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Hello. Good evening. Good afternoon. Good morning. Good day. Wherever you are in the world. And thank you very much for joining the Black Belt Academy of Surgical Skills. My name is Darigan. I'm a retired cardiac surgeon and I'm now a full professor in the medical Education and research unit at the Faculty of Medicine, the University of Malaya. And we're coming to you live tonight from Kuala Lumpur. It is 1130 and we can only run these sessions because we're powered by metal. And tonight Sue Gibson is on production in the background and we'll be calling out your questions if you have any, if this is your first time. Welcome. And thank you and to all our followers, 4000, 240 in 100 and 12 countries. Thank you very much. Indeed. We have 761 followers on Instagram and 1069 1699. On Twitter. Tonight, there are 53 registrations from 29 countries from most of the continents, Venezuela, Ecuador, Zambia, Zimbabwe, Canada, Egypt, Ethiopia, Germany, Mozambique, Sri Lanka, Syria, and Ukraine. Just to name a few. We did ask a number of questions of you beforehand and what you thought the scissors could be used for you have them all correct. But then the category to point was not recognized and I'll just hold up the forceps and the scissors, the forceps, you can see as we discussed before, are quite sharp at the end and could be like a spirit. The scissors as we will describe in detail in a moment, have a blunter end. And I actually use these two point to those things when doing an operation. Obviously, as a training surgeon, these are in my hands. But if I was assisting, the scissors would be in my hands as well. And I could point without putting my hand in to the operative field and ask, please, could you tell me what this is? It's interesting that all of you felt and I'll say all of you with one exception that knowing the history behind an instrument is important, however, one did and I respect her opinion, don't really care about the history and just want to improve my skills. It's a personal opinion. But I think knowing the history helps you think about how to hold the instrument and how to care for the instrument as well. Now, the interesting thing about scissors, it's a peculiar word in the English language. It's a pleural Kham. In other words, the singular and plural are scissors but like glasses pants, the odd defect of nouns. But we say, could you pass me the scissors or pass me the glasses? You also, they can have that pair of scissors or pair of glasses or pair of pants. The word itself can be traced back in equivalent terms in English to middle French. And interestingly, it came from the Latin word suo, which derives from the verb to cut. And we can still use scissor in place of cut. If you taking a pair of scissors to scissor out a figure that we'll do shortly intriguing. That's why English is particularly complicated. Now, humans have been using scissors for at least 3000 years and the Egyptians had two blades which intersected like that and connected with a piece of metal a bit like the old fashioned shears that I noted in my grandfather's shed was Romans who put the two blades together with a pivot in the middle and like all scissors, they were used for cutting hair, cutting cloth and barbering. And that's probably where the barber started and the barbers and started as well. It was Robert Hinchcliff in 1761 in Sheffield that could be regarded as the father of the scissors because he mass produced scissors with a central point and circulated around the world. Notwithstanding that scissors were also in China and not with me. But in the UK in my box, I have a decorative set of scissors. Now, it is still used today in the ancient art of paper cutting and we'll come to that in a moment. Now you're all recognized or most of you did. Yeah, Archie Board mcindoe, and this is his paracis or scissors, a nice long handle with a curved blade. It comes in bigger forms. And thanks to be brown, I have this pair of nels and scissors and you can see they reach a long way into the cavity and very good in thoracic surgery. But Archor mcindoe was at Waikato boys school in New Zealand. And we did his training there. There was a house surgeon at Waikato Hospital and Mod Barclay, one n happened to be visiting and spotted his talent and invited him to come across to England to work with his cousin Sar Gillie, who has an ent and plastic surgery at BS. He then took up a post in London to be moved to East Grinstead. And that's where he gained his reputation because he was the founder of plastic surgery in the United Kingdom and devised all sorts of reconstructive surgery to help the young man who had disfigured in banning spitfire planes. What I particularly like about this man that he was very concerned about their self esteem, that he felt was lost because of their disfigurement. And he therefore only employed apparently good looking nurses who would not be abhorred by some of the appearances of these gentlemen. It has said that a lot of Hanky Panky went on in the room cupboards