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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon and I'm a professor in the Medical Education Research and Development Unit at the Faculty of Medicine at the University of Malaya. We're coming to you live tonight from Kuala Lumpur and I'm assisted in production by Vanish who's 1/4 year medical student at the University of Malaya who wants to do cardiac survey. This would not be possible if it weren't for the platform of metal that allows us to reach across the globe. We have 56 registrants for this evening. I think 58 too short of the 4000 delegates who have registered so far over the past few years from 100 and 25 different countries. And tonight, there's no exception. We can literally go from A to Z Armenia, Australia, Gibraltar, Guatemala, Sudan, Sri Lanka, Uganda, UK USA United Arab, Emirates Venezuela, and Zimbabwe. Thank you very much for your support. If this is your first time. Welcome. And if you're returning, thank you and please pass the message on. Although you can't interact directly with the microphone, the chat room is open and venice will field all questions. No question is stupid and feel free to ask. This is your chance to learn and to ask questions. No. Today, the modern surgeon relies on a range of technology with ever changing equipment, laparoscopic diathermies, endoscopic. It's amazing yet the operation almost always begins with a scalpel whether it's for port big incision and small incision. And it's the profession's oldest intimate and the scalpel is an instrument for making precise incisions in the skin and tissues and organs of the body because it is sharp, it is small and it can be used on all variety of tissues. And that's why it is the most successful instrument. No blades were initially composed of flint. Jade or obsidian. Obsidian is volcanic glass and specific pieces were used because they shopped edges and they were used for cutting and refining tools and words. And indeed prehistoric blades have been found mounted on handles and one particular one was found in 1991 near the Austrian Italian border. And these ancient flints were used for scarification, venous section, lancing and circumcision. And in fact, many of these instruments were used by native tribes in South and North America. Up until the 19th century, the evidence of obsidian plates has been found going back 4000 BC in a prehistoric Anatolia in modern day Turkey. And these were used and demonstrated as being used for craniotomies. Metal blades soon replaced stone and copper was first used 3500 BC, followed by bronze 1400 BC. But it wasn't until 400 BC that the concept of the surgical knife was first described by none other than Hippocrates. And he called it a Maon, another smaller version of a Lado sword called Ara. And Ma Caron was a small instrument similar to the sword, which is a broad cutting blade with a single edge and a sharp point. And that is really almost the definition you'll find of what a scalpel is in. Rome Galen and Celsius used an instrument of the shape for incisions and drainage of abscesses, tendon repairs and VVI sections. In the modern era. Of course, steel and hardened alloys have replaced carbon steel, stainless steel with it chromium content being water resistant. And more recently, they have other additions to blades. Zirconium, diamond and polymer coatings to make it easier as for the modern blade that we see here in news that has its history in razor blades. And King Gillette founded the American Safety Razor Company back in 1901 and to produce blades and handle to make it easy to shave. And it was John Murphy, a surgeon and one of the founders of the American College of Surgeons, adapted the Gillette razor into a tool that could be used for performing surgical operations. But it wasn't until 1914 that Morgan Parker, a 22 year old engineer invented the two piece handle and blade such that the blade could be put on and taken off the handle and was held in a rigid position. According to legend was Mr Parker's uncle who is a New York surgeon, became very impatient with the process of blade exchange in his busy surgical practice. And Parker's elegant solution reveals his genius and he started with the patent for the purpose of securing blades to a handle. He had headed studs and handle to act with appropriate slots for the blade to sit on. Now, he wasn't a business man. So he looked through a book, phone book, an alphabetical order and came across medical supplies, Cr Bard. And together they formed the Bard Parker company, which became one of the iconic names in surgery for producing scalpels and scalpel blade handles. I'm not sure if they let the patent slip. But what came along after that was one Morton. Now, Swan Morton was founded in 1932 by Swan Morton and Fairweather two. And they too made razor blades and it wasn't until the 19 thirties that they started making the Swan Morton scalpels that we see today. And this was based in the heart of industrial Britain in Sheffield down the road from where I trained. And I've had the privilege of visiting the factory and they've got a small rather inconspicuous looking building in the center of Sheffield with 400 employees and they have their own