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Hello, good evening. Good afternoon. Good morning. Good day. Welcome to 2024 and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm the immediate past director of the Faculty and Surgical Trainers of the Royal College of Surgeons of Edinburgh. I'm a visiting professor at Imperial College, London and a retired cardiac surgeon currently living in Yorkshire in the United Kingdom. I'd like to thank you all for joining us this evening. We have 41 registrations from Venezuela to Zambia, Ukraine to Syria. Amongst the many other countries. We have 4240 followers on Facebook 700 on Instagram and 1196 on Twitter. We have some news before we start this evening. Is that our two sensors, Alice Cooper White in Irish Biology have both had abstracts accepted for the Association in Surgeons and Training conference in Bournemouth in April. This is outlining some of the philosophies of the Black Belt Academy of Surgical Skills. I'd also like to welcome as you would have seen on Facebook, Doctor Le Cabrera who is a vascular general surgeon who works at the Basque University in Bogota Colombia. He is president of the Future Surgeons Chapter of the Colombian Association of Surgery and is part of the American College of Surgeons Colombian Chapter board. And he was one of the first founders and mentors of the Association of Women Surgeons in the Colombian Chapter. He's an enthusiast for training and together we are going to be hosting a black belt academy at his hospital and I'll be there virtually later on in April. I've also been talking to Professor Alberto Ferreras of Argentina who is interested in what we're doing. I've shared with you a paper that we've had accepted for the journal of surgical education called Make a Stand. And that is partly the theme of this evening's presentation. Now I'm wearing my karate top and I'm going to acknowledge my son who wrote a very good speech for his sixth form on his knowledge of karate and its implications in daily life. And I was so impressed with this. I'm actually going to deliberately use some of his speech, but weave that in with a knowledge of karate and its application to surgery and to surgeons as well. And this is actually part of the book, The Way of The Surgeon, The Intersection of martial arts and Surgery, written by one of the senses, Malvin macklin, who is a professor of plastic surgery of Saint Louis in America. Now, karate means empty hand. And for many years as a surgeon I was palming instruments and spinning my scissors on my ring finger. Only to be called a bloody stupid cowboy by one of the scrub nurses at the London House hospital. Without an empty hand. You are at risk of catching sutures and causing harm and therefore an empty head is extremely useful. Now, karate is not about fancy kicks or punches or even self defense or just to tell you a secret in Ando, the best self defense and said by all trainers in self defense is to scream and run away because you don't know what your opponent can do. And the martial art we study in karate is wa which means way of peace. Now, karate is a way of thinking and an attitude to life. And I do it summarized by six principles. They are to persevere, to have self control, to have indomitable spirit, to have integrity, to be courteous and to be humble. And these are codes of conduct that actually reflect a way of life and they are shared in one way or another in most of the Dozier around the world. And summarized in this book, the wave of the surgeon and the simple Japanese word, Bohio. See, karate is not a sport like cricket or football or rugby. It's an art and it's an art that is studied and it's interesting that the Hippocratic Oath includes living an exemplary professional and personal life. Now, what the Black Belt Academy of Surgical skills about is focusing on those basic skills because as in everything, the basics need to be learned first, not because they're easy, but because there are the very foundations of the art. So the basic stances and positions that we have in karate are there for a good reason. And they've been handed down for generations and they taught and reinforced at every stage of your development when Mars Mars. But sadly, I don't think that they are reinforced or described in surgery and is naturally assumed. And I hope this evening that we can actually dispel some of those assumptions. My son reminded me that Buddhist said in our para phrase, nothing in the world is difficult. It's only your mind that perceives it that way. No s symbolizes the pristine white belt. That is the start of your journey. And she actually means empty mind devoid of preconceptions. And this is an attitude that I believe that we need to have throughout our career in surgery, the white belt denotes beginning to learn and the black belt beginning to understand. And when I think about that is only when I became a consultant that I really started to understand the art of surgery. There are no techniques left to be learned to black belt or a consultant level. The only basic techniques