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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 now the Professor in the Medical Education Research and Development Unit in the Faculty of Medicine at the University of Milan. Welcome to the Black Belt Academy of Surgical Skills. Thanks to me, we have reached over 3000 delegates in 100 and 19 countries. And tonight, I welcome you from Egypt, India, Mexico, Malaya, Nigeria, Pakistan, Philippines, Saudi Sierra Leone, Sri Lanka, Sudan, Uganda, United Arab Emirates and United Kingdom. So any thanks to companies like metal who share the altruistic view that education should be free and we strive to improve the skills of the future generation. I would like to just take a moment to share with you the philosophies of the Black Belt Academy. And this is shown in a visual graphic that I've put together for an education grant that we're putting through to enable further development of the Blackard Academy. Many people I speak to my generation, even the today's generation say they attend basic skills courses in classrooms as we pointed out before many are sitting down, they teach, taught what to do. But the explanation of why or how to practice is not there. Unfortunately, these courses are often used as income generation courses and unnecessary for certification. I do not believe that model is sustainable. Oh, correct. And the Black Belt Academy ends to enable you to practice your surgical skills at home. And we have taken the basic skills and deconstructed them into progressive steps, reflecting the belts of martial arts at each stage, our syllabus offers you an explanation and models of how to practice. Ideally, I'd love to be able to offer you all a set of instruments which would make it a lot easier and it's something that I'm aiming to achieve. But by doing this, we are not able to teach you how to practice why to practice. Because mastery only comes from a constant attention to the basics. And I have noticed that starting or continuing my journey in yo at the Japanese Club here in Kuala Lumpur only on Sunday, the sense he pointed out to me that I must be right handed. And he noticed that I lead with my right foot and when moving, move my right foot to walk forward. And therefore, there's a pelvic tilt and therefore my shoulders are not square and therefore my cut will not be square either. It took him. He said 10 years to correct this. But having that detail elucidated, I am now practicing and learning to walk again, that as I raised the sword and move my right and pushing off with my back, which would always be on my foot and the heel should be slightly off the ground on both feet. Such that you can slide a slip of paper underneath that nuance of training and explanation only calms from an expert who is well practiced in the arts. And that is what we hope to do at the Black Belt Academy. What I'd also like to do is extend our philosophy globally through this mechanism and share with you what I've called the Black Belt Academy value compass. It's only with a solid foundation of basic skills that are practiced and rehearsed that we will end up with a generation of high quality surgeons. The aim is to achieve a standardized training and syllabus in basic skills which here too has not been obvious as a consequence. We hope that we have improved quality of surgery and reduced adverse events and on a global scale surgery and adverse events contribute to more than 60% of the cost of health care by doing this. And starting at the very beginning, we hope that you will realize the importance of good surgical technique and that you will continue to practice. So tonight's episode, we are continuing our theme of looking at basic surgical skills and our focus this evening is on scissors. They originated as two blades fix together with a strip of metal. And it was only until the Romans put a pivot in there. And that's the derivative of the name scissors, scissor to cut. In fact, the word scissor is rarely used as a verb. By way of example, you can say you scissored out a picture of, in other words, you cut out a picture. But otherwise scissors is an unusual word or tantrum because there's no singular version. It was actually a Hench cliff in Edinburgh that must produce the scissors that we see today. And he produced them. In 1761 many surgeons have added their names to scissors and we'll explore those this evening. But when I look at some of the answers you gave to the questions, it doesn't surprise me, but we need to explore and explain. I did ask, do you put your fingers through the rings? Well, if you look at different types of scissors, you'll see that the rings have different shapes. And now these kitchen scissors used for cutting joints are perfectly suited to put three fingers in and most the thumb and you can use a grip because they're used as kitchen scissors purely for cutting and jointing in the kitchen. Similarly, smaller versions are used for cutting papers or even smaller still. And when you think about it, one of the first things you did at primary school is you learn to cut out shapes with a pair of scissors and this is was fun at the time. But the first stage in teaching motor skills, I didn't realize at the time. Of course, none of us did. This is part of training and teaching skills at kindergarten stage and holding a bit of paper up and cutting scissors is a skill to be practiced over time. The ancient art of paper cutting in China has been refined to cutting out silhouettes of jars