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Hello, good evening. Good day. Good morning. Wherever you are and welcome to the Black Belt Academy of Surgical Skills. My name is a Regan. I'm a retired card student in Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trains of the Royal College of Surgeons of Edinburgh and of visiting with at Imperial College, London. Thank you to all our followers and we now up to 704 7 on Instagram, we also know we are now reaching more than 100 countries and this evening is no exception. Thank you to me. We are covering countries literally from A to Z, from Albania to Zambia. If this is your first time. Welcome, if you're back. Although we go with the subject again and again and again because we practice so we can't get it wrong. I hope to keep you entertained with stories and low fidelity models which enable you to h your surgical skills. My wife pointed out the other day that I was using the word homing skills and she said, you know, it's honing. I said, yes, I'm deliberately using the word home because I'm trying to encourage you to practice at home. And we can. The Black Academy was at university with a neurosurgical Students Association brain and I was joined by my colleague and sp I been teaching basic skills. We had fun and we had people chanting, we love the Lumb course as they bring the palps of the fingers together. And that is what we try and emphasize in our teaching and the Black Belt Academy, it is the feel of the instrument that gives you the feel of the tissue. We set ourselves up on a hall and the society had bought 14 ironing boards. I note at the Royal College of Surgeons event. Edinburgh National skills competition had people seated and stitching. Although we are credited by the Royal College of Surgeons of Edinburgh, I'm trying hard to persuade them that we do need to be teaching people standing and the best and most economical table to do that is your ironing board at home. So tonight, we're talking about the scissors. What's interesting about the word scissors is a pleural tantum. That is a word meaning it's a defective noun. It's used in the singular and the plural like aircraft barracks, sheep and scissors. And they've been in use with the Ancient Egyptians since 1500 BC where they put two bronze blades together connected by a metal strip. And you're probably familiar with these old fashioned shearing mechanisms. And I certainly noted them in my grandfather's garden shed. It wasn't until Roman Times with iron and bonds that the pivot came into the scissors. And that's where the word comes from. CAA Benning scissors and the word has stuck, often used in Roman Times for grooming and cutting beards. And I suppose that's where our barber origins come through throughout history. Different cultures and regions have developed their own variations of scissors. And in China and the company, they produced scissors for cutting paper. A Chinese student gave me a set of these, I'm afraid they're packed away. But these are used to intricately cut paper designs with meticulous care. Scissors were not only used for cutting paper and cloth, but also used for cutting other materials. And it was in the industrial revolution in the 18th 19th century when Robert Hinchcliffe, a Yorkshire man in Yorkshire mass produced scissors using cast steel. And that's the history scissors now became universal. And he in theory holds the patent or design for scissors. You quite rightly identified the name of the surgeon Archibald mcindoe who describes what I regard one of the best instruments in the surgical train. He graduated in Waikato in New Zealand where a fellow sensor David mccormack works and he was doing his house jobs there when he was spotted by Lloyd Barclay Mohan and invited to come overseas to work with Mohan's cousin Gillies at bars. He went through his training and oral max. So fal surgery and set up the first plastic surgery at S Grinstead and you're quite right. He became the father of plastic surgery, particularly in World War two. When he used innovative reconstruction techniques on pilots who are burned in Spitfires, they established the Guinea Pig Club that became disband, I think about 67 years ago when there were no members left. But there's one element of mcindoe skill that I enjoy is that he was anxious that these young men who had disfigured by bands might have lost their self esteem. And therefore he only employed good looking nurses at the hospital who would not be revolted by some of the disfigurement. They had seen. Rumor has it that there was plenty of Hanky Panky going on in the cupboards. And many of these young men actually married the nurses. What I like about the story is that not only was he a pioneer plastic surgeon, but he was thinking about the emotional and spiritual elements of healing of his patients, a true surgeon in the holistic sense. And therefore, when we pick up a mcindoe scissors, I want you to pick it up correctly and show absolute respect for the man who brought this beautiful instrument to theater. As we have emphasized on every occasion. It is how you hold the instrument. And you notice that I've got it held in the pulp of the fingers, the pulp of the fingers enable me to feel the instrument. I'm holding it with my index finger extended down the shaft, my middle finger is applied ring finger obliquely through on my thumb obliquely through the ring as well. For those of you who have got smaller hands to maximize the feel of the instruments, place your fingers through obliquely, never put the D IP joint, the distal interphalangeal joint through the hole. The other important thing to realize is that I'm holding it with a curve down. This means that when I'm