to be practiced and studied at that level. So as I progressed through the basics in martial arts from white bout, I was actually following videos and I could learn and see the motions and progressed without missing any of the graduations. But on reflection, I think I hurried it because my kicks are not as good as they ought. And if I went back, I would think I should have spent more time practicing my kicks and my chamber and getting my leg up to effect a proper k. So there's no rush whatsoever. The other thing is is that as we learn karate, every stance and every position is there to deliver a defense or a punch. And as if you understand the technique that becomes before power and speed, I reflect on my first operation doing kote bypass grafts. And the instruction was just be quick. I do not teach, be quick. I teach technique, accuracy and precision because we shouldn't be practicing it until we get it right. We should be practicing until we can't get it wrong. But part of this that I think is missing is understanding the set up the set up before you go into theater with the patients on the table and then the operation. But and the set up is to be summarized like cyst and diastole. The time it takes you and me to put a needle through a tissue is much the same. The time it takes me to take another stitch will be significantly shorter. And that's with the heart increasing rate. Systole stays the same by diastole shortens and understanding the technique properly and the set up and rehearsing that will naturally improve the flow of your operation. So during the series, we are going to be emphasizing this all the time because the technique also is there to understand how you hold the instruments and the instruments then become an extension of your hand and fingers and you can feel the tissues as Lloyd Barclay Mohan said, we want to caress the tissues and not be the mere cures of flesh. So despite 10 years of doing karate and 25 years of surgery, there's no way that I could call myself a master cos mastery is not a destination. It is a journey to be practiced with reflection, but it's also a journey that we helped in martial arts by, in surgery, by coach or a mentor. Ti is the human. We cannot expect to deliver 100% all the time. And I just saw on Twitter, if you're feeling off it from 40% and you deliver 40%. Well, that's 40% or 40% that's 100%. But what you do need to actually commit to in surgery it, to learn from your mistakes, to reflect and to commit to improving because in surgery, you're only as good as your last operation. What's interesting is the airline industry learns from its mistakes very quickly and the disaster at the Japanese airport has already been circulated throughout the airline industry and they do that and they learn from their mistakes. And it's important that you keep a diary of your mistakes, not to reflect on your errors, but reflect on where you can improve. And unfortunately in the UK, the data system which is there to document errors as a learning tool is being perverted and it's somewhat punitive. But I like Gary Clan statement at the Virginia Ma Medical Center. The more you polish, the more you shine. Now, I graduated first down in black belt five years ago and I continue to train and the grading consists of three hours of serious physical exercise. And only when you've last time I measured my weight dropped 7 lbs in sweat over the grading. Does the examination begin when you're physically and mentally exhausted? The questions are bombarded at you in Japanese. Do it? Fours go back, three, do two, fours. And when I think about it, this is not too dissimilar to doing an aortic dissection and being at the table for 20 hours. Because even when you're exhausted in the middle of the night, those individual stitches are extremely important and accuracy and precision on viable wet blotting paper, which is akin to an aortic dissection can mean the difference between a dry operation at the end and bleeding for hours and loss of transfusion. So therefore, to focus on your techniques and I think of the bad coronary vessels, I've stitched the point place, rotate that we will describe. And I have described before about stitching is enabling me to deconstruct and the stress. And that is my teacup thinking critically under pressure. And you can always rely on a good technique even if anatomy or physiology throws a curveball. Now, what's interesting in gradings? You are invited by the sensor because they anticipate that you are going to grade. And this is interesting concept because you're not set up to fail, you are set up to pass. In contrast to many of the examinations that we have and all of us have gone through where I know when we did the primary, it was a dismal pass rate of 40 to 50% to me. If you get the process right, the past should be automatic. There shouldn't be this arbitrary pass fail, but this is all about instilling confidence. And it's interesting that Chris and I have been to Black Belt Academy face to face training sessions and asked trainees to comment on the stitching. And