Cobalt sterilization process there because of course, with steel, you can't get it wet. And what's interesting when they have to change the Cobalt, they shut down the roads and the military have to come in and support changing the radiation source. But they produce 1.3 million blades per day sending out across the world with more than 30 handles and 70 different types of individual blades exporting to over 100 and 10 countries. And that is the history of your scalpel blade and to go round the factory to see these people making the blade and the pride and care they put into it is astonishing. Now, what's interesting about the blade? And you might see it in the light. Then on one side, you see the blade on the edge glinting on the other side, you see the blade is smooth and on the other side, you see it is somewhat serrated and this is deliberate, the one, if the blade was smooth on both sides, it wouldn't give you that haptic feedback and feel it would be too sharp to do the job. What's interesting that obsidian, that original flint is still used in some of the instruments and blades that we use today before we make our incision, I want to share with you a important point and let me just present. Now, I don't know, this is a simple concept. The National Rifle association made a comment that the weight of the rifle should reflect the weight of the responsibility for the person holding the rifle in a similar manner. I would say the weight of the blade carries an even more profound responsibility because there's decisions before incisions, you have to have the, the right information, the right reason, the right time, the right mindset, the right side, the right equipment, the right team, the right position, the right grapes, the right landmarks. Everything has to be right before you make the incision. Because once you've made the incision, you can't go back up until that point. If something is not right, I would say not even the king of England could tell me to make that incision because once you've made that incision, it becomes your responsibility. And the right angles I'll explain is important. The right angle is the blade needs to be perpendicular to the tissues. So it's a clean cut and sharp dissection is clean dissection. And the important part of the whole process is this is done with feel you've got to be able to feel the blade. Now people often joke as a cardiac surgeon, you just do one operation. Indeed. But why don't you take a scalpel 22 centimeters down the sternum perfectly down the middle with zero wound infection. It doesn't happen just like that and it doesn't happen on a wing and a prayer. And we will come to this later on when we talk about wound infection, the first important thing is obviously, the scalpel is sharp and you don't just pass it around in theater. If you're passing the scalpel, it's best passed in a kidney dish and put in a kidney dish. But you have to pass it, please pass it with the handle first and the blade down. Such if you take it out of my hand, I'm not gonna be cut by the blade underneath since blade down, but preferably past in a kidney dish. So I'm gonna take you over the top to the table and go through some important principles. The first important principle is to understand how you take the blade on and off the scalpel. You'll see that there's a groove and a notch and to take it off, you simply lift it up out of the notch, put a hemostat on the blade on the blunt side with a firm grip and you literally slide it off. When you look at the blade handle and look at it closely. You'll see you've got the bevel, this sets in that odd shape that you see on the blade and my finger now is running in a groove around there and it's that groove in which the blade itself sits. So to put it on, let you find the groove, slide it on and bring it home. Note that my hands are sitting on the table and that the blade is pointing into the table. I've seen people waving the blader around and making it a two handed process when you do that, the likelihood of this flying off and causing damage increases. So please keep it pointing into the table and it's a one handed movement that doesn't require any force. The hemostat on the blunt side. There you go. Failure to adhere to safety in the black bot academy with mounting the blade is going to be considered a pass and fail. Respect the blade, respect the use, feel the weight of responsibility. So 90 degrees to achieve 90 degrees to the tissues, you need to hold the blade in a proper fashion. You hold the knife like a knife. The handle sits in the palm. I am holding the sagittal plane of 90 degrees between the thumb and my ring finger. My index finger is extended down the blade. This is giving me dissect direction and pro perception and note that the pulp of my finger there, thumb and the side of my finger here is enable me to feel and the incision is always deliberate. It's supported by your non dominant hand, providing traction, encountered traction. And it's a deliberate stroke through the tissue. At all stages, the blade should be perpendicular and you should not see the blade itself unless are rotated on the side. And if you rotate it like that, do you start to B and slice and that's not a clean cut. So