inserted at 90 degrees to ensure that it does not deviate from the circumference. So we got a question about anything specific for your endoscopes and simultaneous instrument. I'm sorry, but I'm not familiar with the your industry suffice to say that your right hand and left hand have to do different things. And that is why at the Black Academy, we set exercises for the dominant hand and the non doin hand because they have to do two different things at each stages, the instruments are made with Ergometric in mind. He was asking me about robotic surgery and sitting down at, I haven't got experience of sitting down in, but I haven't got experience with laparoscopic surgery and these sort of grip like things for moving and rotating to pick things up to my mind that is not using the delicate movements of the hands and fingers. So the robotic consoles using the fingers are perhaps better. But again, it's sitting like that. And to me that doesn't feel functional. If you think of anybody playing an instrument, piano in particular, the first thing you do is adjust the stool, the height and the space from the keyboard such that the hands can work properly. It's the same for anybody using a typewriter because repetitive strain injury from typing is commonplace. But what is interesting that a professor in Ent in Bradford was a for in the Bradford orchestra. He used to practice the night before surgery on Mondays because they did cochlear surgery. But he actually said that if he didn't sit properly or hold the flute properly, no matter how hard he tried, he could not generate a note in the flute. See, even in music and everything we do, posture is absolutely fundamental to the way we, what, what's interesting in martial arts and fellow John Taylor is the fifth time in K said part of martial arts is actually teaching people to walk properly again. And what's interesting learning the I I've learned to stand up from the floor without energy. You've got space. So my knees at 90 degrees to the floor and I'm pushing up. So what I'm doing is I'm not pushing up on my front leg but I'm pushing up in my back leg and the back stays straight all the time. I get pump handle movement and that is what's required. It's interesting as soon as you move out of surgery into other domains, posture becomes very important. And it's surprising why we do not address this as part of our basic skills, teaching and training. But we are in the black a surgical skills. Any other questions, any observations? And there are no questions about on, on the floor now. Yeah. Well, I'd like to thank everybody for joining us with this new time and thank you for, for joining us this evening. I hope this has made sense. Please fill in the feedback form that is gonna post in the chat room and we're going to see you next week where we are going to focus on using the knife. Something that many surgeons are a little bit using, but good dissection is sharp dissection and we need to actually use the blade and be able to feel the blade through the tissues. Often lots of examples to practice. II, look forward to seeing you then. Thank you very much. Indeed. Uh Sorry, there is a question, the floor. Yes, yes. Uh Any exercise to reduce hand tremors while doing delicate work. That is a good, that is a good question. There are two things from that. Certainly, I noted as a cardiac surgeon if I drank coffee and wearing groups on a 2.5 millimeter vessel. I have noticed a tremor. I, we also know that if you haven't got your shoulders relaxed and your elbows by your side and you're operating and you're supporting your upper limbs with the major muscles that you've well described. Again, there's an element of tremor. The other thing is with doing delicate work. Usually you can rest your hands on the patient outside the operative field and I use my little finger sometimes on the retractor as a sort of scaffold and stabilizer like that and holding a cat or doing fine movement. If you are needing to cut a depth or fine movement, then please bring in another instrument and rest your instrument on top like a fog, either which way practice or make it better. Of course, the other thing that makes it difficult, especially when learning as if you're feeling a bit nervous and quite a few of us, some training at the beginning felt a little bit nervous going into theater because we practice some patients and not in the retina. And I do the record on some occasions actually taking beta blockers. But again, I would not advocate pharmaceutical advice on that. Uh it can have deleterious effects, but on one or two occasions, if you're really anxious, it might be beneficial but do not do so unless you're sure your health will consult with a doctor, it will get better with practice. The simple thing to do is follow the exercises that we advocate on the black government. There's no fidelity exercises and with time you'll find it disappears. It also disappears. With practice, your confidence will improve and with improving confidence, your tremor will also decrease. But rest assured you're not the only surgeon who started their career out with a little bit of a tremor in very, very few people. We have perfectly steady curls. And the one that I recall was Christopher Lincoln who tied me to a drip stand with a bandage. He was taking a vein when I was doing a top end and he said here, let me help you. And from the bottom end reached out, one of his long hands, took the castros and at arm's length did that in a perfect stitch and an outstretched hand, the seven know needle on a two millimeter vessel without even a tremor. That was impressive. Don't worry, you'll be fine. Thank you very much for joining us. Thank you to all of you around the world. Thank you to Japan for joining the Black Academy. I think that brings us to 100 and 25 countries that have now registered and thank you for your support and do pass the word around if you've got any ideas or requests for topics you'd like to cover. I'm delighted to entertain them coming up. We're going to be talking about life skills, then we're gonna be going on to scissor skills and then starting my cycle teaching again. Was she? Well, ff remember that surgery and surgeons and should be thought of as elite athletes to be manifestation. We talked about exercise. You don't forget nutrition, sleep and hydration. Thank you.