and patterns in the most intricate of detail. But the scissors we're most familiar with for dissection are called the Macintosh scissors. Uh mcindoe, as we said before was famed as the father of plastic surgery who work to these Grinstead and looked after in the most holistic form, the pilots who were bent in World War Two in the Spitfires and therefore knowing his story and what he did and how he treated patients and the development of the flap and these clever reconstructions, he came up with this beautiful instrument. So the first thing to say is you need to learn how to hold the instrument. And as explained before you have more sensory input from the tips of your fingers to the brain than you do from the retina to the brain. The century load that's far superior from your fingertips. And indeed, you'll be aware that braille and blind and touch typing is all done by feel. And that is why we need to hold the instrument properly. Because as Lord Barley Moynihan said we need to caress the tissues and the instruments should be regarded as extensions of your fingers. And therefore, when you hold the scissors, it's important to ensure that you got the lightest of touches. My sensei teaching me with the sword keeps reminding me to lighten my grip and to hold it very softly to let the sword flow. And that is almost a meter long scissors at 20 centimeters. You do not grip the scissors. So what you should do is never ever, ever. And I can't put the D IP joint through the rings for one, you'll lose control, you'll not be able to feel it. And if somebody grabs the scissors or you pass them and they take them off wrong, you could dig glove the finger. What you need to do is apply the tips of your fingers and I put my ring finger through and my thumb and my third finger at top and my index finger extending down the scissors. Now, this gives me direction and proprioception. But also as you see, the scissors are balanced in the triangle between my two fingers here and my index finger at the top giving it stability as I'm holding it, you'll note that the mcindoe scissors have a curve and as we use the scissors in its various functions, you need to see both the tip of the scissor and the curve. If you hold it upside down the spoon opposite way in conca and or convex. I have seen dissection of the lung, the scissors this way, cutting the pulmonary artery because the focus is on the tip. If you hold the scissors in this direction, you're looking down your hand down the scissors and the tip and you can keep an eye on both points. Scissors like the blade need to be sharp, they need to be maintained and oiled at all stages of the washing process. And you can pick the scissors up and you can hear the one blade shearing across the other blade, giving you confidence that is cutting longer versions like this. Nelson scissor are likewise the same shape, but they have a longer stem allowing you to reach deep into the cavity of the pelvis or into the chest. They are to be held in a similar manner and used in a similar manner as well. I like using these scissors particularly when I'm doing a pericardectomy because the points themselves are blunt and because they're not used very often, you can hear that they are very, very sharp. The other scissors available look just the same, don't they? But they are slightly chunkier and these scissors are called Mets and Bums. And to be honest, then, not much to say about my f Metzenbaum who was born on the first of April 1876 and died at the 25th of January 1944. He was an American surgeon who specialized in oral and reconstructive surgery sometimes referred to Metzenbaum la forceps. And actually, if you look him up, there's just a description of his family history. He was the first born in Cleveland, Ohio and his father Joseph was 29 and his mother, Fanny F was 27 and he married Elsa in 1912. All Metzenbaum did was make a chunkier version of mcindoe scissors I could not find and perhaps you could correct me if there's anything in the literature, explaining what else Metzenbaum did. By contrast, we all know that mcindoe was the father of plastic surgery and his approach to the care of the patient in his work at East Greens will stand the test of time. Many surgeons put their names to instruments. But I think if you're going to do that personally, I think there's something of more substance behind just a name. So a lot of you described your favorite scissors, mayo scissors to be honest, are a shorter version. These are typical clinical scissors and you can see their points are extremely sharp. They would be used on the wall for cutting plasters and dressings. Mindful of the fact that is a very sharp point and in the operative field would cause a lot of damage. But the mayo scissors I'm familiar with are not too dissimilar to this. There's a straight male with curve, a blunt end and a curve ma scissors that has the same curve as the mass as well. Of course, for final work, there are scissors that are finger held or in vascular surgery. The pot scissors which are straight or angled or right angled, typically used for opening vessels and they allow a finer control. So the type of scissors is important and will direct your surgery. But I think the macho scissors are probably the most useful of all scissors in the surgical Armamentarium. And I will explain why and demonstrate. So we use low fidelity models all the time. And Lawrence, who is the manager of the G supermarket downstairs often says to me on a Monday, what are we operating on this