the first thing that most people do is start to pick up on the bad aspects of what they've done. Bruce Lee said, be careful of the words you use because that would influence the mind. That is why it's called spelling. And what I'd ask you to do with all the exercises that we are going to set you during this course is look for what is good and practice that good because good, better, best, never let it rest until your good is better and your better is best success. And all life tribulations requires an endominal spirit. And it's not defined by how many times you fall, but how many times you get up? We must persevere through strenuous and it will be difficult, but you have to maintain self control. And it's interesting, I've noticed when doing things, if you start to rush, you make more mistakes. So the best thing to do, if you're uncertain, it just push your instruments down, take a deep breath, step back from the table, gather yourself and start again. Do not proceed with an operation. If you're in a state of anxiety, we must live with integrity and above all, we must be kind to everyone because we don't know what's happening and we don't walk in their shoes to be a surgeon, I think is the ultimate privilege. And what's interesting in martial arts, you bow to go into the mat and your bowel to sense and you bow to your spring partner because part of the ethos in martial arts is respect. And although I'm not asking you to bow when you go into theater, I'd like you to think about that gesture and you're bowing to the patient on the table who has put their trust in you to deliver your best. Because that sku is your indelible signature in a mark two. Whether you remember them or not, they will always remember you by looking at the scar. I remember what you said, what you did and more importantly how you made them feel. And that is the code of conduct. That is the the way of the surgeon. Above all, you cannot do the operation by yourself. As a cardiac surgeon, there are 12 other people in theater. I can't do a cardic operation without the other members of the team. You bow to your team and you learn and grow together and reflect in the briefing and debriefing. What did we do? Well, where can we do better? But above all, you need to be kind to yourself. You need to look after your physical as well as your mental state, nutrition, hydration and sleep, which to be sharp, you have to stay sharp and I liked the comparison between a surgeon and an athlete. There's very little difference in that comparison. So coming on to theater, one of the important elements is preparation en setup and surgeons often rush in to do the operation without thinking about the preparation and set up the preparation is your mindset. But preparation also with the team in the briefing to making sure that everybody understands what is going to go on and you can rehearse potential problems or discuss what are we going to do if this happens? But part of that preparation is to ensure that you have the right equipment. And we ask that briefing. But I wonder how many of you actually think about the positioning of the patient on the table. The airline pilot flying solo, the air own plane would offer walk around the plane and check the flaps and a Arons and the rods and check the XD of the pain. The surgeon needs to ensure the right patients on the table in the right position. And recall Peter Golds, who's an example, thoracic surgeon taking a lot of time to ensure the patient was in the right position for a thoracotomy that there were perpendicular on the table and the table was broke to enable that exposure. I reflect on all those years of training when I called the consultant into theater because I was having difficulty and the very simple things they did was change, the light change, the position made the incision bigger and voila it became easier, but we often forget about the set up. So the first course and the great ultimate in karate is called to and tou is the first car that we learn and it is reinforced throughout your training. Even through to third down where doing a grading you will be doing it 40 to 50 times at least sometimes 100 with a sense going around and deliberately pushing you and testing that you have got the dynamic tension. But have you thought about your own set up and the way you stand? And let's just try this for a moment. You do a number of things at home automatically and perhaps have not even thought about it. Firstly, when you go into the kitchen to cook, the kitchen counter is at a certain height, but I'd like you to suggest in the chat room, why it is that height? Can we have some answers please? To see if I can see the chat room here? Do you have any answers as to why the kitchen counter is that height? Not yet, not yet. Well, it is actually such that you can use your arms properly and appropriately, it reflects the functional anatomy of the upper limb. And I remember Professor Anderson in my first year of med school in 1980 delivering the anatomy lecture on the upper limb, talking about the functional anatomy, the