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Okay, so I think we're alive down there, That's who. Ah, Good evening, everyone. I'm sure, uh, you can tell that I am not. But Gemma used to coordinate all of our events and was in charge marketing. And she has our organization account on metal. My name Is she here? I am a course surgical trainee based. Go. My mood will tell you a little bit about himself. Well, he's also based on God's go. He's a plastic fellow here. Um, we've had some issues with setting things up, but we're all good to go now. And we're very excited to be using the new med a light system we've been using. Zoom until now. Oh, but you know, it's been a long time coming on, but we're quite excited to see how things go with the metal top form. Delivering our lectures and collecting are feedback and everything in the one place. So we're going to have today's lecture, and I've made some announcements on our social media platforms about upcoming lectures. Uh, what I'd say for today is that will allow my mood to go through presentation. And if you have any questions or anything, you talk about these. Keep it in the chat. Know that men would know about it. It looks like we have a small ish crowd today, so it will be really, really good to utilize that opportunity and have a conversation here where you can learn about the things that you may not have people to ask before. If the nickel detected call that you'd like to ask my mood. Then you know, you could open those questions up to him as well. And I think I think without any further today I'll start that you introduced yourself mood on talk to me. So we've been collaborating with them. 20 on be collaborated with them on the principles. Of course. I moved to talk a little bit of keep doing some work together with them to the future. So thank you so much. I'm going to myself. Move. Um Good evening, everyone. I hope you can hear me. Um, I asked why for us by calling to present this topic is basically about the basic food management and the suture ing. Um, here on this orthopedic course, um uh, part of their to be the record of being activities as you can see, there's a look off useful things in the academy for people who interested to take career in trauma. Orthopedic, Um, I'm one of the fellows work in. Um um, Arthroplasty had gotten Jubilee hospital on. Do, um I'm going to talk as they said about would management and suture ing. Um, can you hear me? Everyone. Can you hear me Share? Uh, yeah, but I can hear you just fine. I'm just going to check on the chart of anyone else is having an issues. Yeah. Uh, wait. My move. It looks like you're just sharing the one with, you know, rather than your screen. Um, okay. Just go through the sides there. No, No. So you're right. Probably stop shaving. Yes. And then if you share again, Yes. Yeah. Is that better? Okay, so, uh, you know, we still can't see it. I'm chilling at the moment. Um oh, Can you see it now? Yeah, we can see it now. Um, maybe it's There's some delay, because if the internet So if you click, share screen, and you should just stop if you minimize that yet, Yeah. Now, if you if you from from beginning on presented. But It has a full screen view as a full screen. Yeah, Yeah, yeah. No, this is not like this shaving. Can you see it now? Yes, I can see it now. She could give you presented. Can you see the slides shifting? Uh, no, it's It's still Rosen on the window, I think because probably the size of the presentation, I think. No, no, no. Uh, I think it's because you're sharing it at the window. If you stop sharing. Yep. Yeah. And if you click present, I cannot see present. No option. Um, there at the bottom. Yeah. Present. Now, share slides or share your screen. Sure. Your screen. Yeah. Yeah. And, uh, entire screen. Okay. Yes. Entire spring. Yes. Yes. And if you minimize that Yeah. Okay. Yeah. Not No, it should be fine. No worries. Okay. I'm gonna beat myself from here. Thank you. Okay. Sorry about this guy's so good. The objective is this. Talk to talk about pointless if cation and wound healing, I think is a question to understand. What kind of would be dealing with on the face is a phone healing to help you managing. Ah, Any patient present with the wounds like laceration, etcetera or issued one healing. We're also going to have different types of suture material. Ah, what you should consider when you choose a suture to close the wound. Different techniques of food culture will touch in local static use and safe dosage. And if we have time as well, with touch in the difference between hypertrophic and keloids scar. So one classification. I think this probably known to everyone, was just refreshing. Our memory type one is the clean wound is basically surgical plant wound. It's surgical incision than clean environment. Anteater. The different between clean wound and clean contaminated is the wound is not, ah in contact or their contact with respiratory Jurietti. Or, you know, any tract system contaminated wound, which I would like to highlight about this type of food, which is common presentation in trauma and then casualties is basically fresh wound related to trauma. And by the definition, this wound is contaminated with the risk off wound healing issue like infection. And you have to put this in mind when you, um, dealing with such ah case they're infected wound when the wound has that tissue or there is presence off plus so wound healing faces again. This basic information, I'm sure majority few aware of this process. The first processes him a Stasis which happened within the first 4 to 6 weeks following the start of the injury or the cause or the any reason causing the one the most. A should start by plated leg regain shin on 55 in production. This all driven by plated created growth factors and following that you have the other inflammatory face which is take between 1 to 2 days again. This driven by problem on nuclear cells which later differentiated to monocyte and macrophages Microphage is ah through the phagocytosis process. Clean the wound a breeze and help to, um deliver the growth factors which ah start regeneration process by the position off metrics granulation tissue and the new vessel formation. Epitol is