evening? So our models this evening are tangerine and grapefruit, a capiscum in American terms or red pepper, a sausage and a chicken leg easily available and offer excellent practice and will describe as we go. So I'll take you over the top to our first model here. A tangerine we'll zoom in and please feel free to interrupt or ask questions or make observations as we go and doing many of these dissections. I'm mindful of the fact that I do not have an assistant and a lot of operating. I'd say all operating is always a lot easier with an assistant. So rules one, hold the scissors properly. Two never close the scissors unless you can see the tips and three open, gently, take out and close and you can open and close and develop tissue planes. So the first exercise using a tangerine is very simply, can you develop these tissue planes without cutting the flesh underneath? So I'm going to swap to my nails and scissors here because they're more robust. They got a thinner point, a rounder point and I'm confident that I'm not going to damage my fine Macondo scissors. Now, these exercises all take patience and time. But what I want you to practice is to feel the tissues as you're doing it. And I can use the scissors to probe and push and feel open up once I've opened it up and I can see where I'm cutting, I can cut. So dissection at a small level and focused level is best done with a pair of scissors. If you have large planes, then a knife, which we'll cover in our dissection skills. Next week, I'm using my fingers here as a FP because obviously the tangerine is going to be rolling around the table. But it doesn't mean to say that I'm detracting from my practice of using my scissors. And the challenge is to try and get the skin off for starters without cutting the tangerine underneath. And to be honest, as I said before, when I start practicing this, I find myself getting totally absorbed in the process. So now I have to consciously think about keeping you informed of what I do and, and in surgical training to learn how to operate and talk through what you're doing is a skill in itself. And part of my training, the trainer course as well, cos often when concentrating and you find yourself, please be quiet, I'm concentrating and I cannot actually use other parts of my brain at the same time, quite understandably because as we learn, and as we feel our learning starts with the right brain, then our learning once it becomes practiced and automated moves over to the left brain. So bringing your learning back and talking it through is bringing your learning back from the right brain to the left brain, from the left brain, sorry to the right brain. And in doing so, you're learning again the skill by talking it through in helping to reinforce the processes. So the first part to be honest with this job was relatively easy is to take off the skin and what I'm wanting to do. And I can use, as I said, if I'm in a plane I can use, is there a blunt probe developing planes? So the next stage is right? OK. Can I now separate out the segment? So another layer, so you can see as you would find in the liver or the lung, there are some tissue planes or lobes. So imagine this was a lobe. Now, I got to separate and develop a broncho segment, for example, sometimes it's obvious like that. But on this side, you can see it's not obvious and I don't want to be plunging my scissors in but with a bit of patience and a little bit of ease, easing of the tissue, I can gently realize and develop that plane. You can't rush these things and you got to be careful that you do not apply too much pressure and you don't push your scissors into the tissue. I'm opening, withdrawing and then closing, open, withdraw, close. And I'm working across a very broad surface as I do this. If I took my scissors this way, you can see, I'm gonna put a lot of tension on the tissue and I can. But if I'm too hard, I am going to be destroying the flesh. And that's what I like about organic models. And we've put a tangerine and an orange in a CT scan and we have got the hands field units that we'll be publishing in our paper shortly demonstrating unequivocally what we know that rubber and cy easic will never ever mimic organic material. So this might seem a rudimentary and basic exercise, but I can promise you it'll keep you busy for hours as we develop this plane, I'm getting, getting there. But I don't teach speed and speed is not part of the equation at all. What we're teaching is accuracy and precision and respect other tissues. So I'm gonna persist a little bit longer with this because I think we're getting there. But I see a little bit of juice down there. So in my anxiety to complete this within the time afforded this evening. So I'm exploring further down and just releasing some of the connected tissue holding this pith in. Why not? So let's go one further, shall we? And now look at this and now we got the pit out. OK. Just taking that off the table. OK. Can we actually find a layer to take the flesh off? Oh, I've tried this in the grapefruit, which I'll show you in a moment. But since it's come off, see if I start on this, you can see how easy it is to start getting the flesh and interrupting that. But to show you a simple membrane or pla or fascia plane, not too dissimilar to human dissection around vessels, you get that very thin plane across the top, but in fact, the better one to use. All right, there you go. Sustainable surgery I could do with mm nice sweet tangerine. This is a grapefruit. So