if I'm doing this down here as I'm moving down, you should not see the blade unless I'm twisting it. The thing is is that when you've got a long incision and very few people do long incisions now because we're all going port. But I suppose orthopedic surgeons are doing it for joint replacements. Is that with a long incision, there's a tendency to turn and the blade starts bacon slicing. So once it gets beyond 10 centimeters, what happens is that you need to actually abduct the arm a bit to maintain that vein straight. Now, the reason why this is important in the bacon slicing is demonstrated here, I've taken a sponge and I get to make a clean cut in the sponge on this side. I've actually colored the edges either side and you can see when you've got a clean cut, the color is rather thin and a nice clean line on this side. I bacon slice and been rugged and you can see the blue is actually spilling out. So if I actually take my pen and color this edge to demonstrate a clean cut, there you go. You can't see that cut and a sharp dissection is pain dissection. So one of the things I did and looked at with my sternal wound I removed, using diathermy. The problem is that people given a big blade one, they hesitate to go through each layer of the skin cut, cut, cut, cut and scratch. And as soon as they go through the skin, then pick up the diaphragm and use full duration of the tissues with smoke, which is carcinogenic energy transfer to the tissues, which is burning the tissues. And in fact, a surgeon in Midwest America use the knife only to the sternum and reduced overall when infection by more than a half because clean dissection is sharp dissection. So uh I thought was interesting that one of the answers to the questions was swift, movement is not swift movement. It's technique before power and speed. But when I was opening the sternum, I take a knife all the way through the tissues down to the sternum. Why? Because I was confident I was in the right plane. So I'm going to just demonstrate something to you. Now about the principle of incisions and I'm using a whiteboard here and I've draped up, OK. I'm gonna use my red pen as my knife. OK? And if I thought without thinking about it that I'm parallel to the two lines and I make a cut raw, always fill for your bony landmarks. OK? Bony landmarks. So no matter what size the person is, is the bony landmarks are the most reliable and therefore I cut is down the middle. So that might look completely off. Let us have a look and there you have it. OK? Do not be fooled by the drapes. Now, the other thing just to demonstrate this point of turning, that is down the middle. Ok. Cos that's feeling the edges of the board as I would bony landmarks. So 10 centimeters is fairly good to keep when I go beyond that. If I don't abduct the arm, I find that that happens to the wound. Whereas if I AUC the arm to keep myself going straight, I can keep a straight line. And that's what happens with incisions that are more than 10 centimeters. Right. So the next thing is we understand the burning landmarks only understand 90 degrees. So how do we practice that simple? I've got an orange. You can take any fruit and what I want to practice here with a blade. He's taking this blade through the skin of this orange and feeling my way chew the skin not too much and get a feel. It's very tough and there's a tendency to perhaps overdo it and put too much pressure on it. But the important thing is you got a feel. Now I've made a cut in that I'm gonna squeeze this orange over white plate to see if I got any juice. If I have juice, then I have actually cut into the flesh underneath. OK. And let's have a look. OK. And I think my fingernail went into that. But I think you can agree that I have not cut through that flesh at all. I've cut down through the skin. Now, what's important with this exercise is that I have can demonstrate as I look down this orange, I can see that my blade has been perpendicular all the way. OK? I can see there's been a clean cut. It's very easy. That's called a bacon slice. OK? And it's very easy to bake and slice true tissue. And simply using the orange, you're getting a feel of the thickness and you also can look and see how perpendicular your cut has actually been. Take that little bit out. We'll come back to using the full length of the incision. OK. That is vitally important. The difficulty then is how to remove a small lesion. Let's say this is a lesion on the skin. In this circumstance, the Barron blade is a bit like a pencil if you see this is octagonal shape, a bit like an HB pencil with a 15 blade mountain on it. But the hold is now different. The hold enables me to maintain that 90 degrees throughout a fusiform incision. And again, I can practice feeling keeping the blade perpendicular on this fusiform incision. So one of our regular viewers said, why isn't it in Ellipse? It is not in Ellipse because the ends are not rounded. OK. So I'm going to get a pair of forceps, see if I can lift, take that out. And again, I want to see that I've taken its full thickness out that I've kept perpendicular through the skin all the way round as a fusiform incision. And the reason why you make the fusiform incision longer than the diameter