counters there because that is the perfect height. But there's another activity that you do at home. Perhaps you would like to suggest where intuitively you set yourself up properly. Can anybody think what that is and put that in the chat room? Any responses Gabrielle? So no new responses. But we have some to your previous uh uh questions so that it allows the arms and elbows to move re joint mobility and the uh responses to your new question is that ergonomics, ergonomics? But what ergonomic thing are you doing at home naturally every time without thinking about it, any ideas, I'll bring the prop interview. Now, I hope many of you are ironing and you're not gonna iron up here. Neither are you gonna iron down there. You are naturally gonna set the ironing board up at a height that enables your shoulders to hang and relax. So, what I want you to do and this is an active participation. Now, I'd like you all to stand up. I'd like you to shrug your shoulders. I let them fall with your arms by your side, shrug your shoulders and let them fall. The important element of that is to recognize that the shoulder girdle actually hangs on the skeleton and is only held to the body by one joint. Anybody care to answer which joint that is. Come on, folks, we want a little bit of action here. So this the shoulder girdle includes the humerus and the scapula. All right. And the scapula, as you know, is triangular shaped, it sits on the rib cage and it's held there by 17 muscles. It essentially floats and moves forwards and backwards on the rib cage as the muscles glide over each other with a bursa underneath. And the glenohumeral joint is the shallowest synovial joint in the body. And that is enabling the shoulder to circumduct, but the whole shoulder girdle hangs on the skeleton by the chromia clavicular joint. And this is a plain synovial joint and the a chromium gives you the square shoulders and you can feel it. It is right there. And the chrom clavicular joint is the joint that suspends the shoulder girdle supported by three ligaments and the aponeurosis of the deltoid and treds actually interact with those and the coracoid acromial ligament then completes the joint and shears the shoulder because it is actually a shallow joint. But think about this and again, with you standing up, I want you to just hold your arms up in the air. And as soon as you hold your arm up in the air, you're rotating the scapula and those 17 muscles that hold the scapula are inaction. Now, I'm gonna keep them up there. I don't want you to keep them up there. And let's see how long we can keep her arms in the air as soon as you start using those major muscles. And I'd like you to start writing down in the chat room name all 17 muscles. And my fellow sense, Mr Cad is disqualified from doing this as a senior surgeon in and hand surgeon as well. But hold the scapular up there and hold your arms. You'll find that you're using major muscles, trapezius, Lamis, Dorsey, pectoralis, deltoid, all these muscles are in use. So it's not surprising that you're gonna start feeling fatigued, but also with the scapula fixed, you now got very limited movement of the arm, very limited indeed. Not only that we know that from studies that as soon as you start using those major muscles, fatigue comes in as well as tremor. So standing at the table shoulders down, really, your hands should be palmi fed and the elbows, slightly extended, slightly flexed with your fingers resting on the table. And it means that the table height is about the level of your anterior superior. I'll explain. Now, standing perfectly upright means that the plum line from temple, from ears through the shoulder, through the hips and the knees to your feet that is standing upright. And you'll notice in doing that, there's a lumbar lordosis and a cervical lordosis. When you're born, the thoracic curvature and the sacral curvature are the same as the sea. And I suppose that's why you can cradle and cuddle a baby. Three months when a child starts lifting their head, the cervical lordosis develops. And when they start walking, the lumbar lordosis develops further. And the reason why the spine is this s shape is to maintain stability when moving, but also enable us to support weight. Now, the biggest weight that you're going to be supporting when operating is your head and that's at 5 kg. So let's just look at this. There's my head standing upright, perfectly balanced on seven cervical vertebrae with abundance between the muscles of the sternomastoid and the trapezius and the shoulders are back. The problem is that when you go to 15 degrees, and I don't know if you've seen the thumb hand trick 30 degrees, 45 degrees, 60 degrees, 90 degrees is the hand rule for cosine and sine. If you haven't seen that before standing up, right head perfectly balanced as soon as you go to 15 degrees, your 5 kg head is akin to 12 kgs and then go to 30 degrees. That's akin to 18 kg. You go to 45 degrees that's akin to 22 kg and you go to 60 degrees. You are looking at 27 kg weight supported. So it's not surprising. There's