a shin on the last phase of bone healing. It's, um ah, scar formation, which is can take up to two years to remodel. So, um, it's important to be aware of this healing process. As you can see, if you didn't have a good blood supply, um ah, liver to the wound area you have and issues at each stage or each face of this healing process. So this again basic information what the factors affect wound healing. This could be asked to medical school, medical school, uh, students or any post graduate, um, in their exams, the local causes and typical location of the wound. So, um, areas in the body has the better reputation than others. For example, if you're ending with the small cut knees, you expect that wound to heal quite quickly without an issue. Ah ah, another hand. If you have a wound around an area with high skin attention, for example, around the shoulder is just very moved by the area or, ah, the bottom off the foot you might expecting issue with wound healing. Also, the blood supply as they mentioned, and areas with good blood supply like hand upper name James speaking the wounds. Normally, he'll quite quickly without any major issues and also presents off the existing infection or foreign body material. For example, of somebody present to casualties with the laceration caused by ah, broken glass, you need to make sure there's no for um, material left behind before suture in the wound. Sometimes this for, um, materials because inflammatory action infection and lead to issues with one healing. Other factors. It's systematic factors like Asia, the patient and a mole older patient you know they have. The healing potential is less in comparison to Children and young. Other presence, of course. Connick illness, for example, diabetes. You know, patient with diabetes. Just speaking, they have issue with wound healing, and also with the elective surgery you always council. These patients say the risk of infection generally high, and you need to make sure your diabetes and blood sugar will controlled other factors. Is smoking excessive alcohol in take poor nutrition, especially in the Jones surgery patients and the medication, for example, patients on long term steroids. So the goals off one suture in what you want to achieve when your suture a wound, you want to opposition the wound edges you want to eliminate eliminates any space is. And the reason why you want to eliminate any dead space is to prevent any collections like a fluid collection like hematoma, which is would be good environment for bacteria growth and potentially can lead to infection. You want to provide adequate attention to support the wound until that's inside strength is recovered. You want to achieve on, maintain hemostasis again when you bringing the layers together and you close that the space this help with him a Stasis and the hill healing process Starting the healing process of the wound you want except the wound healing and prevent complication as I mentioned infection. And finally, you want to achieve a statically a pleasing scar. So we're going to talk about the basic classification of suture material. So we have, um, two type of suture materials, monofilament and multi filament suture material, as you can see the time with the cross check section difference. Dislike, breathe, type, suture and the difference. Monofilament material is easy to pass through the tissue. It cause less tissue reaction and the irritation. However, they have memory, which I'll explain one of the videos I mean by memories. So we'll be slightly difficult to handle. And this not security is less um ah desirable in comparison to multi fella minutes, the the searcher. They are rigid. Example. The common examples for this type of suture is prolene it alone, which is nylon and monocryl. In the other hand, the multi filament one is more it can cause more trouble trauma to the tissue when you pass because they're they are less smooth. It can cause more tissue reaction. So if you're dealing with with potential, develop infection or ah, wound healing issue you preferably. You want to use monofilament rather than multiple A mints future. Another hand. They are easy to handle and not security is quite good. Um, potentially they can, um, be source for bacteria growth on microorganism growth because if the ah structure of the future and takes common examples for this stuff, Suture uses Vicryl cell and the Autobahn. So another classification for ah suture material can be classified as absorbable. None observable, observable like like the synthetic or natural commonly used now is synthetic like vicryl, monocryl and PDS. Non absorbable synthetic material is like nylon prolene, polyester natural um, and none of visible structures. For example, silk and the surgical steel and the advantage off, um, absorb suture. You don't need to worry about sexual movil. You don't need to arrange full up, um, for the patient to take the scooter out and, um, in other hand, not observable searchers. It's, um, used inside, where there's ah, height inside strength. So basically, the provide ah, good support for tissue until they heal, especially in tissue with heightened sile strength. For example, feet fascia. Ah, large standards like in the hand or in the feeds cetera. So, um, this table demonstrate the common suture materials used and the the complete absorption time for each future. For example, Vicodin is, as we mentioned, it's not absorbed. It's absorbed, will switch your and it's a multi filament PDS. It's absorb a lot and smaller filament monocryl absorb well, monofilament. So the vicryl complete absorption time is about 42 days on vicryl, about 60 days PDS take longer time and monocryl about 100 days. You have to understand there's a difference between complete absorption off the suture and how long this suture provide inside strength. Both ah has different, um, definition. Basically that inside of strength of the suture is that the time the searcher gives in total to support the wound during the healing process. But absorption time is the time for the material to to completely disappear from the wound, so I hope that clear. So what's the idea of suture material you want? Suture material cause minimal soft tissue reaction