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Hello. Good evening. Good day. Good morning. Good night. Wherever you are in the world, we have people joining us from across the globe and thank you very much indeed. For joining the Black Belt Academy of Surgical Skills. If you're returning, thank you very much. And if this is your first time, welcome. I do need to see a special greeting to two colleagues. Mr. Christopher, Caddy is a plastic surgeon in Sheffield and a fellow sensei at the Black Belt Academy of Surgical Skills. And my guru and mentor. I shall cherien, who's 35 years in cardiac surgery. And I refer to him as Yoda because the forces strong with him this evening. We're going to talk about skin deep. But in keeping with the Black Belt Academy, I would like to share with you some of the philosophies of martial arts because I do believe they applied to surgery. And this is from the Book of Five Rings, a classic text on the Japanese way of the sword. Buy me a mutual Musashi, an undefeated samurai warrior from 16 43 in the practice of every way of life in every kind of work there is a state of mind called that of the deviant, even if you strive diligently on your chosen path day after day. If your heart is not in accord with it, then even if you think you are a good path from the point of view of the straight and true, this is not a genuine path. If you do not pursue a genuine path to it's confirmation, then a little bit of crookedness in the mind will return into a major war. Reflect on this so Miyamoto Machar, she writes five scrolls. Earth, Water, Fire and Wind and the fifth is Emptiness Scroll, and the reason for the scroll is entitled. Emptiness is that once we speak of emptiness, we can no longer define the inner deaths in terms of the surface entryway, having entertain the principal one, the patches from the principal. Thus one has spontaneous independence in the science of martial arts and naturally attains marvels to signing the rhythm. When the time comes when strikes spontaneously and naturally scores. I do love the bit of deviating from straight and true and the crookedness of the mind and a major warp because deviating from the straight and true and crookedness of the mind result in poor scars. And the first thing to say is that the scar is your indelible signature on the patient for the rest of their life. You may never remember the patient. You may indeed not remember the operation, but every single time the patient looks in the mirror looks at the scar. They'll remember what she said, what she did and how you made them feel. And therefore, I feel it is important to take pride in your scar because it's your signature and your mark and by way of fun, I just want to show you two marks for me. And this is sandy job. I'll try and align myself. And this is fun with the there. San Gym is a plastic surgeon. He took off some certain characteristics of my eyebrow. Yeah, and another scar. And this is not me showing off scars but highlighting an important point. You might see a pale white line on my neck there where I had fusion of C five and six and Jake Timothy, a neurosurgeon and meat was my trainee and he left me with that Jake, you can be proud. That is wonderful, and I'm pleased I taught you properly. I did joke with him beforehand that if I get a wound infection, I am going to see you. But indeed, I reduced my wind infection to a medium of zero for the past nine years because we introduced the tissue care bundle that respected the bundle of physiological factors that improve wound healing. And we're going to go through some of these as we talk about how to close this evening. I was delighted to see on Instagram not instagram LinkedIn, the banana being used as a model for surgery on a three D exercise of remote robotic surgery across the Atlantic. And they cut Institute of Banana and again on LinkedIn. I was concerned that a person had written some comment about closing and tap in the clock, and I do worry that when it comes to closing time, people think it's coffee time. Leave the most junior person to leave clothes, the wound and everybody is tapping their watches. Not that you should wear one in the theater asking you to hurry up fundamentally. That is wrong. So let's just come over the top and look at some of the basic principles. And I've used the banana in this case. So, uh, what I'd like to point out is the different problems and errors that you see with stitching. First of all, one at all times. Your stitch should be 90 degrees across what you want to stitch and 90 degrees into what you stitch. But what we should see is that the stitch on either side should be aqua distant, and in this case they're in There is a difference. And number two, we need to remember the lag zone of healing is within five millimeters to seven millimeters either side of the wind and in this case, that's too small. Bite here I interrupted. Suture obviously is too loose and comes undone. But in taking I/O of the skin, the bananas told me that I have actually drag it in and drag it out. In this situation, I make the distant and if anything, I'm slightly skew if and not parallel perpendicular to the edges. But the opposition is clean and the entry and exit is clean as well. But I wouldn't give myself 10 out of 10 here. Quite obviously I have come in and gone out died only across the wound. And that is poor. It needs to be, as this line shows perpendicular now, simple interrupted sutures, I believe, give you been clean and potentially dirty and dirty wounds. The best results, but sometimes vertical mattresses and horizontal mattresses are used to get that slightly version. But here you can see I have done a vertical mattress and look at