looking at my dissection, I'm looking down the curve of my wrist, the curve of the blade and the points. The important point here is that I can see the blade on the curve and the point. Whereas if it was this way up, not only is that dissing mcindoe, but this way up when dissecting through solid tissue and I've seen it in the lung, people are focusing on the tips and forget the belly or the curve of the blade can potentially cut the PMI artery. And I've seen it done so a lightness of touch and it's only with the lightness of touch that you start getting the haptic feedback through the instrument itself. Many surgeons have lent their names to curved scissors. The thin elegant ones being the mcindoe scissors, the slightly stockier ones being the Metz metal. But the scissors that I enjoy certainly for redo operations and thoracic surgery. And these were kindly given to me by BRA ASAP, other N and scissors. And the other reason why I like them is because they've got a blunt tip and because they're not often used, they are certainly sharper than others. And if I take a doctor in my ear, I can hear the blades slicing over each other, there's nothing like a clean cut. So going back to the ancient Chinese and the art of paper cutting, it's only sensible that we start our very basic skills with our scissors with paper cutting. Now, you might poo poo this as an exercise that you did at kindergarten. But this is different. Now, we are standing, we are putting the paper on the table and you're going to cut out shapes. It may be black and white. You might think it's simple, but to do it accurately, it is difficult and certainly it is not as intricate as some of the Chinese designs that I have and were given to me by the student. So let me take you and demonstrate. So what we've got here are circles in black and students have already cut out some of these circles. And you can see when I put it against a white background, there's a little bit of black left over. What was interesting looking at the students operating at the weekend is that they picked the piece of paper up and started cutting out. And I joked with them. They have to inform the anesthetist. Please hold on to the tube as I pick the patient up to try and c now the paper exercise is important in another respect because it is there to emphasize that we do not open the scissors any further than necessary to do the job. And that would be the maximum amount I would like you to try this paper exercise with a paper on the table and as carefully as possible, cut the circle out on the curve without leaving any dog ears and without leaving any white, all black and placed against respective surfaces. And you'll suddenly find that as you're going around in a circle that you're going to have to move your body around as well to ensure that your effectiveness of cutting is maintained, you cannot pick the patient up obviously to do the dissection. Now, what I'm looking for here is accuracy. I'm not looking for speed and I'm not looking for cutting out. So if you look at this now and this is the thing about the feedback is as I've gone around, I've left some black on that. So in the true sense of practice, what I need to do is do it again and reduce the amount of black. Now, if I cut it out irregularly, you will see dog ears and the dog ears, certainly unseen on vessels mean that you'll not get the surfaces back together. I give a and you should never cut with the belly or the scissors, I've cut that out and I'm putting that against a black background and now I can see the white that I've left behind simple exercises, reinforcing simple skills going around in circles with curve scissors is relatively straightforward. But how about cutting in a straight line using scissors, care of scissors? And again, but being trying to be as careful as possible. And I am looking to see if I have left any white or black. And if I'm honest with myself, there is a slight bit of white there And if I turn this up the other way, I can put it on a white background. Have I left any black on the edge? Well, there's a very thin line of black on the edge. You might not be able to see it on the camera, but I can see it there and I can see a little bit of white there. So this simple black and white exercise is something that we're going to put on the Black Academy app and you too can test and try and practice until you can't get it wrong. The action of keeping the C open just enough to do the job is very important when we dissect tissue planes. And considering that vessels invaginate into the mesenchyme and the organs. And that's how the vascular system grows. It takes with it layers of tissue. So especially when dissecting through the lung, the liver, kidneys or solid organs, the best way to find the anatomy is usually following the arteries. But on top of the arteries, there's usually a wonderful plane, not too dissimilar two, the skin of the sausage. Now, I particularly like capillata sausages because the skin is a lot thinner. And this exercise is designed to enable you to grow confidence, developing tissue planes. And the secret is to this exercise is to take the skin off without damaging the sausage meat underneath. From the forceps point of view. What you're doing is holding gently because again, it'll crush or you could stick the forceps through the tissue. A useful way to use. The scissors also is gently probe. You see it's relatively blunt at the end. So I'm confident feeling my way into tissue anatine. Once in tissue eye open, I open the scissors, take it out and I never close the scissors. If I can't see the tips. If you're closing the scissors without direct view, you're potentially cutting something without knowing it. So