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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon and immediate past director of the Faculty of Surgical Trainers with the Royal College of Surgeons of Edinburgh. And I'm a professor in the Medical Education Research and Development Unit in the Faculty of Medicine at the University of Malaya. Thank you very much for joining us this evening. If it's your first time, welcome. And if you're returning, thank you. Thanks to med O. We are now reaching 100 and 19 countries and this evening, we have registrations from 19 of those from America through to Australia, Colombia, Egypt, Jordan Kenya Maldives, Pakistan, Singapore to mention a few. Thank you very much indeed. And thank you for the feedback. I'm getting from many people. We did do a poll on the time of this right now. It's 2300 hours in Kuala Lumpur Gabriel who's doing the production in the background is in Lithuania and I believe is five hours behind and seven hours behind is a Chris Caddy in Sheffield in the United kingdom. It's very difficult to get the perfect time to meet everybody. But we are open to ideas. We recently did a poll and almost 60% of people preferred this time. I appreciate. It's four o'clock in the afternoon in the UK and doesn't meet everybody's requirements, but catchup is free. Thanks to me all. So this evening, we're gonna be talking about the scalpel and sharp dissection. It's clean dissection. But have you ever considered what is sharp? I never wondered what the sharpest tool there is if it cuts a chop, right? But like most things, scientists have been trying to actually pin a definition of sharpness down. And one thing's for certain, they haven't found a universal definition and there are lots of ways to define it. Really, it's the eight pointedness or the narrowness of the blade. But actually, if you go down the age, the blade pointed, in fact, it is. And that round is circumscribed by a circle that is given a and the smaller means that the edge is really, really sharp. And indeed, stone tools can be quite sharp, especially flint that can cut through PVC pipes, sapphire scalpel blades have a wedge angle of 2025 Newtons nanometer. So that's the radius then so you've got a radius diameter. But if you put the two edges together, the ankle subtended by the two sides of the blade gives you an edge thickness. Again, defining edge you can imagine too thin, then it becomes rather fragile and anything less than 20 degrees is using a blade. But if it goes too thin, becomes brittle and certainly very difficult to put through a sterilization process. I enjoyed while I started cardiac surgery, a set of diamond blades, they were perfect for cutting into the coronary vessels. But it was quite clear with the sterilization process that these will be blunt after a few cycles. And the way we looked after instruments was something to be desired. If you've ever an interest in it, I do recommend that you walk the process and have a look yourself. So what is the sharpest object ever made? Well, scientists at the University of Alberta took a tungsten needle, put it in an atmosphere of nitrogen with high voltage electricity and drew it out to a needle thickness. Almost the tip being the thickness of an atom and these tips are called nano tips and they're used in scanning tunneling microscopy STM and used to reveal the surface of materials and give you atomic resolution. People have been using flint stone for many years since the stone age for scraping and cutting and obsidian, which is a volcanic glass as the perfect blade for this. Indeed, they are still made by a Virginian archaeologist using a pressure flaking process. And these obsidian blades can be used 10 to 20 times before they discard it, but they can be crafted into a wedge radius. That's the roundness at the top of three nanometers. So having something this sharp is very, very useful if you're making cuts into things which are quite squishy or full of fluid. The eye is the obvious example, these obsidian blades can actually cut cells in half under the microscope, but it doesn't quite end up because the geometry, the wedge angle and the radius does not describe how easy it is to cut something. Thank you, relax. When you will relax, it's the momentum and the force and the pivot and mech mechanics that bring the ax to life. And you will note that kitchen knives are of different sorts depending on how you cut a flat blade or round blade, but often used in that sort of action and cussing. And this is where you need to start understanding that cutting requires a force and behind that force, you need to understand there's a feel. So sharpness therefore, is not only the geometry or the mechanics, but also is the feel or the fourth that is required to make the cut gets complicated, doesn't it? But like many things are like the katana. I am told off by the sensei for putting too much force in my cutting, I'm chopping, I'm not cutting, I'm not letting the blade do the cut and doing the blade doing the cut. He has pointed out my right leg bias and therefore the tilt my shoulders. So when