is easy to handle and, um, provide good, not security. Basically, when you um tied the note, it's secure, and there's a small chance the not will slip and you, uh, the suture. It will fail. Um, it has good inside of strength, and the suture should be sterile. So there's no suture. That's idea for everything. You have to think what kind of suture you're going to use for each seen. Are you dealing with? You have to think about the location of the wound you have to think about would classification of one classification. So if you go back and if they won't clean, you'll be, um ah, sorry about this. So if you go back to the one classification, if they won't clean, you'll be thinking about using observable. None. Observer suture with the less concerned. But if you're dealing with contaminated wound, you'll be thinking more about, um using and none absorb a suit, your monofilament. So also you have to think about inside strength. For example, as I mentioned, if you suture in dif ASHA or ah, large tendon, you have to use future has a good inside strength like it, the bone or proline if you switch oring um, skin, for example, in the face, you be thinking about using five old kind of suture, which is fine suture, reasonable to side strength to support the wound and cells here. And it's not causing any ah, scar marks. And also you have to think about overall, then static results. And as I mentioned before, does this patient need for lab how the suture be removed, etcetera? The other thing. We're going to talk about these types of Sichuan suture needles. So as as you can see here in the cross section, there's different type of needles attached to the suture. Material could be around triangular shape, which is called reverse cutting or the convention cutting type needle. And they brought the broad classification off needles could be cutting needle on on cattle cutting needle cutting needle. It's Scotch when, when you when you pass it through the tissue, which make it easier for you to suture. And um, um especially when you're dealing with the tissue, has, um um, like a tough tissue like, for example, fascia. 10. Don't would be thinking about more using cutting needles, for example, if you suture in bowel or ah, vessels. You be thinking more about using non cutting meals, because is the structure is fragile. You don't want to cause more damage by passing sharp needle truth. So here you see cutting needle. It's ah, tap taper point kind of shape in the cross. Check this section and you have reversed cutting, which triangular and cut from at the bottom. When you pass this the needle and you had and you Also, there's conventional cutting, which is cut, um, at the top when you pass the needle and you have a taper cutting and you can see the difference between each one. So, um, um, this, um, when you when you passed the taper pointed needle, it delayed rather than cut through the tissue and other hand. When using reverse cutting, it's cut through the tissue and easy to pass, especially view suture ing and some particular or ah, take layer on subdermal area. So the uses off the next slightly talking about the uses of different sizes of searchers. You can see here we have different sizes of searchers and the the the end there use. For example, if you, um, suture ing large tendon or fashion. Be thinking about using take suture. Be thinking about number or term number two, either Vicryl or PDS. If you doing subcutaneous suture and you you'd be using a slightly smaller, smaller searcher with a good chance, I'll strength will be number zero or two all. Um, if you stitching skin in the upper lower limb or around the trunk, you be thinking about 30, size suture, for example, tree or nylon or monocryl or tree? Oh, vicryl for the hand. Because you have fine structure there and the skin is quite sensitive. You need slightly smaller size types. Actually be thinking about using four or 50 size future again. It would be either, um ah, nylon Ah, monocryl or ah, probably in and in the face because it's, um, sensitive area, especially for ah, um, ecstatic result, and you want you to use something very fine. Doesn't keep scar marks. Um, ideally, would be five. Oh, suture material. None absorb about something. None observable, and it's small enough elements, so it doesn't cause a lot of inflammatory reaction. And ideally, you want to take the suture quite early, has explained before one of the factors affect wound healing. Is the blood supply in the face about supplies? Quite good. So by five days following suture in the wound, you would be able to take the stitches. As far the wound is Looks fine. And there's no concern for microsurgery. For example, off the molecules surgery, um, vascular surgery, vascular repair, abusing microsurgery types. Future, which is start from 8 to 10 hours. So a disappointed other know she'll if you can hear me. Yes, I can hear you. Yeah. A disappointed if anyone has any question before we move to the second part of the talk. Yes. So I'm just looking at the chart, so I'm not sure if everyone is being able to use the chart or not. But, you know, there's a chat function at the right time side of your presentation screen. So I haven't seen any questions there yet, Mehmood. But if I see something that comes up, we can perhaps, um, you know, put that to you. In the meantime, I'll try and think of some things as well. Common things that you can see on the job. And maybe you might be able to give us an answer stuff. Okay, so this case, we just carry on at the moment. So in this video, we're going to demonstrate it off the reef, not or the square. Not this basic surgical knot and this type of not provide ah, security when you suture in and the prevent, um, the wound when you stitch from opening up and failing. And also, if you tying your vessels if you use this kind of not, you'll be more comfortable closing the wound than making sure there's nothing happened later. Like the suture fail and lead to bleeding and the wound healing complications. Or maybe, um, issue with the patient Human dynamics state. Like, for example, if you're dying major vessels and this ah, suture failed. This can lead to bleeding. And you might need to go back and take a take a