at East Grinstead and many got married. The Survivors main, the Guinea Pig Club and the Guinea Pig Club came to an end probably 10 years ago in the last Survivor died. What I liked about this is not only did he produce what I think is one of the most elegant instruments in the surgical tray, but it's certainly one that is put to most years. So let's just consider the ergonomics for the moment and handling of the scissors. And I'm going to bring you over to the camera to emphasize some of these issues because what we teach in the Black Belt Academy is how to hold the instrument. The kitchen scissors as you see here have two rings. Yeah, underneath ring, they can take three of your fingers and the one above your thumb. And if you look at this and as a squeeze, you can see that the flexor muscles on my forearm are at work because the kitchen scissors have robust blades necessary to cut and join the chicken, for example. And the force generated is generated by the flexor muscles of your forearm. And what you're looking at here is essentially a grip, a form of handshake. I had a reputation of having a very strong handshake. My father told me to actually give a good handshake rather than hold a hand like a wet fish. He said my handshake was only broken by one other neighbor Christopher who really had a handshake of steel that aside. So what we're looking at here is it scissors with a slender length, two rings and a curved blade? You know that the scissors are sharp. If you hold them up to your ear, you can hear the sliding of one blade over another. It's almost like a automatic pier. It is a sing sensation and noise to how to hold them is on the tips of your fingers. I have my thumb and my ring finger obliquely placed through the rings. In order to ensure that the pulp of my finger is maximum applied to the rings themselves. The action of opening closing them is really the intrinsic muscles of the thumb. You are not using the forearm muscles at all as they open and close. It's the opponents and abductal muscle of the thumb held in the tips of my thumb and ring finger. My middle finger is on top of the other ring to add support and my index finger is extended down the shaft to give me direction and proprioception. They're held such that the curve of the wrist and the curve of the blade on the same way. Because if you are dissecting in a deep cavity, you can see the blade and the tips at all times to turn them upside down and hold them like a spoon. I can see the tip here, but I can't see the belly and I've seen pulmonary arteries cut because people are focused on the tip and not on the belly. The scissors themselves should not be opened any further than necessary to do the job. They should never be open like that and they should never be closed without being able to see the tips. They're very good at opening up tissues, take it out and close. I always say that you have to hold this instrument properly out of respect for mackinder. So to my colleague who doesn't really care about the history knowing mcindoe work, I hope now that you would realize how to respect you're going to hold his instrument properly. One of the first things that we learned to do at kindergarten and is actually a joined to a development tool is being able to master the scissors and cut out shapes. Interestingly enough, I went to the toy story to, to toy store today to try and get a coloring in book. I didn't find a coloring in book, but it had these pre painted colors on bits of paper. I've never seen that before and thought it was quite innovative. But holding this piece of card or paper simply practicing taking a scissor round is curve shapes deliberately two is taking you back to those kindergarten G of cutting shapes out and a very basic skill in the Black Belt Academy. He's learning how to cut out shapes again, bearing in mind as you cut them out that you do not want to leave bits of white or bits of black on either side and that your cutting of these shapes should be really accurate. And following these lines with a curve pair of scissors, it is actually difficult. But what I trying to take part upon you is the need to be able to control the direction of your scissors. Now, this bit of card is perhaps too thick for my task this evening, but it's also highlighting something important because if I look at this, I've left some white on that side and some white on that side and I have gone completely down the middle, simple feedback saying that as you cut something out, do attend to stick to the lines, simply having black shapes of rectangles and circles on a piece of paper as I've demonstrated before can be used. And we are looking at that as a scoring system fosters the skills you can take any shape you like on a piece of paper. The important bit of scissors is you got to use the right scissors for the right tools. Now, I wouldn't use a Mac scissors on orange skin. I'd use a heavier pair of scissors for taking off the skin of this arm. Now, this is, yeah. How often do you need to sharpen surgical scissors or would or should you discard