is. Now, you can see that that is going to be pulled back together and you would stitch one there, one there towards the middle, taking the tension and you have a perfect incision. Langer was an anatomist in Austria who described Langer's lines and he noted that using an ice pick on corpse, going around with an ice pick and making holes and corpses, some of them stayed open and some of them closed. And in doing so recognize what we describe as the Langen lines. And to achieve a good incision, want to consider the line as lines. Each time you cross a line, the healing is going to be more scarred. We cannot leave our banana out of our food exercise. And here we got the banana again. When do you change the blade? Well, I've used that twice on an orange and it's very likely now to be blunt. So you changed the blade when it is blunt. And gentlemen who shave, you don't shave with a blunt blade cos it actually hurts your face in the same way that you'll find that the blade will be uncomfortable to use if it is blunt. So change the blade wherever you feel it is bland try on a banana. Can you make an incision without cutting the flesh, feel the blade through? And there I noted I bacon sliced, but I wanting to actually take this out and demonstrate to you that hello, I have not cut the banana underneath. You can see a thin line where my incision is, but there's no incision in the flesh underneath. And this is the important element of dissection is being able to feel and understand the depth of the blade. So how can we do that? Well, I have actually got here some ham thinly sliced from the delicate ham beef, whatever. And I've got a number of slices here. All right. And the idea here is that I need to be able to feel my blade. I'm gonna change a blade again through each of these layers and feel it one at a time supporting my incision and feeling it. Shall we see? It's the fun thing about live TV. Have I cut it underneath? I haven't cut it, but I've got a slight mark there and slight mark there. All right. Let's try again, feel, feel it through the tissues and I'm not pressing hard at all. And it's interesting using my kana. And every week I go training with a container and blade that the sensor says lighten your touch, relax. OK. There you go. No cat. So don't worry, this is sustainable surgery. I got some decent ham because I fancied a ham and cheese sandwich later. So that is how about can I now cut two layers? Good point. Shall we try? Those are the two layers I am going to try and cut and feel my way through two layers. How have we done one? There's one layer. Not quite, I went through two there in there but I am through two. There you go. Not all the way, but I have gone through two but I haven't cut the third. Yeah. So this is one way of teaching you to feel your blade once you got down to the last layer, which is on a slice of bread again, can you actually cut for ham without cutting this slice of bread underneath like that? And I haven't cut the slice of bread. These simple exercises are there to enable you to practice the feel of the blade. And I would like to hear from you what sort of incisions and material you have used. I previously made a pasta cake layers of lasagna pasta cooked and I colored them differently and cut through layers of pasta again, a challenging exercise. And I'd ask you to think of novel ones yourself. Now, one of the exercises I use for coronary artery stitching is a poach dig. This is dried out a little bit. I'm afraid a poached egg. And I asked the surgeon with a 15 blade to make a small arteriotomy across the top. See the membrane, all right, then split it. But you want to practice and feel cos it dried out. You wanna feel the blade and actually feeling that I think that feels rather blunt. It surprises me but try on every surface to make an incision just through the membrane because this has dried out, it is separating. But if it's a fresh egg cut through the membrane without covering the yolk underneath, again, this is giving you a feel of the tissue and it's that feel that is vitally important. So, lastly is the blade is used for dissecting tissue planes. And in this circumstance, again, you need a sharp knife, but I'm gonna change the handling of the blade. Now, I'm going to put it across my fingers and they're gonna use the blade and brush literally using the flat of the blade as a woo a brush against the tissues to develop a wide tissue plane. And one of the useful things to use, and you see in cooking skills, they always look for knife skills. And what I want to be able to do is brush this blade against this edge and develop and see if I can take the skin off without the flesh. Once you start it, it becomes easier. And of course, in this circumstance, there is a way you need a good assistant to maintain traction over a broad field, so you can use your blade appropriately. But note that I'm brushing the blade against the edge. All right, I'm not cutting into like that. I'm not cutting in to the space between the skin and the flesh. I am literally brushing my blade against the skin. And as you get used to the idea, you can be kind of vigorous in doing this. And it's a neat way of developing a tissue plane over with a second assistant holding traction