the skin is really hard. I probably use curve mayo scissors on that hard cortex, cos they robust scissors. But you can see here, look in that as a lay. Can you explore and test your surgical skills in that clear? And to be honest, when doing pericardectomy in the past, the process is painstaking if you get in the wrong layer, however, you find yourself stripping off the vessels of the heart. So although this might seem a silly model, what it is actually doing is really pushing your scissor skills to the limit. And can you develop that plane and with a little bit of traction, I'd combine this level of dissection with perhaps a gentle stroke with a knife. But there you go in getting there. If I go too deep, can you see that if this was the heart, I'd be in the epicardium, removing the epicardium and into the layer of all the vessels. You can try it yourself. You can see that the segments likewise are a little more buried. Can I actually developed the plane of the segment? I can't see it. And sometimes when you're dissecting, if you know your anatomy and you're following the line, you sometimes have to just try and explore again. It's a model you can use at home and I hope you appreciate, you get immediate feedback and looking at that. I think I'm in the right layer. It's sort of separating and at the present moment, difficult to tell. But in fact, I think I'm looking at it and probably in the wrong layer there and now down to the flesh itself. Yes, I am cause you can see the juice coming out. So I'll have to start by dissection in another place and come back to that. I'm not going to continue dissecting there because I've determined that I'm probably in the wrong plane do if the, if it goes out of view, I can't see the camera at the same time. So please shout if it goes out of view. Um It's OK at the moment, thank you. Say again, difficult, very difficult. But these models that I'm putting out are that for you there to test and try and work out for yourself. And indeed, sometimes when you're dealing with some fibrous tissue or segments, you do end up in situations where it is not poss possible to dissect it out cleanly and you end up with a sort of compromise back as far as possible. You try and find this the segment. Now, to be honest, I am finding this a challenge. It is difficult, maybe it's a segment too far. But what I'm doing in this is I'm learning and appreciating as I go a feel of the tissue and I'm getting feedback each time I dissect because I can see the juice appearing in some cases when doing some of these dissections, it may be necessary to stand back and say, well, hm, I can't take it off. What other mechanisms or tools do I have at my disposal? Another tool would be an ultrasound cutter or cutting this off with a diathermy. And I think diathermy actually fulgurate tissue. And to be honest, I presume I prefer the ultrasound cutters because it would appear here that this, so that looks a better opportunity. Then you see I'm not in the flesh, but OK, I'm taking it off. So you practice yourself, you can see that segment is coming out, it'll probably take another probably 40 minutes of dissection to take that out. And to be honest, I might have fun doing it after this. Cos I personally, I always like a challenge and that is gonna be a challenge. I will rise to that challenge later. So our next item that we're going to put on the agenda is the humble sausage. Now, you can get chicken sausages or beef sausages wherever you are. But the important thing is about the sausage that there's a wonderful skin over the surface. I just come out. So you can see me a bit further. And the idea behind this exercise is using the skills of snipping, opening, cutting, separating probing or the adjectives are used in the questions all apply to the function of the scissors. And usually when you start off dissection, it's the starting of the dissection. That is the most difficult bit because once you found the right layer, it should be plain sailing from there on. You can see my scissors underneath that membrane and I've got nothing between Tyromyces. I can probe it. You see, gentle probe to develop that now. And the idea behind this is to get the skin off this. Oh, now, that's a nice thing you see that I found the right plane with my tips up a bit like cutting Christmas wrapper. I can run my tips along. And that's a beautiful example of once I'm in the right plane provided I know my anatomy, I can run my scissors all the way up that skin. It's been like cutting wrapping paper. Once you start cutting and noticed that I only opened it up very slightly. I was able to shear it off in a smooth cutting motion. But keeping the tips of the scissors up an hour can continue this process of dissection and literally used by scissors as a blunt dissection tool to help me get around the sausage occasionally needing to cut deliberately, but at all times trying to develop and the idea is to get it off with this minimal amount of sausage on the skin. I'd have to do some cutting on occasions to continue the dissection and keep it moving. But most of the time and obviously, here, when I've got a large surface area, my dissection would be facilitated by a assistant recognizing the need to hold this there to enable me to apply countertraction and further dissection. So these models are really enabling you to explore and play with the different functions of the scissors. The important thing is that you're holding it correctly with the lightness of touch, you're not applying excess