I come overhead and bring my katana down. I do have a here. I was prompted, I'm waiting, going to get a, a live one. You've seen it. But when I do bring it down of the top, the technique has gotta be perfectly straight and that I'm slicing with this end of the blade, the round of the belly end and this is called the Monoi, which consists of the kaki, the tip, the bashi just behind that and the hii there and that's what does the damage it slices. So the sharpness, the shape and the mechanics all come into the cut. Think for example of the pizza knife, which is really a circle that you're willing across the pizza. Perfect for cutting pizzas as you will see in dominoes. So a sharp blade is really difficult to define and the definitions to be honest overlap, but to cut to the chase, excuse the pun. Yeah, feel it. And in order to be able to feel something you need to be. And this is where we come down to the Mr William Frederick South who told me and I see life now how you hold a knife is described in the breaths in etiquette, but the handle of the knife is in the palm and your index finger is extended across the top. Many people are holding knives like this that is not recommended by the rats, but you are not going to be effective in actually using it. So there's another thing you need to understand feel and the feel comes from the pulps of your fingers, as we have said previously, but also understanding the weight of your arm but never understand, underestimate the weight of responsibility behind life. I'm a, a adapting the phrase used by the National Rifle Association. I want to share with you a few very important points when you make incision and the knife goes through the skin. That is the point of no return. We compare it to pilots. That's when the wheels leave the ground and you now have to fly the plane. It's decisions before incisions. So the decisions are the right information, the right side, the right reason, the right person, the right mindset, the right consent, the right equipment, the right team, the right position, the right grapes, the right landmarks. And you could probably, and I challenge you to put in the chat. All the other right things that need to be there, suffice to say if it's not right, not even the queen of England can ask me to make the cut. I'm sorry, I'm not happy I'm stopping. And once you have made the incision, your knife has to be at the right angle to the tissue. And I'll explain that in a moment and you proceed with precision and the precision comes with feel people often scoff at cardiac surgeons because we make one incision. And I was reflecting that the art of making an incision might be disappearing because we're going down the laparoscopic route. I do think the smaller the incision, the bigger the mistake. But the principles are the same. But I challenge you to make a 22 centimeter incision perfectly down the middle. And of course, you remember when you cut through the skin, you're cutting through the most sophisticated integument that protects you and the inside from the inclement weather and all the bugs that are particularly found on the skin. So shaving with a blade is an absolute. No, no. And what is recommended is chlorhexidine. But alcohol also is a potential. No, no, because it catches fire and you won't see the flames. Povidone iodine was used for many a time. And in that paper, New England Journal of Medicine that compared chlorohexidine and Povidone iodine. One thing I noted is that Povidone hiding was painted on and I remember we called it Holy Brown and splashed it on liberally. I didn't know a single surgeon who would wait for it to dry. And that element of waiting for Povidon iodine to dry was not actually described in that New English made a change to my, we waited to dry. I must say it's very difficult as a surgeon to stand at the table and not fiddle for five minutes as you allow it to dry. But I'm totally convinced now that Chlorhexidine and Chlor prep is the best thing to use with very good results. But attention to tell him cover this before and after your wound isn't an accident. It doesn't happen on a wing and prayer and it all starts. But you make an incision or talk about wound infection as we've done previously in another session, the semi of 1645 ma had a number of principles that I think applied to surgeon. Think of what is right and true practice can cultivate the science, become acquainted with the arts, know the principles of the craft, understand the harm and benefit in everything you do. Learn to see everything accurately become of where or what's not obvious. Be careful even in small matters. And the last one which I love is do not do anything useless. It sums up in general. What's interesting studying ei do you have to know all the parts of the katana? What do we actually teach all the parts of the scalpel and how to use them? I think not is the answer, I think not. So things a few cakes. Good surgeons c Well, just take, for example, here I've draped up and I've done it very neatly on this corner and put down the perfect drape and I'm going to make an incision. Ok. Wow. There