on this and have a larger area to brush, I guess. And it, it literally is doing that against the surface or if I use the pallet knife, that's the plane I'm in, it's in the plane on the skin. And this is enabling me to develop this layer. So if you are cooking fish for supper, and again, this is not gonna be wasted. You will be getting back in the fridge. I we got sterol scalpels and I'll go back in the fridge and can be used tomorrow. And I would say my blade is getting somewhat blunt and let me try 10 blade and I have to thank Swan Morton for sending me a consignment of blades. And Chris fellow was recently over in Kuala Lumpur and he visited the Swan Morton factory and brought with him a fresh consignment of 2215 and 11 blades. You get the message and really, I should be preserving the flesh and have very little in the way of salmon on the skin itself. Simple, easy at home dissection technique. The last thing to cover is the 11 blade. Now the 11 blade you can see is really sharp and stabbing and that's what it's used for a sharp stabbing incision, ok? This is not as 16 of you replied used for dissection. We don't use the point for dissection that's for scratching. You might want to do some fine work, but most of the work of a blade is done on the belly. That is where the cutting happens. This is lancing and the lancing. You don't want to just stab it in like that because it can cause damage, severe damage. You got to be able to control your stab and to control your stab is put the blade against the pulp of the finger again. And the depth is determined by how much of the blade you cover. So that is the banana skin there. All right. And I want to just stick it through the banana skin there. OK. And I'm not into the flesh underneath. I'll zoom in on that to show how you can control the depth of your incision. Yeah. OK. I'm through the banana skin, but I'm not into the flesh. All right. And that you can see there is the thickness, I can't push it in any further. And it's that technique that I used for making the arteriotomy in the aorta. For cannulation. I gently scraped the adventitia, hold it with a pair of forceps in a controlled manner. Insinuate the blade into the aorta, hold the avent tissue over the hole and then insert the canyon. One last thing going back to my board is to describe the principles of incision. So if we take the red line there as an incision. OK. Then you've got adipose tissue underneath. Yeah. And let's put another couple of layers underneath that and the layer again underneath that, OK. What usually happens when people are making an incision? They don't use the full edge so they'll start off the incision from there to there. And then the next incision will be from there onwards and the next layer would be from their onwards. And if you note that what's actually happened is that from a big incision up here, I've now got a smaller and smaller incision and that's what I've left with. So the idea behind an incision is that is your first incision through the skin? OK. And remember the skin can move over tissues, your next layer, that is the incision and then through your muscle layer, that is an incision. And note now that my incision rather being focused and giving me this is now giving me that. So if you look at the length of the black line here compared to the length of the black line here, when we started off with a similar incision on both sides, and we've got something three times longer. And this is important. And certainly when I was training, we did open appendicectomy, I could get an appendix out within a two inch incision because the layers underneath were actually longer and the skin moved over and allowed me great rhexis. And remember the important thing is that wounds heal from side to side, not end to end and making sure that you're perpendicular through the tissue that you're clean, non cauterized, burnt piece of tissue is going to heal or not better. So this is where we say clean dissection is, in fact, sharp dissection. What you need to do is you need to become comfortable using the blade. I've often found trainees reticent using a 22 blade. In fact, one of my first trainers, Mr William Frederick WWD, he was like Zoro with a 22 blade. He could do a gastrectomy in 20 minutes and open up a redo abdomen. His confidence wielding the knife was something to behold. And it's quite interesting that the instruction that I get wielding a katana, which of course is 1.5 meters long again, raise the shark. But the direction the cut is absolutely described, prescribed and meticulous. And it strikes me as odd when I first got my Fr CS exam and started in bath. They said, here's a knife, there's an operating list. You obviously know your anatomy because you've got your primary Frcs and off you go. Interesting God. But Mr Southwold said, when I asked if I could do a Ramsay procedure or to a mastectomy, he said, I'm gonna teach you how to hold the knife. You hold a knife like a knife. As I've demonstrated with a blade in the palm index finger down, supporting the sagittal plane. He wouldn't let me do a pediatric operation until I could cut perfectly perpendicular to do a mastectomy. I needed to learn to brush and developed the planes using a 22 blade. Basic skills are important and it's attention to those basics that are going to help you with surgery in the future. So whether it's a small incision or a big incision, please, wounds heal from side to side. So, Venice, do we have any questions? 