a 27% musculoskeletal degeneration from poor posture in the surgery. And I'm interested to see there are new loops that are coming out fitted with prisms that enable you to maintain your proper stance with your chin in, without it slipping forward, without the shoulders rolling forward, without the loss of the lumbar lordosis and the anterior pelvic tilt, all of that is gonna have a detrimental effect and these loops, I've tried them. I'm very interesting cos you look straight, but you can see down the limit is in cardiac surgery is that I'm looking around all the time and I can't see the loops. And I was just wondering thinking of those Hova aircraft that have the jet jump jets that go from there to there, whether the loops could build in that. But I might be giving something away to loop manufacturers. But it's interesting that people are becoming more aware of musculoskeletal problems. But I think it's more than this, just the posture, understanding the functional anatomy of your upper limb and removing the gross movement of the major muscles will allow your hand to function to its best ability. Because if you take out the forearm muscles, the upper arm muscles and the shoulder girdle muscles, what you're left with are the intrinsic muscles of the hand. And this is what we're going to explore next week as we discuss how to hold the instruments in such a way that you can feel them and the instruments therefore become an extension of your hand and fingers. You will not be able to do that if you're operating, using the 17 muscle. I don't know Gabriel, how many muscles have been named for attachment to the scapular so far, six, six ladies and gentlemen, I think we can do better than six. And since you did your anatomy more recently than I did, we can aim for more before the end. But the important thing is to enable the optimal function of your hand and to feel the instruments, you have to understand the functional anatomy of the upper limb. And that standing a bit like it was probably you too young. A thunderbird's puppet, a string puppet like that. Now, the geometry that's involved in all of this is significant. And we have published that in our paper called Maker Stand because when I looked at all the photographs for basic surgical skills courses, advertising suturing of the 109 102 were sitting down and the displacement of the wrist from the elbow has a significant impact on the angle of which you mount the needle. And we will discuss that further. I think we are teaching basic skills wrong. We need to understand the techniques, the functional anatomy of the upper limb, how you stand, how you sit up, how you just table height. I do wonder how many of you were asked to operate, adjust the table height. Christie and I smile to each other when we set up ironing boards for the basic surgical skills courses that we run and we have people paired according to heights to move between the skill stations. And we stress this at the beginning to adjust the table height, but nobody does the first course. And great ultimate is not the obvious. It is all about how you set yourself up mentally, physically, the theater, the team, the patient, the operation, and you set yourself up for success. Thank you very much indeed, for your attention. Be very happy to take comments, questions from anyone. I do appreciate the learned responses from your all that practice, communication, teamwork and patience were at the top of your agenda. You also said good sleep and physical fitness were important and core muscles, plank squats are very good for physical fitness. You also put lightness of touch and good exposure at the top of the list. Although as a surgeon, you may not be in charge because who's in charge certainly in the cardiac theater depends on where you are in the operation. The scrub n counting, beginning and end the perfusionist, the anesthetist or the surgeon, the leadership of the operation is fluid and moves around theater according to the task and what needs to be done. But ultimately, you as the surgeon are responsible for the team, the patient and your actions throughout life and martial arts is a mindset and I hope you appreciate the parallel with surgery. Ok. Any questions from anybody? Not yet. Although I think there's a slight delay with the chat. So maybe like one minute for people to type their questions, but I've counted 17 muscles. I'm just trying to count if there's any of that that are repeated. But I think, I think we have 17, well done. I have to applaud. That's very good. 17 muscles, Mister K. I'm not sure if you got all 17 yourself, the Blackb Academy would not be possible without the support of metal and the production behind the scenes by Gabriel. She tells me it's minus 20 in Lithuania at present and she kindly supports a live broadcast every Monday. We look forward to seeing you next Monday where we will go through in detail, how best to hold the instruments that we frequently use and how best to get function from your hand. Thank you for joining the black belt and look forward to seeing you next week.