you go. I make an incision. But if I take these drapes away, you will find that I'm not perfectly down the middle. And in fact, I'm offline. So before you even make an incision, make sure your patient is positioned properly on the table that the hips and shoulders are aligned. And if you're putting a steri drape on the patient, you put it in from top to bottom rather than side to side because side to side will pull any obesity or loose tissue. Uh All incisions should be made according to bony landmarks. So no matter what size your patient, you should be able to feel for the Boni landmarks and make your incisions even for the small ones. So, one of the exercises we have in the Black Belt Academy and it might be forgotten. Art is how to do an incision. We first support the tissues with a non dominant hand and we deliberately make a decision. But what I find is that once it gets past 10 centimeters that happens and you get a curve and this curve happens because there's a tendency to turn around the hips and not abduct the arm and elbow to continue your incision in a straight line. And not often, not too infrequently. I find cardiac surgeons in particular, in training, forget to do that and you end up which I would call a Yorker at the other end because you haven't straightened your incision. It's probably a minor detail that many people will not pay attention to because the incisions are not long enough at the present moment. But as a cardiac surgeon to get 22 centimeters perfectly straight down the middle is a challenge. So therefore, it comes to how we hold the blade. The blade is held just as I said in the palm of the hand, the index finger extended down the blade. And you note that the sagittal plane is maintained between my thumb and the side of my middle finger, my index finger down. So when I'm holding the blade, you should not see any at all. And I'm cutting with, I'm not cutting with a point, I'm cutting with a belly. But this does mean that often vision, if that is the skin and those are the deep tissues, you find that the cut is made and you don't use the full length and each layer you go through, you'll find that you're not using the full length. So the principle of an incision is use the full length and in fact, deliberately go longer because you'll get and better view this way you end up with diminishing returns. Whereas the other way you're ending up with a wider field and exposure, remembering that the skin can move around over the surface. So I had competitions when I was an sho doing append how small you get the incision and got it down to literally 2.5 centimeters because you can move the skin around provided all the deep tissues giving you that space to work under. That does mean you have to be careful in closing each of these layers and turn. So accuracy precision is and why you have to be nine degrees to the tissue is summed up very neatly using the sponge. I've a straight incision with a blue felt a pen and when held together I get a nice clean line on this side. However, I've allowed the blade to move from side to side and I have not kept it straight and I've bacon sliced the edges a little bit and a baking sli in the edges. You can see I got mo more blue and indeed using a sapphire blade and a clean cut. It has been shown to make a very good incision. Too often. I see people cut through the skin layer by layer and scratch it and do not make a proper incision. Likewise, I see them make a very small incision and pick up a cutting diaphragm and start fulgurating the tissues. The transfer of energy from the diathermy to the tissue is gonna full great all the surrounding tissue, increasing inflammation and scarring notwithstanding all the smoke, which is now recognized to be carcinogenic. So it doesn't matter how big a blade you use 10 or 15 other common blades. And I must take the opportunity of thanking my fellows Chris Caddy for bringing these in the suitcase from Swan Morton. Well, you know, tell us about his visit to the factory and Adrian glossip at Swan Morton for giving me these blades and keeping me in supply. And hence, I'm able to present the evening with Swan Morton actually produce something like 1.7 million blades a day and 57 types of our fellows and say Mr Caddy will come back to us on that. So simple things to actually understand the field and you can go to the supermarket and try absolutely everything and everything. So the task here is to feel my blade going through the skin of this orange in appreciating the thickness of this. And I will actually do a second cut, feeling it through, keep the blade perpendicular. And what I'm going to do now, squeeze the orange. There you go, squeezing it and I haven't got any juice coming out underneath. In other words, I've cut through the skin of this orange. There you go, I've cut through the skin of this orange and I have not cut the flesh. So to know when you've cut through something thick and you haven't damaged the tissue underneath is an important skill. And the other important element of the orange is I can see here that I've kept my blade perpendicular all the way