01 thing I must point out this Swan Morton gave me this great disposable blade. Look at this, put the blade in, laid off. Isn't this wonderful? It's like posting letters in laid off. Isn't this an innovative company that has the ability to actually produce played off? Fantastic safety is paramount. I love it. It's not gonna take that blade I'm afraid, but it'll take the 11 blade as well. Emla off. Thank you very much. One Moreton for that lovely bit of kit. It's called the blade flask. You don't have to worry about taking it on and off. So, ish any questions from our audience, please? Uh Yes, there is one question from Sophia. Uh She asked, what do you mean by the wound heals from side to side and not end to end? Very simply this, the wound healing is from side to side. It doesn't heal from end to end. So if you got the wound, teenagers like that, all right, clean perpendicular edges, beautifully put together, they are going to heal because there's minimum space and your respect of the tissues. OK. The other thing is that people often find with a small incision when you put a retractor in it and it's in for a long time that the edges, the ends of the wound. If I go back to my diagram here. OK. So that's the end of the wound. And I've got a retractor in what happens over time with a retractor in. You've got this area here of tension and ischemia. And this often also happens in port surgery. You make a small little incision you put, there you go, small little incision, you put a retractor in and hold it at the end or at the end of the wound, you have caused a lot of tension and ischemia on that wound, the wound heals from side to side. There also used to be an old saying, correct me if I'm wrong and it is probably generational is the smaller the incision, the bigger the mistake. Now what's interesting is laparoscopic surgery and I do wonder and I have not debates conversations with colleagues. What happens if you're doing a laparoscopic operation and you make a mistake and you need to open. Do you call a team that can open? Should we have an opening team or should all laparoscopic surgeons have a fundamental basic surgical skills to my mind. I think you need to have fundamental basic surgical skills. And see Jack has asked, how often do you recommend practicing blade skills throughout medical school? Well, the simple question is, I don't know if you play sport, Jack, the more you practice, the better you become. The important thing is that I hope that I've demonstrated this evening. It is the feel and appreciation of the blade going through different depths that is important and that will give you confidence, you know, when to put a bold cut in. And I been doing a Steny would go bold cut straight to the skin down to the sternum through that amount of tissue perfectly down the middle and then pinpoint diathermy to pick up the bleeding edges. But what it meant was at the end of the operation, the tissue looked rather fresh and because it looked fresh and I hadn't dithered or cauterized the tissue, it healed very well from side to side. Try these skills, try anything with the skin on small, large. The important thing is to feel. So get to a scalpel, get some blades. Remember they go blunt and do not hesitate to say, could I have a fresh blank, please? And in fact, some would say having cut through the skin, you should change your blade anyway. Not only because you've cut through thick skin and perhaps blunted the blade, but you have gone through scan, which we know despite preparation and chlorhexidine would be covering caring and bugs. So the purists would say change your blade once you inside as well for that reason. But also because it's blunt. So any other questions from anybody? Yes, there is one question from uh Rinku. She asked, can you not mark the skin incision before the drape? Yes, indeed. And in fact, the plastic surgeons often do that. And the little saying is think before you ink, which I like the important thing to remember when marking the skin, make sure you've got the right side. I have a little story there. I was doing a herniotomy on a little boy of three and I'd been on the Sunday evening to go and consent the patient for the operation. The next day, the anesthetist was there looking at the notes that the other ran. But parents, we're at the bedside. I didn't interrupt the anesthetist chatted the parents like many hernias and kids. They're not obviously a parent. So I asked the parents which side is the hernia. And they said left side, I said left side, I said, yes, it's the left side and I marked the left side and drew an arrow on the leg. I said this side, left side and on the consent form said left side, got to theater. I opened up the left side and thought this is strange. I can't find any hernia sac. And obviously in kids, you're looking at something that is really, really thin, but it wasn't a hernia sac at which point they need to just said are you sure you've got the right side? I said yes, because I