patient back to theater. So we started the video and the show This So as you can see, um, I'm crossing my hands. Seven. You on. Can you say no? No, you're slight. Doesn't move yet. Um, on I can see the movement. You're moving. Playing. I mean, uh, no, I don't see. I don't see it playing on this. And if you stop sharing your screen and then share it again, okay? Yeah. Yeah. I just thought you could share it again. There. Okay. It was playing for everyone else. So maybe that's just me. Okay. Oh, is it that same shooting? That is reassuring. That's guys for coming. Okay, I'll be quite, uh, just give me a second. Now I have to go back to this, um, screen. Okay. Having difficult, you know. Can you see the screen? Yes, we can see the screen. So you minimize this window that you're in. Yeah, we can see it now, and you can just share it here. Fantastic. Thank you. You. Can you guys see the video? Now? I can see it. And I'm sure everyone can probably see it too. Sorry about that guy. So? So this square. Or if not, we start this again. Um so as you can see my right hand go up, that's the first throw or the first note. And my right hand goes down in the second. No, to create that brief. No. And I'm probably able to demonstrate it better in the ah, the next light. Yeah. So we doing the same lot now, using a needle holder. It's the same technique. Rather than trying with my hand, I'm using a needle holder. So I'm creative throw or a loop and my needle holder at the bottom of the screen. And now I'm going to cross my hand and take the end of the suture to the top. And you see, I'm creating structure looks like a square. And the idea of this, um, is to stop the not from slipping and providing not security. And now I'm testing the not which is a sound. Now we're going to demonstrate, Um uh, now I'm going to take about talk about different type of notice called surgeons, not the different between, um, square knot and surgeons. Not instead of doing one, though initially you do double troll and this type of surgeons knot is superior than square knot in them sleeping when you suture ing a tissue under tension and it provides secure way to the to tie searchers or like it vessels and useful when you are using none observable monofilament switcher, which I explained before, and it has slightly inferior, not security. So that's video demonstrating surgeons knot and you notice the difference between this type of not on the this. The reef for the square? Not so. I'm starting with the double stroke on bringing the searcher to the bottom with my needle holder. Now I'm going to do anticlimactic throw and crossing my hand by taking the needle holder to the top off the screen, and now I'm bringing it down. You can see it's secure, not it does not slip. Are you one more time before we move on? Double troll, another anti clock throw, and each time I'm crossing my hand. Now we're going to talk briefly about the version of the skin itches. So when you start, suture it especially for the beginners, the first spiritually types that you you're going to learn to do. It's the simple interrupted suture and that you're aiming to divert the skin edges toe. Facilitate the wound healing. Minimize the scar tissue formation and the prevent skin edges overlapping when you have skin edges overlapping each other. This will delay the wound. Healing, create more inflammatory reaction, and you the would could ending with complications like superficial infection, etcetera. So the key thing when you do a simple interrupted suture is you start with the tip of the needle, 90 degrees to the skin, and this demonstrated nicely here. So when you go and you start 90 please, to the skin you're ending with this shape is like a square shape. When you tie the knot, you ever eat the skin edges. And if you do the technique in the wrong way and you start with an angle, you're ending with triangle at the bottom. And when you try the suture, this we're ending with even in inverting the skin edges. So that's important to remember. That's the key basic skills, um, for skin stuttering, and I'm going to highlight the different type of such suture ing technique for the skin. One of them is the vertical mattress, and the advantage of the vertical matters is allow everting. The skin edges, especially when you're dealing with area, has lax skin or abundance of the skin. Ah, provide better distribution of the one tension, a deal for wound when the skin, as I mentioned lax and is not ideal to use for ah face or neck suture ing, because can provide the or can leave behind the future marks. So you start. Um, um, about with the five millimeter from the wound edge to the other side and you go back few millimeters closer to the skin edge and you come out, you may meter closer to the skin edge. And when you tie this will either the skin edges nicely and also provide them, um adequate hemostasis when you close bleeding wound. Um, the next technique is the horizontal mattress slightly different to the vertical mattress because you don't When you, um you passed the needle when you come back, you don't need to come closer to the skin edge. You just need to go at the same level few millimeter from the exit point from the initial exit point. So the advantage of the resented map mattress is useful for wood again under the high tension, provide strength and and would Iverson at the risk off using presented mattress risk off suture suture marks as I mentioned with vertical mattress and also you could, um, if you try to much this can affect the blood supply to the skin edges and lead to skin adjust. The close is so in term of wound suture ng process what you need to. There's for certain steps you have to take or bear in mind before you start the procedure. First of all, you want to explain to the patient what you're going to do, and you want to consent them often The consent are Do you take a verbal consent or it can paper kind consent? You have to think about the way you're going to position the patient. Sometimes if you're dealing with the one that the back or at the back of the shoulder, you have to think how you're going to position patient in the best way to allow you to do the procedure comfortably and achieve optimal