spread, take it out, develop the plane and progress gently. The great thing about this exercise as well. If you hurry, you will end up with a lot of sausage material on your scissors. And that means that you have not respected the tissue plane and haven't felt your way through and you need patience for dissection. It is not to be hurried. And I'm also using my scissors sometimes to gently push the tissue away. So not only is it used as a probe, it can be used as an instrument of potential blunt dissection. So having developed the tissue plane there and that's in my skin. I can brush the skin off using my. And if I was running a competition on skill exercises, I would watch somebody skin a sausage. Does it come out complete? Can I ensure that I've taken the skin off with this minimal tissue? Oh, sausage meat on the skin? I hope you agree. That is the case here. Note that I can put my scissors behind thin fascia layers and in doing so, if I'm uncertain if there's anything across the tissue plane, because neurovascular bundles frequently cross tissue planes. I can put my scissor behind to highlight whether there is an issue there or not. If in doubt, you don't cut it and you dissect around it may indeed be your vessel or a the art of dis dissecting the tissue plane though is feeling opening, taking it out before you close and developing the plane all the way through. There are many things that you can use to aid your practice and part of our competition that is still alive. We, we are asking people to offer their versions of exercises on exotic fruits and materials that you might find in your country. The tangerine skin here and Tangerine offers a tantalizing test of sensitive scissor skills. And what we're going to do is try and develop a plane and firstly remove the skin. You'll know that you're in the wrong plane. When you get the juice coming from the tangerine. Again, this is an exercise in patients and part of the practice of this model. And I find when I'm doing it myself is that one gets immersed in the practice of doing it to the extent that I forget that I'm alive and we're talking to an audience. I'm very happy to take questions as I'm doing this. I am very happy to take observations as well. This is not an easy exercise far from it and like most dissection requires feel and understanding of the tissue. My first task is to remove the skin. My second task then is to dissect out a segment of the tangerine without damaging the segment at all. Now, it reminds me of redo cardiac operations that if you get in the wrong plane, the pericardium, you start stripping off the epicardium itself and thereby start removing blood vessels from the heart. It literally ends up as a bloody mess. Some of this dissection, ultrasonic Dissector knife uh oh appropriate to use. There you go, open it up and you can see I'm developing a plane there, but I'm not closing my scissors without seeing the tip. Once I've got the plane a little bit, I can open it up a little bit further and having identified the layer, I can see clearly where to cut. What fortunate about the tangerine. The curve of the tangerine fits nicely with the curve of the mcindoe scissors. And I want you to get to a stage here. And again, I should not feel pressured to try and progress this any faster just because we are live on camera. And in theory, got a time slot to fill in. I should not be doing that because what I should be focusing on is accuracy. So having peeled that from top to bottom, my task now is can I actually separate the segments of a tangerine without cutting the flesh itself? What was interesting? The students had fun on Saturday but the ironing boards were covered tangerine juice. But uh what I enjoyed was the enthusiasm and willingness to try it again and again and again, without even asking, people repeated the exercises because when you've got an exercise that gives you the feedback that I'm describing, you're now on the process of reflecting on your progress and the skills. And that's the best thing about the models that we're offering here in the Blackard Academy. And what we're trying to do is encourage you to have fun exploring these models at home. So I've got a segment here down this side and down that side. And it'd be nice to think that we can get this segment out gently and I'm not pushing or probing hard. I'm trying to feel that resistance of the tissues as I am doing this, I'm opening the scissors up within the tissue plane and we're drawing the scissors before closing them. Sometimes you can actually go across but I'm not going to do that too hard because that's when you start damaging. So I'm now trying to separate the tissues. But if I separate too far, I'll be damaging the segment itself. I can use it scissors as well to try and lift things up. It's a sort of a blunt probe. I've got a little spurt of juice there. I don't know if you saw that, but they gave me immediate feedback that I was perhaps too overzealous on that bit in developing the plain. There you go, segment dissected out. And the important thing is is that the skin of the segment there is not too dissimilar to the skin of the sausage. It's another next next layer that you can perhaps explore in your dissection. So just take it off and I'll put that on the plate and let's see if we can find the layer of the segment. Yeah, I hope you'll agree that looks very intact. We might start. Yeah. As you can see, as I go into that layer very quickly, I mean to tangerine tissue, I'm trying to dissect off that little film. You see that film there that's thinner. But now I'm down to the flesh itself. Excellent way of actually practicing skills giving you real feedback, sustainable surgery because I can enjoy