these after a while? Well, that is a good point that all scissors will have a shelf life. And I think if you speak to the manufacturers they should be inspected and certainly the joint is oiled. The washing process and the sterilizing process affects the joint of the scissors. And what we see is a lot of debris collecting underneath. These need to be inspected as part of the cleaning process and the instrument needs to be oiled. But we can ask my colleague Mr Cad at the end if he is actually seen the instruments oil because the oil that you get up for this is a sterile oil. But you're quite right, you need to care for your instruments. And when you think they're all gathered up and dumped in a tray and put through a sterilizer, it's not surprising that they're going to become blunt. There is a shelf life, I cannot put a number on it. But if you feel they're blunt or damaged or have found some damaged instruments in the past, it was a side biting clamp where the two ends did not meet cleanly. And I think as your role as a surgeon, when you pick up an instrument, if you see it as defective, do take it out the system. I've seen, seen the same side biting camp that crossed over, come back on the trade two or three times and on this occasion, clipped it on my gown and confirmed with the sister that need to be destroyed when I took it to see. They said, let us deal with that and we're sorted. I said no we are going to destroy it right now and I put it on the floor and jumped on it and put it out of action as it should have been. I got into trouble, of course, for doing that. But I think I saved somebody, the embarrassment of a failing instrument. It was beyond repair. So, what I'm doing here is I'm developing the plane using the curve of my scissors and this is a curve. It is very useful. What I am doing is insinuating my scissors into the plane and clo taking it out and closing it. What I like about these and scissors is they are not used that often for regular dissection. So when coming to remove, yeah, fibrous tissue and the pericardium or the pleura, these are wonderful. And if you think of this orange underneath as I can to epicardium or long, I need to be able to take this off without causing any damage to the tissue underneath because the damage would be bleeding of the epicardium and bleeding or air leak on the lung and sometimes some of the inflammatory tissue and scar tissue. One has to take off is as thick and is difficult in some of this tissue and simple organic things are much better. A more lifelike four operating and surgery. So once I've actually done that, then I need to think to myself, well, I can go further with this dissection. I've taken the skin off. Now, I want to see if I can remove a segment. So I'm gonna change my scissors to the finer Mado scissors. And you see, I've got a segment here and often your tissue planes r as thin as this and I've got a little bit of juice there as you can see. And I might not be quite in the plane. I wanted to be the thing is that you would not get this feedback on any other model. And wouldn't it be better to actually practice these skills on a tangerine or an orange and not on a patient? Because I can tell you now that the feedback I'm getting in doing this, his very much like the difficult surgery that I've attended to in the past wins, dissecting tissue of lung and of the pericardium. Like all things in surgery, there's no need to rush and you need to do it accurately. The operation takes as long as it takes and what I'm trying to do here. And you can see and I zoom in more closely if I go out of view, please shout because I am focusing on my dissection. And as said before, with many of these models, I too find myself getting totally absorbed in the dissection. And it's an interesting thing to practice is to keep talking when I am trying to concentrate. And in that regard, I think this sort of model is fantastic because it is stretching my skills, especially as I'm trying to describe what I'm doing. I have got a little bit of juice coming around there and this is trying to actually, you can imagine doing a segmentectomy. Now, if I put my scissors in like that and open too widely, my scissors themselves and the blades will start crushing the tissue. This is a particularly stubborn and difficult segment and I can feel my colleague Mr Caddy, who's that fellowsi looking in earnest at this, but as I'm doing it, I'm getting feedback all the time on the amount of pressure that I'm putting on. I'm gonna just gently see if I can open up and develop this a little bit further. David. I'm gonna ask a question now. OK. So anyone that's listening, I'm not surgical, but um the most surgeons use their scissors to like spread things. You like, you're kind of spreading things out rather than snipping. Kind of. Well, ii it's a combination of spreading, separating and snipping and this is what this exercise is all about as I'm trying to define the plane here to actually get the segment out. So I'm using a nibble, nibble, separate and trying to develop the plane and this