all the blackening of the banana. I'm going to cut the future around and put it out to show you that mattress sutures, strangulate tissue and you can see the mark of the center on there. Here is a horizontal mattress suture, and it highlights another important issue, not turn frequently. The skin edges are not sitting together, and you see this overlap in cramping as well. That is not good, that is poor, and the horizontal mattress seizure itself will cut this out. Likewise, strangulates the tissue and the horizontal mattress suture like that is very good for bringing solid organs together. What it does is Evert the edges, whereas you want a little hit look so you don't see the full thickness of the skin. But the two edges are brought together in a relaxed fashion and not under tension. So the next principle of your seizures is how far apart do you put them? Well, the depth, I believe, is dictated by the size of the needle and the diamond of the needle. So if I put a four Oh, here you can see that the diameter of that needle is reflected in the depth from the edge, and I'm taking 90 degrees in in 90 degrees. Out mathematically is recommended. The space between your seizures should be half of that. So the space between the seizures is almost the diameter of the needle itself. And in a horizontal clean wounds like this bearing your mind 90 degrees across what you want to stitch 90 degrees into what you want to stitch The alignment of the needle is fairly straightforward. However, as soon as you have any irregular wound, then one has to think about how we put this together because we can't start at one end and think that it's all going to fit together keenly. The best thing to do in this circumstance is start in the middle, align it correctly. Remember that the vector is 90 degrees to the edge at each part. So the vector is different there, there and there because your needle alignment snack two degrees and you start having it and having it again. Of course, if you have excised lesion, one can't take your needle through both sides at the same time and autumn frequently. I see people take a needle in through this edge and in the same needle, force it through the other side. But the alignment is different, and 90 degrees across the edge is different as well. And you start from either side adhering to your 90 degrees and placement. So what does that mean? When it comes to tissue, we'll come back to our banana because the banana, as you see here, is totally and utterly an unforgiving. And the best banana stitching I saw was from Charlie s and Sienna, who put together a beautiful, continuous road of searches on a banana skin. So there you go. My challenge to you is you sent me pictures of your stitching of banana skin and the winner will get their own set of instruments to do that. How about borrowing some instruments? Please don't steal know from theater to do this exercise. So let's come on down to how we close the skin Now. Closing the skin itself is not going to do well unless you close the deep tissues. So here I have an incision that is going through many layers, and it reminds me of the most difficult decision to close as an open thoracotomy because you're going through many layers. And if you don't line up properly, you end up with a big watcher tissue, particularly the back that the patient is going to be sitting up against leaning against and the important thing with deep tissues. Same thing remembering your suture. I/O. Principals have to be adhered to and opposition, not strangulation. The important thing with all your deep seizures is to bury their not particularly if it's a monofilament. The not will end up sticking through the skin and causing problems, so please bury that and attention to detail. Closing the layers will make your skin closure a lot easier, and again do it in two rather than a couple couple couple in one, and you're bringing the two edges together without strangulation because this continuous stitch is hemostatic. But obviously, with a Dema physiology of healing, the stitch will become tighter, and it's true with every continuous stitch that you do. So bring it together without strangulating as you see there. So let's look at a simple interrupted suture, then simple, interrupted suture is literally as it says, and I can for regular wounds straight like that. What we're doing is taking a needle I/O, attending to the alignment, bearing in mind that your forceps are dangerous instruments, and I'm using these two forceps not to grab but to reflect the skin. My plastic surgical colleague would use a skin hook to lift the skin on both sides. The hook that I use on a tooth and forceps is much the same, and then interrupted sutures. One end is short to throws around your instrument, holding that end. Excuse me, hold it flat. Pull it across one side to cross the not to hold it, and then you can complete the number of throws. And what one should see is an IV version of the edges without any tension. How long do you cut them? Short enough, such that they don't interfere with the neighboring stitch, but long enough, such that your son does not come and done. Why do we put stitches or to one side? It's to help you remove them. Basically, one needs to lift it up gently and cut it so you reduce the suture material that's on the outside being dragged to the wound and see that the naturally version occurring. Now where do you make the incision well wound healing starts with 90 degrees to the skin with your incision, but also importantly with Lange's lines now. Lana was an anatomist in Austria, living between 18 19 and 18 97 and he took around ice pick like terror and went around cadavers and put holes in the skin and noted that