spoke to the parents, I marked the skin, they consented to the left. I asked them which side they affirmed it was the left. He said, well, actually it's the right. So I called the parents to theater to say, I've explored the left as we discussed and there's no hernia there. Which side is the hernia? Oh They said it's the right important lesson. There is no matter what the patient said. Look at the notes beforehand. So right, information on the right side for the right reasons is vitally important incisions before decisions. So when marking do remember that some of the inks, if you cut through them will actually tattoo the skin. And the last thing you want to do is leave the patient with a tattoo, talk about an indelible signature and you got to remember that your signature is the wound. So I had one of my trainees did an operation C 56 for me fusion on my neck. All right, you can see a little white line, neck, not bad. OK. There's a little white line, but in fact, this side is more prominent than this side because he didn't quite get the Langer's lines. But quite frankly, that was not bad. And if you think that your incision and the scar is your indelible signature, so you might have done 100s and 100s and 100s of operations, you'll never remember the patient and unfortunately, we always remember the errors and mistakes, but the patient will look at that scar and remember you what you said what you did and how you made them feel. That is why I called your incision and scar your indelible signature on the patient for life. Think about it. Thank you very much indeed, for joining the Blackboard Academy Venice. Do we have any other questions? Prof there are no questions, but I just have one question. Of course, I am. Firstly, is uh how uh how likely do you hold the blade? And secondly, if you were to put an extra pressure on the blade to cut deeper, for example, uh would you use your arm or the wrist to help with this? No, really? Because I'm standing properly. All right, my arms in this position. As you said previously, you don't need any force at all. How I'm holding the blade is with the lightest of touches. And it's interesting when I was doing some practice on my sixth car on Sunday, which is imagining somebody in front of you, two people in front, one behind. There are movements and striking with the blade, stabbing with a blade with drawing the blade on the same plane, taking it up on the same plane and straight down the other side. What the sense here was saying to me in moving with a blade, he said, relax your elbows, relax your shoulders, do not hold the blade and this is 1.5 m. A blade, relax the shoulders, relax the elbows, relax the hands and the blade. The weight that you need is no more to be honest than the weight of the forearm. But this is, I can't tell you how much this is what depends on your body shape and habits. You need to actually take the blade with the lightest of touches between your fingers. All right, feel the blade as an extension of your fingers and feel and get to learn to feel the blade going through different layers. Can you take a stack of sliced ham, sliced beef and cut one layer at a time? And once you've done that, can you do two without cutting the third? Can you put, as I demonstrated a slice of bread there, cut through the ham without cutting the bread. Underneath. All these simple things is teaching you to feel the blade and to feel you're going through the different layers. And only once you've done that, I believe that you will gain confidence using the blade. So whether it is big, whether it is small, the amount of pressure you put on that edge is exactly the same. You use big for bigger areas, smaller blades, for smaller areas, but the field is exactly the same do not grip the braid. One last thing about film, I said that I did a coronary artery bypass graft on a patient who has hepatitis C positive was a young man and therefore needed radial arteries and internal mammary artery, the registrar who is helping me and as the senior register at the time, decided to double glove. Now I asked this person where they used to wearing a double glove and actually, if you double glove, you put the big one on first and then the smaller size on afterwards. No, he did not regularly double glove. And I said, please, I don't want you to double glove cos you're not going to be able to feel the blade. He ignored me. So I continued with the meeny open the chest and then I heard they made, I said yes. And I looked up and what this individual had done with a 22 blade is gone straight through the skin, straight through the radial artery and I had hepatitis C arterial blood spurting all over the place. Why? Because he couldn't feel the blade going through the tissues, maybe didn't practice, but I would say double gloved and lost that sensation. I was not impressed. Any other questions. Uh There are no more questions for. Well, I would like to thank you very much indeed for joining the blackout academy. Thank you, Vin for fielding the questions. Thank you for joining. Please fill in the feedback form. I look forward to seeing you next week where we're going to use the other instrument for sharp dissection, the scissors. Thank you. And have a good week.