plane is being very difficult. Indeed, actually, to be honest, I'm finding this particular one a challenge and I'm in already into the other segment. I've got a pip there and I've got juice, I've got bleeding. So this segment is not as well defined. And when you're taking out segments, sometimes the planes are not defined at all. And taking out in the segment was without damaging. The adjacent tissues can be very problematic. If this was a segment of a liver, I'd have a very big raw area here. And I have to think about the application of topical hemostats on this. But as you can see, the plane has not been as well defined as I'd like, I'm actually into the tissue. There was here. You can see I was in the right plane on this side, the plane wasn't as well as divided and this is what happens in surgery, but I've got this segment out. I can enjoy the rest of the evening, continuing to stick, cut this and continuing to practice out, taking the rested segments off and having sort of inverted commas, not satisfied myself that it come out as cleanly as it. I've not refined myself wanting to have another go to take out another segment to see if it comes out better. And that's the thing about these models that we are offering in the blackout Academy is because of the immediate feedback, you inclined to immediately say I can do that better. So definitely I might have a, a bit more and the layers are not as well defined, but I've set myself a task by choosing an orange this evening. And the segments are sometimes not as well defined, but you get the drift and I'm using the scissors to actually separate the segment out as part of the dissection. The thing is that everything we do in surgery has got something to do with the tissue planes. I'm finding the right tissue planes and getting in the right tissue plane is the essence of operating. Now, the sausage, it comes with the skin and the terrific thing about the sausage on the skin, the thickness of the skin is not too dissimilar to the thickness of the fascial layer that you will find over a vessel. And the question is, can you take the skin off a sausage? Same principle, I'm using it scissors to develop the plane as a blunt dissection tool. And I'm only using the scissors opening up as much as necessary to cut this facial plane once you're in the right plane and you're familiar with your anatomy, it is possible to open your scissors and literally strip along there to lift and off the scissors themselves can be used. It's a blunt intimate tool delicately remove the tissue without the sausage meat sticking to the side. Now, I know we have these hydrogels and plastics and all other materials. And I went to the Simulation center the other day and they had a plastic mannequin and for practicing insertion of urethral catheters and rectal examinations, et cetera. Now, I can appreciate why they do that. But to examine somebody in the perineum with soft tissues and you're putting, teaching people on a plastic mannequin. The thing about it is you certainly will not understand how delicate and sensitive the tissues are unless it's the real thing or organic tissue like this. Now, I can use my scissors in my dissection and place it behind tissue layers like this. And in doing that, I can confidently say there are no vessels or nerves running across this tissue at that point. And if I was assessing somebody on scissor skills, I'd give them a sausage and I'd give them an orange to see how they manage and use scissors. These models require a lightness of touch and delicacy that only organic material can offer you. And I do recommend you try these yourself at home. And while I'm thinking about it, we've got a competition that ends on the first of July where we want to hear from you about the most innovative model that you've used at home to practice your surgical skills. Email it in with a photograph and a short description and the winners will receive their own set of instruments. I personally cannot walk around the supermarket now without looking at the possibilities on the shelves and what is available and certainly ring in Malaysia, the food and the produce is such, it is always stimulating. I now I got a pepper and at the bottom of this pepper, you'll see there are pips. But if I try and take my hand in this way, my hands obstructing the view and it's rather awkward because my arm is abducted and how in the air that is not relaxing, it is taking a lot of energy and it is very awkward. So in this circumstance, we hold the scissors a different way similar to in the first, in that the fingers do not go through the rings of the scissors. I have my thumb and now my index finger completely applied to the rings. It's supported by my middle finger and my ring finger down the shaft. And now my fifth finger is extended down. So I'm going to be holding the scissors and using them like that. And with simple rotation of the rest, you can see that I've now got a clear view down an ent cavity or throat. For example, there you go. I'm gonna cut that out because OK, just some white tissue in a