force. But like my sense saying, do not hold the katana too hard, do not play too much force in it and let the sword do the work for you. Marvelous. There you go. Dissection of the sausage. Obviously, there are lots of things that you can pick up at the supermarket to make things more complex, more realistic. Simply take a chicken leg, for example, look at that lovely fascial planes as you can use. And if I put my scissors underneath, you can see there's nothing between my scissors. Oh and the space underneath. And I can feel with lightness of touch, there's no resistance and there's no neurovascular bundle in that and therefore can proceed to cut it. And I think good surgeons can operate on any part of the body provided. They know the anatomy because they are adept at using the instruments and respecting the tissues as they proceed with dissections. Now, I confess, I'm not familiar with the anatomy of a chicken leg, but I can have hazard a guess where the neurovascular bundle would be. And as you've seen previously, we've dissected that out, it's usually covered in deep two, these are ductal muscles and you will note that most tissues are separated by loose areolar tissue. But occasionally, as you see there, we come across a vessel in this vessel, we need to dissect out a mixture of sharp dissection and blunt dissection. And I can put my scissors underneath that and I'm holding that vessel up, I can pass a suture underneath. I've demonstrated previously, I can open up the scissors gently and between the scissors gently grab a tape or something and pull it through. Ok. So I can gently grasp and pass and end of a tie as well. So separate, open, separate, open and cut and to make sure again of sweeping probing cutting, please, as you do this, feel free to use all the techniques. But as you're doing so, think of what it feels like and the amount of pressure that you're applying. Remember your left hand, holding the forceps, as we have demonstrated previously, cannot grip or tear the tissue inappropriately. As you have previously said that it generates significant amount of force and can damage. So that muscle is isolated. I haven't actually found the neurovascular bundle yet. Um And we'll continue to explore. So please, if there are any questions, do shout any observations. No questions. I lost my colleague here. People are saying that your dissection is marvelous. Oh, this is extremely kind. But the thing is what I'm doing is just enjoying myself. Here. There you go. There's a vessel. It's a lovely big vein there. All right. And by putting my scissor behind dissecting it out, I still got loose area of tissue around and remember that all vessels need to be cleaned. So I've cleaned off that vessel. So when I ligate it, I'm comfortable, I'm ligating the vessel itself and securely without having to tie any other tissues in. So as a tool to probe explore, you can now understand why I think the scissors are the most versatile instrument on the surgical tray. And I like mcindoe because he epitomizes what all surgeons should practice is holistic care. And you put your patient first all the time and do the right thing all the time. And if you haven't got the right, don't proceed until you're happy. Very simply nobody, but nobody can tell you to operate. And it's your duty to ensure that the conditions are appropriate and it's your duty to ensure that you maintain those conditions by your own temperament and demeanor. So, there we go, we're coming down further into a bundle here, I'm sure it's here somewhere. Ah There you go. I've got a hint of it, hint of it at the bottom here. Let's see. Lovely. Marvelous. So if you want to dissect out the femoral canal of a chicken leg, I think I zoom do. I'll probably increase the brightness and zoom down further at the bottom of here. There we got a fe vessels and I think that white structure there, you see that white structure there. That would be. There you go. That's it. Pick it up. I'm gonna pick it up with a forcep. There you go. You've got the femoral nerve of a chicken leg and there next to it, you got the two vessels, the big blue one and another one next to it. So thank you and provided you provided you gentle. I can move that up and down in the plane. If I'm moving it side to side, it's likely it, it but in the longitudinal plane as I got my forceps underneath, I know, I'm not damaging the vessels. So they're the two vessels. All right. 12. And there is a nerve. I hope you can appreciate that. It is the femoral canal of the chicken leg. Oh, what fun. Oh, what fun. So, there's one other way to hold the scissors that I will now demonstrate. And I'll demonstrate this using a capiscum or red pepper. So, as we peer down into this, it almost looks like we're looking into the nasal cavity. Yeah. But if I put my hand at the top, you can see my hand is in the way of the camera and it would be in the way of my vision. So I will not be able to see what I'm cutting. So therefore, I'm now gonna change my grip. I'm gonna change my grip to what I call the upside down or ent grip in this circumstance. Again, I'm applying the pulp of my fingers, the thumb, my index finger, my middle finger is in the same position, but not at this time that the triangle and stability is achieved with my baby finger. And now when I enter this, I can see past and this rotation of my hand and wrist that I can see where I'm cutting. So this is a lovely exercise. I can turn around either way. But if I do that, you see, I can't really see the