results. Also, you have to think about adequate light source and and, um so they allow you to visualize what you going to do. And you have to prepare all the equipment for suture in which you're going to talk about in a second. And if you're going to do this under local, is that think you have to prepare the lawn static? You have to be aware of the safe, those off the local anesthetic and how you calculate the dose. You have to follow the infection control aspect of searching and safe disposal of sharps. You have to prepare the scan using antiseptic agent and you have to make, and you need to make sure the patients not allergic to anything. For example, if using, I would die in some patient allergic to iodine, you have you need to make sure patients not allergic this. And if he's allergic, maybe you could use something like Clarinex Indian, and you have to use them. Um, draping. Ah ah, this stuff provided in suture in like in wound structuring. Disposable kids will be steroid drape, which you can use to provides a steroid feel when you do the procedure. And also you have to think if they won't contaminated, which is the common presentation for, ah, trauma wounds. You have to think about giving the wound washout, using saline and considering fresh in the skin edges. If there's something you comfortable to do or you, there's somebody senior supervising you doing this. If the skin edges looks and healthy, it's ah contaminated wound. There's no harm to take in two millimeter edges from each side to get to um, healthy Edge is with better blood supply, so this minimize the chance of infection in fasting state wound healing. So, um, this video, we're going to talk about the basically quit equipment you need for suture ink. So, as you can see, on the right hand side, I have three equipment, which is the ah two forceps. The needle holder. You need the steroid system to cut the future and the suture material. This video I'm using, um, it'll on which is nylon. And you can see here the triangle of the shape of the needle is reverse cutting needle. And I'm pointing toward the expiry date in there. Um, yeah. Then this video we're going to talk about or demonstrate how you and hold the needle holder. Uh, just started. Yeah. So to hold the needle holder, you have to hold it by your ring finger. Your come and you supported with your middle finger and use the index finger to control and in the direction with the rotation on. I'm demonstrating in this video how I've taken the searcher from the pack and if you notice I have stretching the suture out And the reason I did this to reduce the suture memory on will be easier for me to use This will make it easier to handle, especially when you are dealing with or using Ah nonabsorbable monofilament searcher. If using Vicryl, you don't need to do the step But I'll show this one more time. I don't know if he had experience when using something like it alone is very slim, See And like you cannot control it by doing this little step. Make it smooth and easy to handle So I recommend especially for beginner to do the step Make your life easier And you you find yourself for you progressing quite well this another video demonstrating how to, um hold the needle holder and about the movement happening in the forearm when you suture it is everything happening in the forearm and not in the rest. So you can see I'm producing supination pronation movement and I'm controlling the needle holder by my by my index finger is not pressed movement. It's ah for our movement most of the next one. So here in this video, I'm going to demonstrate simple interrupted suture. Um so I go to the through the skin perpendicular to the skin with the first pass that top and has to come to the bottom. So I'm crossing my hand Now I'm doing double troll like some surgeon's not, And I'm doing anti clockwise throw and the keep crossing my hand to make sure I'm achieving Secure not on This stitch will not fail with the non absorbable switcher. You need minimum for not to achieve security, Kid. I would play it one more time without me talking so you can have a look again and again. Guys, any questions that you may have problem in? So that's important. Step keep crossing your hands. Okay, so this video I want to demonstrate how you can turn the needle, especially when you do in a vertical and horizontal matters. And also it's useful skills when you start doing some particular you to turn the needle to get to the apex of the wound like here. So this maneuver based again in the forearm movement you have the right forearms, pronating and the left forearm Supinating like this. You know if you can see me in the camera But if you watch this video so if you if you notice my right forearm pronating my left forearm supinating for more time. This video, we're going to demonstrate vertical mattress, which we already talked about. And, um um so I'm starting from the forage away from the wound, about five millimeters away from the edge, coming out in the same distance and the other side. Now I'm using the technical demonstrate in the previous video. How I turn my on, how it turned the needle on. I go in with the needle few millimeters close to close to the edge of the wound, and you can see I'm using the forceps to allow infested gliding off the suture material because sometimes be difficult, especially dealing with tough tissue and following that would be something like tying off the the note used, like doing it by crossing your hands. You can see the suit you're able to divert the skin edges demonstrated one more time, so this vertical matters. It's feasible option to use when you're doing with slack skin. Or you think the skin edges is inverted and you want to either the skin edges. You don't need to talk over. Tie this suture. You start initially when you're making the not the first one is slightly slack, and the next one you try little bit and a little bit as far the not secure and their skin ages coming together. That's fine. You don't want to Over tie This one, as I mentioned before, can, um, affect the blood supply to the skin. It just can go skin the closest this video going to demonstrate the different technique of skin, cause of which is horizontal matters slightly