way I can feel it probe it with my scissors and I know there's nothing significant and I'm gonna remove that from you inside. I have all these pips and now I am going to either cut the individual pips off one by one. And if I was combining this with my forcep exercise, I put them into a straw on the left hand side so I can combine all the exercises that I've suggested to date to incorporate both right and left hands. But now what I'm going to do is I'm going to take the pips off the inside by using the scissors partly opened and I'm going to scrape them off a bit like you would scrape ice off a windscreen. There you go. I see I can reach down into the pip and into the pepper and clean off. Oh, the peps as a game round. You can see because of the geometry of this. It is presenting a 3d shape at depth and I'm having now to move around and get myself into a position where I can clearly see what I'm doing a and get the scissors working effectively for me. This is now using my scissors for dissection at depth as well. If I was too vigorous, I can easily stick it. There you go into the tissues underneath. All of these models are just giving me haptic feedback all the time and how to use the scissors. So if I was doing an O SA scoring system on this, I'd be looking at the position and handling of the scissors, the rhythm and the flow, the lightness of touch, the appropriateness of the interaction of the forceps and the scissors as well. And seeing the effectiveness of the combination of the two skills together. Again, like all the other models, I'm finding myself totally engaged in doing this and forgetting t talk to you as I'm explaining it. And there, I've almost cared the inside of that pepper of all the pips. There's a simple scissor exercise at depth, giving me haptic feedback all the time. And even though my hand is coming over the top, you can see, see what I can see. I'm looking down my scissors. If I'd had my hand the other way, the back of my hand is obstructing the view. One can't go past the fish counter at the N SK supermarket in Times Square. They are marveling at all the produce that is available. And this little fellow caught my eye, lovely bright eyes, but they don't gut the fish. And what we have to do here is literally gut the fish. So say, I see a cardiac surgeon did a cookery book on surgical skills and cooking. And what I like about it is a heat talk, simple things that we take for granted in the kitchen in preparing our daily meals and change them to skills that can be applied in the operating theater. And this is one of them opening up the fish and there is soft membranes and the guts on the fish. Now, am I going to throw this away? No, there's a cat downstairs, feral cat is going to love a bit of fish for breakfast and I'll take it down for the cat. But even these elements that we're looking at and the fine tissues and layers that we're dealing with here also give you lots of opportunities to practice your dissection and scissor skills. And at that point, I'm going to actually ask my colleague and fellow said, say, car to come in and offer his thoughts on the scissors. Now, what's interesting we've got, as he knows, scissors for microsurgery that are a lot smaller. I certainly use pot scissors for opening coronary vessels. These are not the ones to be held in the hand, but they were in the spring and held with the fingers like that to give you the feel and the stability. So fellow sent and colleague, Mr Caddy, as a plastic surgeon involved in dissection in the hands. What are your observations about the use of scissors? Uh Well, once again, we, we use a different um range of scissors to use. So the mcindoe scissors are uh bread and butter and you learn your, your skills with the, the Mado scissors. But for most of our in sections, we tend to use finer instruments like Stevens tono scissors, which are very sharp, but they've got blunt tips to them on, on a basic set. You would have stenotomus and Iris scissors and we'd use the Iris scissors for cutting sutures for instance, and we would use the Steven Tenotomies to carry out the dissection. What what was interesting was Rinker was, was talking about um instruments and saying, um you know, how do you, how do you sharpen the, the instruments and do they need to be tested? Uh So that's where you need to understand that you're part of a bigger system. The instruments need to be decontaminated and then sterilized. And certainly in the UK, that's a whole system which lies out with most major teaching hospitals. At one time, every hospital had its own central sterile supply department. And even before that, each theater had its own, um, little sister where if you dropped your instruments or needed something sterilized, you could put it into the little sister sterilize it and it was back in your operating theater. That's no longer the case. Um, because of Prions, mad cow disease, um, that system is no longer safe. And so we've had to outsource a lot of what we do. And I think it's important that all surgeons who operate should find out where their