this tangerine at the end and the sausages will be added to the breakfast menu, sausages and beans. There is a second way of holding the forceps and I'll just take you up and over for a moment before I demonstrate it clearly. When you're working down in a cavity, there may be limited movement. And although you're staring over your wrist and over the belly of the scissors and watching the point, you're going to be limited geometrically by the holding of the scissors. The other way of holding mcindoe scissors is what I call the upside down way, frequently used by ent surgeons and maxillofacial surgeons when operating in the oral cavity. The way I'm holding it is much the same as the previous. Again, on the palps of my fingers, the thumb, the ring finger supporting the shaft, the index finger obliquely through the other ring and now my baby finger is down the length. So as I'm operating, I'll take you over as I'm operating. Imagine that this is the nasal cavity. I move my sc around. I can see the belly and I can see I'm just taking tangerine off my forceps. I can see the belly. I can see the tips, but with the ability is improved because I can move my elbow and flex my wrist. And this exercise is simply to dissect the pips off, going back to the forcep ex exercise. The the other day, I can take these pips off and now practice the same exercise, combining the forcep skill, not only by taking help, holding the pip as I dissected off by picking them up and putting them in a straw off to my left. But what I'm going to use this for is to appreciate that in the same way you k Christmas paper, once you start the cut and you've got the scissors slightly open, you can continue your cut. There is a shearing mechanism with your scissors. And if you're in the right plane, you can do that gently as I am with the, the pips on the inside of this pepper. And again, the feel of the scissors holding them lightly and just feeling that slight resistance, ever so slight resistance of the pips and the core. You can imagine if I'm actually overzealous with this, it is very possible for me to literally stick it through into the flesh itself. That would not be a good idea at all because this central core is well, the fera and unless you're feeling the tissues and careful, not only can your forceps go through as I demonstrated last week, but just scissors themselves as can damage the tissue. So the pepper, I think the Americans called us a capiscum. I think this is lovely red pepper. Again, this will not go to waste, it will go back in the fridge and go into a very good pasta sauce, recyclable, reusable, sustainable, low fidelity eco-friendly organic operating. I'd like to see your examples too. So to prove you can operate in depth here, I have the sausage with the other bit of the pepper at the bottom of a glass. And you can see if I try and get my scissors in a regular hold, I cannot cut effectively or dissect effectively. So therefore, this inverted hold is very useful and I can use same skills, the same principles too dissected out tissue on. You see, I got it in the right plane there and I was starting to gently strip off that layer. There you go and gently strip off that layer. There you go. I've got it in the right layer and I was able to strip that off. So even operating at depth, this is possible and the same scoring mechanism, scoring system of no sausage meat on there's chipolata skin is what we're aiming for. And we want to ensure that it comes off intact without damaging imaging any of the tissues underneath. Again, I would love to see this as a skills exercise but done standing as we usually do because only by standing do we actually then start practicing the muscle memory and rehearsing and learning the functional anatomy of the upper limbs. So there you have it simple folks, you can home your scissor skills on the lowest fidelity models and find these models engrossing, giving you feedback all the time. So you could c when you get it wrong, it is visible black and white bits of pork tissue juice from a tangerine or punter the center of the pepper. I see my pillow since Mr Caddy online. He said, Yum Yum, as we talk about the recipes, the recipe book, I know there's a recipe book produced by Nizam, a cardiac surgeon and he highlights foodstuffs for practicing fidelity. I reached out to him and he's agreed to be interviewed on the Black Belt Academy and I hope to come back to you with that. In due course. I'm very happy to take questions. Please leave your feedback after the event, Gabrielle who kindly sits in the background is Lithuania and is always here on the production side. And I'm very grateful for her participation. She is a medical student but also a qualified lawyer and a very talented photographer. Next week, we're going to be talking about Knots and I brought Knots forward because I was going to do knife, but that would have to require lots of supermarket material. But since I returned to Kuala Lumpur next Tuesday, I didn't want to waste that and it for it to sit in the fridge. So we'll do Knots next week and the week after that knife. And I look forward, I walking around the N SK supermarket and look for more tantalizing teases that will enable you to he your skills. Thank you very much indeed, for your attention. Thank you for participating. I didn't see no questions in the chat room. I was very pleased with your answers on the pre session questionnaire. And I hope now when you pick up scissors you all understand who Archibald mcindoe was and we're going to show him serious respect. Thank you very much. Indeed. Do pass the word round tonight. We had 30 countries and we're now reaching over 100 countries globally. Goodnight and be well. Thank you.