different to the vertical matters. But the bird principle is the same. Look closely to notice the difference. So again, I'm starting about five millimeters away from the skin itch coming to the other side. I'll turn the needle using the technique explained earlier with the horizontal mattress, you will enter the skin again at the same level. You don't need to come with this technique. You don't need to come closer to the skin edges and you do the standard surgeons or reef. No. Okay, share. At this point, I will stop on on, see if anyone has any question or yeah, nothing in the nothing in the questions here. Yeah, I'll give people a moment to respond. I'll ask you a couple of questions about some things that I see on a day to day basis. I appreciate your, uh, your lower than centered more than, uh, upper than that. Correct? No, I have the experience of a limb, and they did the plastic before, So the problem. So in distal radius, uh, fractures when you're doing in or if you're closing the skin, how do you prefer to close the skin? Because the question that sort of want to ask you those things where people will be allowed to assist that nerve the stage of their career on. But what advice would you give them? So they're asked to close up, um, the wrist or if there are still close up a hit, what kind of advice would you give them for that? So we'll start with the risk first with the rest. If the patient had the or if you first of all, you need to look the amount of suspicious swelling. If you think patient had the reason trauma and the soft tissue swollen and there's a lot of tension in the skin itches. So in that case, I would be thinking more to use like something like vertical matters or interrupted stitches, because this will give you advantage to bring in the skin edges together and they reduce the tension across the wound rather than using some particular like Monocryl. However, if they're like, obviously depend on the the surgeon itself preference. But there's no right or wrong answer here. The main thing you have to look for is the quality of the skin itches the skin itself. Is it like 10 skin for for elderly lady. For somebody elderly with very 10 skin, you'd be thinking more about using some particular like Monocryl because the skin is 10 and the most like you will be coming together nicely. Majority of this group patient for somebody had, like significant Roman. The whole forearm is swollen, the result of tension. You'd be worried about using some particular be thinking more about using simple, interrupted or vertical matters to reduce the tension. If you closing the hip depend which layer you closing in the hip like about the skin or so because this is you need to make Yeah, I'm coming to this, causing the skin the principle here you want to go? You really may eliminate the dead space as I mentioned in the same suture in so you don't want to keep any space behind for hematoma to form and lead to infection. So the principle of any hip causes it has to be watertight. Closer. So you start with the fascia. Lata, you do a minimum suture we use. It's like one vicryl vicryl, because the fascia is ah has heightened salt strength. And if using any suture less than one vicryl, it will fail through the process of closing and even early following the closer. So you can. If there's also a lot of tension, you can put one interrupted suture in the middle to help you to bring the tissue across on. Following that, you can do nice, continuous suture. Or you could do a continuous with locking suture and you tired and and make sure you're applying the principle of secure not, ah, suture it. And it's just give you an answer for the question. Yeah, no, absolutely. I think it's it's good to you just have these things in areas where they might be able to assist. Now, obviously, the more junior they are, they may not be assisting as much in the hip, but in an ankle or a wrist. Certainly if they have the skills on when it comes to close and skin people might be given that opportunity. So I hear people go to courses and stuff for this. Uh, yeah, I think this is this this presentation Give them the principal's on the Their homework is to practice. You could practice missing disposable suture kids attending course is attending basic surgical skills. Course, but you need to develop that muscle memory. And this happens by practicing. Practicing, practicing. This is a question. Yep. Start. Sorry. There's a bit of it today. There are interrupted are saying there's a question there. Um, I've often seen ah, surgical statement use for wound closure. Are there any advantage to speed of using surgical state thing on? But when would statement you consider the most appropriate method of culture? Well, um, with the stabling, the advantage is what I want. And as you mentioned, the speed, um, also is nice to Evert. The skin ages notion of the skin edges. But I personally, during my training I never remember myself When they have the choice. I closed on Incan using stables. I My my choice always was almost always was. Ah, vertical mattress dropped it vertical mattress. And the reason for that? I know I can. Even the skin edges I used to be, Oh, it alone, which I know I'm not going to compromise. The blood supply depends on the quality of the skin. For example, if you have a lady on the steroids, she has very tense skin, very fragile skin. You'd be worried about using clips. And also, if you have a patient that has nickel allergy, that's one of the contraindications to use the clips and clips. Ideally for ah area when the skin is like good quality, you don't have any concern about the blood supply. You're not concerned about the ah measure issue with the infection and things like that. I think that's, uh, no harm fusing clips. But if you have an area with the poor blood supply, poor skin quality patient allergic to nickels, for example, the uh, the neurosurgeon and the spine surgeon they don't use the clips when they closed the spinal ones following surgery, and the reason for that if the patient developed neurological symptoms, so in surgery need MRI scan, the clips would be something like metal in the way to do MRI. So there's things to consider is not black and white, you