cos there's a clean cut. Cos if I hadn't, you can see that is what I call a bacon slice. And that's a bacon slice. You can use this simple trick and try anything at all and practice the field. Now, really and truly, after each cut, you change the blade when you feel it is blunt and ideally, I'd probably change the blade. Now, cos I've cut through an orange. And therefore my perception of cutting through this banana skin is probably not as good as it ought. But to be honest, I need to save precious blades. So there you go. Same thing again, cut through something thick and have I cut through the tissue underneath. Well, I have scored it a little bit. Not significantly. It's only a slight scratch on the surface, but I haven't cut deep into the banana, try anything and everything that you can get your hands on to actually feel what it's like to cut through something cut through the skin of a peach, the organic materials. Uh give me feedback and not unlike tissues and I literally only have to stroke the blade on the surface and then I could be able to peel that off. I'm sorry, I grabbing the flesh up, I haven't cut into it. There you go of cutting in to the very thin bit of skin on the peach. So all anything and everything in the supermarket offers you an opportunity to practice the skill of dissection. Of course, the smaller elements and more challenging would be a poached egg. And I use a 15 blade for opening up coronary vessels. Can you actually make a little arteriotomy in the membrane over the yolk of the neck without damaging all the tissue underneath. You can see that that is arteriotomy without getting in to the yolk. So anything and everything from the softest of eggs to the thickest of oranges are all giving me feedback on the feel of the tissues. Now, one of the commonest things we are do particular doctors and one of our first surgical procedures perhaps is to excise something and you want to present it with a lesion and this point and make another lesion. There you go. I've got a lesion on my orange. And to remove this, I need to do a fus form or I shaped excision, the length of which should be longer, then they doesn't need to be brought together with our tension. But this bringing together with our tension adds a new dimension to making new incisions. As described by Langer, the anatomist in Vienna, who described these having gone round using an ice pick on cadavers that were frozen and noticed that some of them spontaneously fell back together while others were left as gaping holes. And he therefore mapped the whole of the body with Langer's lines that will give you an indication of where to make incisions without tension. Now, the difference here with a barren blade is that I can now hold it like a pen because the handle is not too dissimilar to a pen pencil. And that enables to maintain the 90 degrees throughout my fusiform incision. And that needs to be maintained at 90 degrees throughout the incision to enable the two edges to be stitched together without tension and the two edges perfectly aligned a plastic surgeon removed a sudden lesion from the back of my hand. And I was quite frankly horrified that they tried to do a small, the length of it was rather small. So in the end, it meant that they're trying to close a circular almost incision rather than a fusiform. And of course, being pulled together under tension, under sutures, it didn't heal very well. And I thought to myself, hang on a second. This is a consultant plastic surgeon doing this. And the simple principles of 90 degrees to the tissues and a long fusiform incision was ignored. Now that even on this orange, you can see come together very well to form a nice closed incision. There you go. And that's why you make a fusiform incision. So 90 degrees to the tissues all the time gives you that nice clean straight line. But of course, there are other occasions where you need to use a different style of dissection. So how often do you change the blade? You change the blade whenever you feel it is blunt. And the scar on the back of my hand was the caddy. It's just the, yes, it's just there. It disappeared with time. But actually at the time, it was quite a nasty grotesque lesion and didn't really take it out in line with the tension. So I'm gonna take the opportunity to reinforce another important principle is how to take on and take, put on a blade the blade sits in a groove on this oblong shape. I'm going to lift the bevel edge up there and then apply a hemostat to the blunted of the blade. And I would draw a handle. The blade is always pointing down into a surface not to a patient, went into a surface and I disposed of the blade properly. Putting on a blade is very similar. You'll see that the blade handle has got a groove that fits the end of my nail and that is the groove that accepts the blade and has a bevel, you line the two up, you insinuate that groove. Again, only one hand is moving and slide at home. Blade safety is paramount. And to be honest, if anybody in any of our doos demonstrates recklessness or poor bleed courtesy, they will not progress when passing a