point. This way, I can again see both parts of the scissors. But I'm using this as a scraper note that the blades are only just open and I can gently scrape off these pips or when they actually stock, nibble them off and double them in the way my hand is not in the way my hand is relaxed. And the same principles of probing srping, opening and closing apply for this inverse group as well. Of course, the smaller the hole, the smaller the scissors and some of that then comes back down to holding instruments and applying the same principles as we do when holding forceps. In other words, you're maximizing your fingers in their application. My fellow Sensei has been with me this week in Kuala Lumpur and he is joining us from his hotel room and in Kuala Lumpur, he's a plastic surgeon. He uses lots of fine scissors and I'd like him to comment on his experience and offer advice on using scissors. So welcome Mr Caddy. And it's a pleasure to see you in Kuala Lumpur. Are there, can you see me? Yeah, I'm there. Uh No, once again, exemplar demonstration of how to use uh use the scissors. Um So the these are for mainstream dissection. Um So there are other scissors, microscissors um and they're used in a similar way, but between the, the thumb and the index, once again, using the pulps and you can rotate the scissors rather than opening and closing the brades. Um So they've got a spring in the er, in the handle of the scissors which open it and then you close it very carefully, but the same principles apply. Make sure you see the tips of the, er, er, of the scissor blades, er, and know exactly where they are. It's, it's about situation awareness with applying your, uh, your instrumentation. I think one of the most critical skills of a surgeon is actually having visual spatial awareness and where you are and what you're doing, not only anatomy, but at visual spatial awareness. There you go. I do like some of these models. They keep me engaged. Well, if you go back to your chicken leg, it would be good to dissect out the uh the femoral nerve both proximately and distally. Um So it's a challenge for you. Well, I think we almost, almost time is up but certainly having identified that plane and I'll zoom down again. Um And again, I'd like to thank Wet Lab and Edward Life Sciences for giving me this camera, which really has revolutionized the delivery. And a thanks to my colleague, Kevin Austin of Wet Lab for securing this for me. But you see how I'm pressing it down and just scraping off the tissues. I'm not making any rash, cutting, I'm opening, withdrawing, opening and withdrawing. And I've really taken this, this nerve right away right up there. So as, as your assistant, I would either like to put a self retainer in there or um some small RNAs to retain the tissues. Indeed. Indeed. So it's about thinking about what you're gonna do next and then pre empting that. See there, I've got the canal. Yeah. Yeah, it's going under now. Open it up. I II can open it up. There you go. And there's a bifurcation there, bifurcation of that nerve there. And when I'm opening it up with vessels like this, I'm not opening it across, I'm opening it up in a, a plane parallel to the vessel and then open, withdraw, open, withdraw. And you can see there lovely, aren't we ba the nerve and the nerve here you can see are solid white structures compared to vessels. Wait, yeah, obviously have blood in them. So what we tend to do then is to put a elastic loop around either the nerve or the vessels and use that to retract them rather than using the tips of your scissors. So, and the other thing, yeah, exactly. The other thing is you got to be mindful when you put retractors in to hold it out that you don't catch these because the retractors would put sustained pressure on earth and cause a neuropraxis. So, so elastic slinging these vessels with so elastic slings and putting a te on the end gently holds them out the way and neighbors. So what I do is put something underneath there with femoral artery or veins, especially in patients with peripheral vascular disease. I wouldn't even though that's small, I wouldn't even cut that. I would just put a tie around that a loop with a house there on it to hold it out the way and at the end, take it off and I've maintained the regional blood supply because in vascular surgery in diabetics, et cetera. Obviously, you don't know, want to compromise any blood supply. That's a lovely some day the bottom there. Thank you and or not anything else to add, Mister Curry. No, thank you for uh demonstrating this. Great, greatly appreciate it. And thank you, ladies and gentlemen for joining the Black Part Academy. It's always a pleasure to have people around the world, sharing and learning with us. Please send us your observations and comments. Would love to hear what you are doing. You're gonna invite innovative models. Uh We closed our competition, we are deciding and the winners and they will get their own set of instruments in due course. I'd like to thank Gabriel who's part of metal, who's in Lithuania. She's a medical student, also a qualified lawyer, a fantastic photographer whos spending her Monday evenings producing. So very grateful to Gabrielle. Please. Will you fill in the feedback form when you do that? You'll get a certificate. We are accredited by the Royal College of Surgeons of Edinburgh and you'll get CPD points that are recognized. Please join us next week as we continue our dissection story and we revisit the knife. Wish you well be safe Thank you.