instruments are decontaminated and sterilized and if possible, go and visit them and you find that. Yeah, it's certainly interesting to walk the process. Well, it's fascinating to watch the process. And so I was saying to, to Rinko, it's not about you spending your time sharpening your instruments, oiling your instruments. You're training to be a surgeon. And so you should concentrate on that and you should leave looking after instruments to your technician. He or she is trained in that loves the job and does it to a level far superior to one that you would be able to do. It's a bit like sharpening your samurai blade. Yes, you need to learn how to do it. But you have master class men that do that on a regular basis. And the sharpness of your blade. It is very important in the way that you are, remove people or operate. II wouldn't use the Kano as an example because part of the being at one with a G is the ritual of actually cleaning it. So the people who do that actually cleaning it, uh There's just one other thing I wanted, you remind me of something that I had a prop on the side but didn't show and I just want to show you this, the ring finger advantage I had as general surgeon is I could actually flick the scissors up and would free up my hand such that I could still tie a knot. The thing is that I never desecrate a dissecting scissors by trying to cut something like that with this. And I'd use irregular scissors. There's a Twitter conversation on the same thing with regular scissors though, particularly these as they're very sharp, your hand will get in the way. I think if the suture is less than trio of, preferably less than four, I think it's quite an order that you cut the suture with the Mac scissors because of the convenience. But on the other hand, I'd also say this is what I did when I was practicing as a general surgeon and used to flick this back out and cut the scissors. But since we're talking martial arts and we're doing, karate, karate means empty hand. So to keep your hands empty throughout an operation is important so you can respond accordingly. So that was just my final prop. I wanted to add to the discussion, the, any other questions or observations, Mister Caddy. Well, my, my other observation was that what we're not seeing is the splash of, um, juice as it lands on your hand, we're not smelling the juice as it goes into the air. Uh, and, and so we're the, the haptic feedback that you're receiving while you're operating is far more than we're able to pick up and see, um, at a distance. So it's, er, I, I'm, I'm aware of what you're going through, but we need to sort of think, well, what's happening here, what are we not seeing? And how do we indeed. And I'll come over again to that orange and I'll zoom in a lot closer and hopefully you'll appreciate what I was talking about about. I'll take up the brightness and you can see that it looks wet on the inside hearts. Here, that segment is intact in this area, but here I lost the plane. So you can see it is wet and in essence, you want to be able to get these segments out. The side is better. My, my observation on that is that human tissues are often far more forgiving than your, uh, vegetable tissues. True. So you're going to find the blame there. But it is, I agree with you. But the thing about models, the models that you practice on should be harder than not doing the real thing. And if they're not, then I don't think you're quite appreciating the skill and the feedback that's involved with them. So I make no apologies for these actually being very difficult models and challenging because when it comes to dealing with the real tissues, to be honest, I hope not only with practice, but because the feedback, you'll find it easier. I think too often the models we use, in fact, that's too easy. But the other thing with um any particular model and we're writing a paper and the ideal surgical model one, I think has got to be organic because I have not come across any hydrogel or synthetic material. That is the same two that your model and dissection should engage your attention and you should be absorbed in it. If it's not absorbing, then I don't think it's quite hitting the mark either. And three, your model should be giving you feedback on the intended learning outcome. The intended learning outcome for this uh orange was defined in established plains to see that I had entered the plane on one side but not the other is giving me immediate feedback. And I actually felt compelled to do it again, to improve. And I think this is the difference between a learning model and a self reflection model and a regular model. Your thoughts, Mister Caddy. Well, as I said, it's all about continuous quality improvement. It's about continuous learning. What went well, what didn't go so well, how can I do this better and going back on that continuous loop? Um And in most teaching and learning situations that doesn't happen. And it's one of the benefits of the Black Bells Academy of Surgical Skills. But the key element here is to get that feedback because you