blade. It is best done in a kidney dish. Otherwise you pass it handle first and blade down as somebody takes that the blade is not gonna cut your hand, but it's always in this day and age preferable to pass the blade in a kidney dish. So my next trach is, can I take the skin of the salmon? And this is a very useful skill for developing planes. Now, I'm not wanting to cut into the tissue to, I'm wanting to develop to take the skin of the salmon without cutting into the flesh. Now, I'm going to hold the blade across my fingers and hold it out. And my blade is not gonna be perpendicular into what I cut. It's going to be perpendicular with the layer that I'm dissecting off. And I'm literally using it like washing the layer off as I go, if you can think of it as using pet spot to dissection with this skill, a useful skill in practicing how to divas, note that I'm brushing it against. And uh and I am using the blade, I'm brushing against the skin uh without try not to actually damage the flesh underneath. So I'm not cutting into it. And of course, in doing dissection across large planes like this, it is useful to have a second assistant that is holding that tissue plane under traction. So I would be asking the assistant to hold the plane like that and hold it out or I had a forcep keeping it here. So to do a dissection like this without a an assistant then becomes difficult and more challenging. But this is an assisting skill that I would expect you to learn. And we talk about the use of forceps question from Fatma. Yes, of course. Far away. When do we cut with the tip of the blade? And when do we cut with the belly of the blade? And do we cut towards or away from us or did you? I'm sorry, could you say that again? Yes. So when do we cut with the tip of the blade? And when do we cut with the belly of the blade? And the answer to that is very simply, we never cut with these round body blades. We never ever cut with a tip. Ok. We cut with a belly. That's the cutting part. You never ever cut with a tip. The only time you're cutting with a tip and I'll demonstrate to you is cutting with an 11 blade, which is specifically used for incising abscesses. Mm ST stabbing an abscess, stabbing an arteriotomy and um, putting a drain and putting a drain in, in and making a stab incision. And that's when I'd use the tip of that blade and otherwise would not use the tip of these blades at all. So, you know, it's gonna take me a little while to get the rest of this off. And to be honest, I think I would need an assistant at this stage to hold that. But I see, I think you get the IVUS and I've got very little in the way of salmon tissue on that skin and I have, um, keeping the skin, I'm not, if I start cutting into the surface like this, you see that it becomes irregular and I'm starting to cut into the salmon itself. So literally, I'm, I'm gonna exaggerate the movement. I'm brushing the flat of the blade on the surface, allowing the edge and you can play with this yourself to get a feel of how much force. And I'm I'm, I'm doing this exaggerating the movement now to get it. But as I exaggerated it, you can see that I'm starting to cut in. So it literally is a brush against the surface like that. I'm brushing all the time. There's no force and it's a bit like my instructor with a container saying feel the blade hold it lightly, let the sword do the work. So the fascia layer that I'm going through here is I'm literally taking the skin of the fish. And those people who are in kitchens and work with kitchen knives, they too would be sharping the knife and using big knives to do much. The same as we're doing here is learning to use the flat of the blade and to when I would say paddle almost the skin off, it was very, very good for developing. Uh I was used to do this in developing uh the plane with a mastectomy and finding the plane between the breast tissue and the subcutaneous tissue and making sure that you've got a nice vascularized flap of skin. Obviously, if this was skin, you, I be devascularized it. But the thing about this is it's giving me feedback on my ability. Now, I'm finding this blade is actually rather blunt and I would have no hesitation in swapping it. But I hope you can see that I've now removed quite a lot of that skin and I can assess my ability by looking at the tissue underneath and have I left much skin here. When I find about these models that I've been describing and developing with the Blackbar Academy, I find myself getting engrossed in doing them and enjoying practicing them and because I can see the result when I start doing it or I say, oh, I can do a little bit better. I can do a little bit more. I can go a little bit further and find myself totally engrossed in doing it. And I think that's where practicing on models like this becomes relevant and fun because it's giving you the feedback and it is engaging you in a task because of that immediate feedback in willing you almost to improve on your skills. So I've used pork belly in the past. But of course, in Kuala Lumpur, pork belly is found in the Chinese restaurants is actually quite expensive, but