know? Yeah, that's Ah, I have this accident. Uh, yeah, that. I think that's quite good. And these are little things that some of us are very stages may not think about. Is there anything left in the presentation or would you like more question number? Whether there's a few things, um, I haven't finished this few techniques. I want to show enough to that we can take more questions. No, because it's so This just I would maybe around this quickly is a continuous running suture. And the advantage of using such this kind of suture is you can't even the skin ages and also picking up the speed. So there's something nice you could use for Ah, ankle closer. Ah, ankle fracture. Closer or ah, you could use it for ah, wrist wound closer. That's reasonable option you could use. Um, so you start like a simple interrupted suture. So it's a bit and they're following that. You just, uh it's continuous like interrupted suture. But you make sure you had the skin edges. You entered the skin 90 degrees perpendicular to the skin surface. Then you carry on? Are we okay with time you're here? Uh, yeah. We should be okay for time. Yeah. I'll also remind everyone that, you know, But if you have colleagues that couldn't make it, this will be on catch up a swell. So you should be able to watch the video, uh, in your own time. Okay. So the only thing I want to highlight in this video if you notice what I'm doing with my forceps each time I using it to pull the suture this like, um, more appropriate way rather than keep handling the future with your hand and the ah spending more time so you can look what they do with the forceps in the left hand side. That's a good tip. I recommend you guys tried to do it. And sometimes in between, you can use your hand to just get appropriate attention. I did. If you have assistant, you should pass the future to him and he maintain this attention again. I'm using my, um, forceps to pull the searcher. You just diet, then done with this. So this importance, um, technique, especially for ah, course surgical trainee and and my experience, it take time for Ah, the courtroom Need to understand this technique. Um, so this technique using deep layer, simple interrupted suture on the idea of this technique you want to vary the suture? Not so how you do this by starting in your side. So I'm using Vicryl here. It's two. Oh, vicryl. It's cutting needle. That's common suture material used for such layer. So I'm starting on my side deep from inside outside and I'm going at the same level and other side from outside to inside. I put I pulled the searcher to try to save suture material. And now I will make you not now if you notice I'm pulling in the direction off the incision, which it does help to bring the edges together and following that would be just standard. Ah, trying. And by doing it this way, you buried the not which can be, um, source for infection. You know, if you have a superficial clot can cause irritation. Ah, stitch abscess, an infection. So that's a good way off. Doing deep interrupted, um, stitch and the, uh, recommend to watch this video one more time and the both ends if the suture has to come out in this in the one direction One side. I mean, if you once one end of the not in the right side and the other one in the left side and you're trying, you're not achieving deep. Ah, not will be actually super efficient to the loop. That that makes sense. So you need to make sure the both suture ends before you tie. They are sitting on the one side rather than each one in each side off the loop. Just the last, um, videos. This is just to show how you can, um, past the needle back safely to the Scribner's if you're in theater or dispose it in the sharp box. If you're doing simple wound the suture in and casualty or any So, uh, the first way in the here. I'm covering the tip of the needle, the shop tip. If they needed with the needle holder and I'm passive to the scrub nurse, that's safer. Unique. You making sure nobody could injured because you covered the tip of the needle the other way. If you want to dispose it by yourself to the sharp box you cut, the searcher was attached to the needle and you drop it to the sharp box. Okay, This slide is quite important in my experience the junior doctors and the medical student not aware off the same dosage off local anesthetic use. If you're anything working in casualties and you asked to post it your wound, you need to make sure you're familiar with the safe, those off different times, local anesthetic. And also you need to know how to calculate the door. So she come to it in the in secure questions. Um, so common local static. Use this little K improve a cane and the karaoke in this little paper cane. And is this different type of local anesthetic. There's rapid acting and the slow acting the so acting like vivacaine level of a cane, the maximum those for use this stuff to calculated kg. So you need to know roughly. Was the patient weight did the cane without That doesn't mean you can use up to 4.5 from the Grand Marquis. With adrenaline, you can use up to 7 mg, 7 mg higher. Those the reason for that You making sure it's not spread to the systematically and because of other knee causing Ah vascular construction is localized In one area with a cane, the safe there was a slightly smaller than the cane is 2.5 mg per kg with other any you can go up to 3 mg per kg. Cocaine is commonly used these days is um ah slow acting. Ah, local anesthetic and the same. Those is 2 mg Berkey. You can make sport to give the patient, um, pain relief when you're doing the procedure immediately by giving look a little pain and there would be overlapped by Levaquin which would work up to 6 to 8 up 6 to 8 hours. I'm not sure if you have time to talk about this. You should hear the hypertrophic scar and clothes car. What you think, um, if we can maybe somewhere out well, with the hard to summarize. But we could talk about it very briefly, where they could possibly see it on when to possibly recognize and escalate if they need to. Yeah, sure. So hypertrophic scar and colored scarf they are both complicate long term complication, off wound and wound healing. So the difference between hypertrophic scar from keloids car