can't see what you can't see, you can repeat something over and over again, but you can make the same mistake every time and you need to question, am I doing this perfectly? And so that's probably easier if somebody else points that out to you. Exactly. And we practice until we can't get it wrong. And that's why martial arts is not a sport. You study martial arts because it's a journey and you'll never get it perfect. But the drive is to do that. I ask how to hold scissors with left hand while right hand is busy. Yes, man. That's a very good question. And unfortunately, it is, the last is in surgery is the lefthandedness. And there has been a talk on this and I think my suture was running a conference on the lefthand bit. Uh Wilson, who uh Chris who's in New York contacted me because he's left handed. And my advice to him was try with your left hand, but also start landing with your right because in the end, you'll end up a better des surgeon with the right hand and the left hand working Chris and I have a colleague who is the Secretary for the Royal College of Surgeons of Edinburgh. As you know, we are branded and accredited by them. And Robin is left handed and he describes the struggles he had as a trainee, but he taught himself to operate with the right hand. But I left him much better off in my experience. One of my trainees was left handed and to actually help him, I learned in that 12 month period to improve my left hand. And I swapped hands with the instruments as well. To such an extent, I was doing an anastomosis one day and found it awkward and I was able to put the needle holder in the opposite hand in my left hand and continue the anastomosis. And I'd asked the registrar at the end of the operation, did you notice anything you haven't halfway through the operation? I had swapped from right hand to left hand. I'm afraid it is still a problem in surgery. Scissors, as you quite rightly say, are designed for the right hand, for the left hand. The only way to get the pressure of the scissors is to use them in that sort of manner. But you can see that it's not supported and it is not stable. I am holding it with the tips of my fingers, but I've lost that stability direction and proprioception with it. And sometimes I've cut with my left hand, I thought, but holding it in the same way, some scissors if they knew do work the same. But that's because the blades literally scissor across themselves very well. But acknowledges the problem in surgery and is the last is and surgery as well. I mean, it's interesting in that you can have left handed instruments specifically manufactured for you. The problem with that is decontamination and sterilization because you then need a backup set of instruments for everything that you do. And also if you drop one on the floor, one gets contaminated, it's not just one backup. You need a number there available so you can continue your operation. So the logistics, this is where situational awareness and decision making comes in. You need to think what am I going to do? What are the potentials for me doing this all left handed or all right handed? So I think if you can learn to use both hands so that you're ambidextrous in your surgery, is it also harder for the rest of the team? Like, you know, ii only watch like Grey's anatomy and that kind of thing when you see the nurses handing the instruments, is it harder for them if the person's left handed to right handed, like where they stand and everything else, what impact does it have on the rest of the? Well, yes, potentially it does. But that's where you need to rehearse with the team. Uh You have to be aware of that before you start and you have to mitigate that in the planning of your operation as well. Um And, and that all comes down as Mister Carrie says to situational awareness and using, using the skills of your team to their maximum, your scrub nurse needs to be aware of what stage you are in the operation. And she may need to mount the needle as a backhand instead of a forehand, seeing that that's where you're going to need to put it in the next time. Otherwise she hands you the instrument, you then have to change the needle and move forward. But when you're working as part of a team, all of that should appear seamless, but you need to understand your team and they need to understand you. We will be talking to Paul Barrick on the 17th of June and the title of that is you're only as good as your team and that is very true. So I'd like to thank Su Gibson for production this evening and she doesn't usually do the slot with Gabriel is got clinical commitment. And again, I'd like to thank my fellow and Mr Chris C for adding significant insight into how, how we use instruments. Thank you very much indeed, for joining the Black Belt Academy. Do pass the word around. Please offer your feedback that is in the chat room and feedback is important to us and we are listening to what you say. And I look forward to seeing your ideas and photographs and how to practice at home. I wish you very well. Thank you very much for joining.