any tissue here is useful. So I've got a chicken leg and this is just to emphasize the fact that the skin is usually quite mobile. And therefore when you make an incision, it's important that you support the skin and keep the tension between the thumb and the index finger of your opposite hand, that your cut is deliberate through the tissue and through the skin supporting it all the way you can decide whether you want to go deep or to just cut through the skin itself. And again, look at this much easier on the chicken skin to use my blade in a similar fashion. I've opened it up across the my finger base of my fingers and very quickly I can literally scraped it off. But when it comes to separating muscle layers, as we demonstrated last week, it's much better in these situations than to use your scissors and see if you can separate and develop planes in that regard. And I don't think there's a plane there, to be honest, there is one. There, there you go. Now, I can open up the plane and that's where the mixture uh scissors. Mhm blade come into play. So using both with your toes, when you're confident with a blade, you can make quite rapid progress in with your dissections and exposing tissues. And last week we dissected out the femoral canal and here we go, marvelous, I think, and I'll take you down a bit further. We are in a very short period of time. No, at if I can now um a chicken leg because I'm confident using my blade, I'm also confident using it around the tissues here. So just to show you look at the nerve. There you go. There's a nurse. I see artery is pinker and there's a blue thing on the side. There you go, vein, vein, artery, nerve femoral canal dissected out in moments. So the blade, when you get to know how to actually use it, how to feel it, it becomes a very, very useful tool. And the important thing is also when your feel through the pulps of fingers is indicating your blade is blunt. That's when you change it, get a fresh blade. People would also advocate once you cut the skin, get a fresh blade for going the inside because you could be taking germs from the skin into the tissue as well. It's very simple for those of you who use a razor. I haven't for a few years, but it can do and part, you know, when your razor is blunt, cos it actually starts to feel very uncomfortable. I think it was in a Western Clint Eastwood movie when I was younger, somebody with a cut throat did not put any lubricant on the face and started cutting with a blunt blade and caused a lot of damage. I watched that film as a kid. Now, I'd like to ask my fellows Mr Caddy to join us. He actually visited the Swan Morton factory in Sheffield and witnessed these blades being made. What's interesting that one side of the blade is actually grooved and the other part is shiny because if both sides were shiny, you would not have that feel. So to have one side in verticom was rough and the other side smooth, gives you that haptic feedback. But also enables these ladies to pick up batches of almost 2, 300 blades and flick through them and see where it glis pointing out a defect in the manufacturing Mr Cuddy, your impressions of the scalpel and the scalp. Well, once again, thanks David, another tour de force. Uh So I currently live in Sheffield and almost on a daily basis I have driven past the Swan Morton factory, but never visited. And on your suggestion, uh we made an appointment and I went and visited them and it's uh the history and the way the area has developed is um is a real, it replicates all sorts of things in South Yorkshire. So they wanted to have everything in the same area. So they would harvest the um, the coal, the water, the steel. So the steel was made in Sheffield and it was then taken to the factory and shaped into um, into surgical blades. Um And it's not just surgical blades, it's any craftsman uses a blade. And they, they've got a things like a swan that has been uh carved and placed in the eye of a needle. And they've got snow white and the seven dwarfs once again inside the eye of a needle and you have to use a microscope to look at it, but the blades are so sharp and so well defined that they're able to do that. Um The manufacturing process has evolved over many years and they literally mass produce blades on a scale nowhere else that's available. And they looked at and it's not just manufacturing the blades, they then will sterilize the blades and ship them all over the world. In order to sterilize them, they use um radiation. There are other ways you could use heat. But as you said earlier, that tends to blunt the blade, uh I can use ethylene oxide, but the best way of doing it is with radiation. And they have an in house um microbiology laboratory where they test all of the materials to ensure that at the end of the process, there's virtually no contamination and it then goes through the radiation process. So it's a continuous quality improvement process and they develop the machines. So as moving more into A I and robotics, they've had to build the robots that do this work. So it's um it's very informative and John Rudd, who's also on this