it's a cure the hepatic scar scar happened earlier than the old scar happened between 4 to 8 weeks following one. The infection, especially when the infection or the area has high hit with high tension and family happened following traumatic injury or traumatic wound would heal by secondary intention. Has the rapid growth for face devote quickly over a period of six months on Following that tend to gradually progress common areas for hypertrophic scar. It's, um, areas with high tension area like shoulder neck around the ankle around me and another hand keloids develop over a longer period and the persist it that does not regress spontaneously. Keloids car. Normally bulky, they expand beyond the initial scar surface. They can be tender, they can be, Ah, they can have shiny surface. And also you can see little vessels inside the scar. Like to inject Asia common areas for keloids scar, uh, upper limb on teary, a chest around the ear lobes and also is common. Certain ethnicity, like African be in now, which says you have fuel. I'm secure questions. And the reason I put this question, especially for local anesthetic to make you guys aware how to calculate calculate local anesthetic. Those the first question that inside strength of monocryl Lost in how many days? 15 to 20 days. Less than 10 days. 30 to 45 days, 60 to 80 days. Eso think about them. So you come back to it in a second. We don't have option to vote in the insulin. Afraid Ah, the second week in October that Yeah, Okay, people can answer the question in the chart. The second question. How many milligrams and 10 mills off 0.25% tear. Okay, that the question How many milligrams and 10 mills of 1% lidocaine. And the last question which the phone would suture Technique is appropriate for stitching face laceration. Do that. No answers yet. Uh, we'll go back to the third one. So we as explained before, there's a difference between the total time for suture material absorption and the time that the material Houston silence trend for monocryl can take a long time for monochromatic to be absorbed, especially if you use it for some particular. But it was that inside the strength which the strength the future provide too and support the wound. The correct answer. It's 15 to 20 days. So how how many milligrams in 10 mil off, you know, 100.25% Carrageenan. Can you answer this question here? Sorry. Can you answer this question? I answer. All right, How many? Million milligrams and 10 mil. 0.5. Uh, I would have thought. Answer number three. 25. Correct. Yes. So how you how you manage to work it out? Um, so I would have thought they'd be 100 mg and in 1% of 10. Mill on 0.25% of that would be 25. Yeah. So? So for each each. Mel. Um, you, um you have ah, and 2.5 and you multiply it by 10. It's like 25 to the gun. And And this one How many milligrams and 10 ml of 1% lidocaine. So the same principle. You have 1%. You have to mail. You must apply it. So, for each meal is for each meal you have 10 mg. You have 10 mg. Sorry. You have 10 meals would be 100 mg. 100. So how you work it out? You know the percentage you multiply it by 10. And after that you must apply it by a number of smells you have in the ankle. So this common I know it's my experience, a lot of junior's. They cannot work it out. So, for example, if you have ah ah, 20 mil off 1% lidocaine, you know, you have in your search engine your hand, 20 mg of lidocaine. And according to this safe those you can work out the maximum dose you can give to the patient. You don't want to ending with local anesthetic toxicity. Overdosing as you know, the pain is like a cardiac medication used for until right near which can cause cardiac arrest in serious complications. So it's important when you consider using local anesthetic, you are sure about the does you're using the safe maximum those you can use. And this I think, simple question. Everybody can answer. Um, the right answer is simple interrupted suture, and you want to take the future out of the face A. Really within 5 to 7 days. If you just continue a suture ng technique or vertical matters or her central matters, the one probably will heal. But this can lead to suture Mark, mark or ah future scarring, which is not the desirable, especially in sensitive area like face. Um, so in summary. Ah, try to learn and expand your knowledge about the common suture material. See news. Devote good surgical skills early, especially if you pursue Can Career in surgery is a good thing to develop good habits and good good skills early rather than start lending bad habits. And it would be difficult to, um, get red off. Remember the dosage of common local anesthetic in use and how to calculate them? And my advice. Everyone practice, practice, practice. Use disposable switch. Your kids practice with friends. There's a lot of materials, a lot of facilities, a lot of hospitals have skill. A lab on, um, under a postgraduate facilities. So, um, my experience All these places have, ah, future training kid and scootering facilities are recommended. We want to practice, practice and develop muscle memory so feel more comfortable with, come to structure a real wound or helping theater or ah, assistant Yater. You know, I second all that that was that was really, really good memory, and I think you'll be really useful for everyone. Toe have this available to them to job, their memory if they need to. Absolutely. About the dosage. Uh, I thought I agree. I think I for you, the presentation. And you I'm happy to forward it to everyone. Okay, So, uh, are you having off? Um, and you want to add from your side here? Uh, no, I think I think that that's absolutely fine. I I enjoy that. I was paying attention to some of the stuff because you see it quite a bit on. But I tried to add some snippets from my day to day life. Thank you so much. Mood. We really, really appreciate it on. But if there's nothing further will end here on the feedback form will be available in the chat. But also, if you are at the end of the lecture, you should be able to go straight to feedback as well. But I'll posted here again. Okay. Thank you. Thank you. Thank you. Thank you. No problem. Thank you. Thank you. You're still around them? Oh, Mr Bean. C go to the y