call, he will be coming up to the factory next week. I look forward to meeting him there, what I we've discussed before their, their philosophy on how to run a business and uh we'll share that the they look after their stuff. Yeah. And the staff look after him and the staff only. He's got the problem visit and some of their four principles sent out by swan that are ideal and explain how to run a factory. So we talked to mention the 11 blade, the 11 blade is a dangerous instrument. This is where you use the point and you can incise something. But the way to control the depth is to put your finger on the side and you can see there that I am actually controlling the depth. So I can stab and see the depth. And I'm not actually hitting the tissue because the shield is my finger. So I can control the depth with my finger on the side. And it's a deliberate incision. And there you can see I'm now into the tissue as well. Ok. So that's just using a lemon. There you can see the blade underneath, but I can control the depth, uh my finger on the side and I can safely incise something without going too deep. And certainly when putting a chest drain in is the chest wall is that thickness. I don't want to be pushing it in and stabbing the lung or anything underneath. I want to be holding this and going deliberately through the skin without going deeper into the tissues as you see there. So simply putting your finger on the side, gives you that control on how to incise and use the 11 blade, David. Why you've got an 11 blade in your hand? So the 11 and the 15 are a different handle to the 22 blade. Of course, there's a different mounting system on the two handles. Um, no, on the 11 and the fifth, you use a number three handle. Yeah, it's, it's the, it's the same, it's just a slightly smaller version then on the 22 blade. Yeah, it's the same version. It's the same, same principle and the taking on and off is the same principle as lifting it on the side and taking it off. What Swan Morton did give me was a very nice gadget that I hadn't seen before called the blade flask. And I can literally, there you go. And my blades off a wonderful piece of equipment allowing me to dispose of my blade without actually having to try and wrestle it off and run the risk of injury. There you go. What a lovely gadget. So having moved on to that, they, they have developed um plastics in order to link the blade on plastic. Uh and you have to make sure that the plastic is rigid enough to hold the blade without it wobbling. So, you know, we talked about innovation and incisions and things. I don't think you will get any better than a cold gold steel A at all for s and the feedback and provided you go to a good sterilization system. Obsidian lives are extremely useful. I learned the hard way in my card practice. I had diamond blades, but a sterilization practice and the way they were all put together did not enable me to actually maintain them very long. And that is a whole new area that can be talked about is maintenance of instruments and repair. And having visited the Ba bra factory in Penang in Kuala Lumpur and seeing the loving care as Chris Swan Morton in making these products I think is very useful for a surgeon. If you ever get the opportunity to visit these factories to understand the quality control that actually goes into making that instrument. And I would say the love and the care into making those instruments for you to use, that will make a lasting impression on me for life. And if you ever get the opportunity, do the same cos it'll have the same impression on you. So as we talk about impressions, your incision is your indelible signature on the patient for life. You might have done 100s of these operations. You will not remember that patient very often. We only remember the ones that have gone not so well or spectacularly badly, but the patient will look at that scar and remember everything you said you did and how you made them feel for the rest of their lives. So I put it to you that you cannot pay enough attention to the way you open the wound and how you close the wound because that is your indelible signature on that patient for life. Think about it. And next time you close the wound, lock my wedge. Thank you very much indeed for joining the Black Part Academy. Thank you very much Gabriel for the production in the back ground and fielding the questions. Please. Would it take time to fill in the feedback forms? They are important. We do look at the answers and we do actually pay attention to your suggestions. Next week, I'll be delighted to introduce a new col colleague here at the University of Malaya, a professor in neurosurgery Provan. I heard him talk about research and why it is important for surgeons to do research. We are not only wanting to cultivate your surgical skills. We want you to also have a sharp and critical mind in a way of thinking. Hope you can join us next week and it's a pleasure to have you join us in Kuala Lumpur. And it's good night from Chris in Sheffield, Gabriel in Lithuania and me in Kuala Lumpur. We really are across the globe. Thank you.