some remained round and some went elliptical and went diligently over the whole body and described Lantus lions and the Lantus lines of the natural orientation of the collagen fibers of the skin. And he attributed to this to Baron Do Pegatron, who first described but longer, described it in detail. You can see that by holding the skin and stretching it either way to see how it falls and sits and is Crystal, who described it in more detail on living tissue and described it on the face, and he talked about maximal tension of the skin. So what you do if you've exercised a wound and you have a fusiform excision? And in that case, the best thing is to start from either side and work to the middle. And I've left this stitch in here because it's an example of a bag stitch because the edge of this wound has been folded and see that fold that is not good, and I would therefore recommend you cut that suture out and do it again. I don't use mattress sutures or vertical sutures to close the skin, but let's just show you what it entails anyway because it sometimes it might be helpful to achieve the version. So we'll come back to the main incision, so vertical mattress suture is useful for closing a deeper layer. We start off a centimeter or more from the edge, come across directly opposite for the same distance, and then you come back the same way. But this time you pick up the skin edge itself. There's a small bite both sides, and there's quite a nice way to start an IV version. But remember the banana? It did cause strangulation, but it is useful when there's a lot of deep tissue. What about traumatic wounds? One would see after a trauma road traffic accidents, etcetera. How do we close them? And the answer is carefully to remove or the debris foreign material, actually for glass and foreign material. But in this circumstance, we've got a zigzag wound and not only a zigzag wound, but this area here. The skin itself has been bacon sliced. See? It is thin. And at the micro left, the skin needs a blood supply. When the wound is jagged like this these corners all those tempting to stitch that corner to that corner. That corner is at risk because the blood supply has been compromised. Stitch either side it. This bacon sliced bit of skin here will not hold a stitch in the cruise. Do not stitch that, but use the same principles of taking your searches edges together and having the distances between each to get perfect alignment. Remember, a good blood supply is necessary. So caution for those areas of the body where the blood supply is poor, like the anterior tibia. I've seen an 86 year old lady die of a cat scratch to tibia that had a lacerated skin like this and became infected and dirty. The knowledge of Lantus lines knowledge of the blood supply is important systemic factors, as you've already highlighted in answering the questions. Diabetes, nutrition are vital. Trace elements are vital smoking as well, and control of glucose. An elective surgery contributes to wound healing as well. The other thing, of course, is temperature. Cold edges are going to suffer from basal constriction, and cold contributes to wound infection. And indeed, it is now part of the surgical site infection fungal. And if patients are not actively warmed in theater with warning blankets, these skin edges are at risk, sometimes complex wounds. Less is more, in other words, only a few stitches to generally hold the edges together in the right position, supplemented if necessary, with steri strips, particularly on the areas that have been bacon sliced. I do wonder sometimes whether we ought to have closing teams in theaters, So once you've done a long operation and feeling fatigued, you call in an expert team to close the wound for you and adhering to a standard operating protocol tissue care bundle. As I introduced in my practice, perhaps we can reduce wound infections and clean wounds to near zero. So the last thing to actually cover and discuss them is we talked about ideal healing. So what else would actually help? Well, moisture is important. It's important that the wounds is kept moist because the character night sights and the migration of cells is best in a moist environment. That's what a scab does that protects the wound to allow the epithelialization underneath. But the moist dressing will encourage that, and there are lots of different types of dressings on the market. But the other thing about addressing is that it holds the two edges together, and then holding the two edges together will help reduce the tension and the pool on the wound. I think there are two other important bits of addressing. Itching is the mildest form of pain, and even in your sleep you would scratch and I had a POSTOP. Patients who went through the tissue care bundle and on discharge had the perfect wound. However, that follow up he had a wound infection, so I cultured it and it turned out that he had a bug in there. It could only be found in the potting plants of tomatoes. I called him back to scrape his fingernails and CSI style and sent that off to pathology to complete the circle because he was a potter, He grew tomatoes, and I wanted to demonstrate the bug underneath his fingernails and showed that he scratched the wound, contributing to secondary wound infection. But they threw it out. One last thing to actually cover this and I should have mentioned is the subcutaneous stitch. Now, the subcutaneous stitch is fabulous for very clean wounds. And I recall as a trainee working with Mr William Water Frederick Southward in 1987. He loved putting black silk searches in skin wounds. And I would say, Mr Southward, you must be tired. How about having a cup of tea and I will sort this out for you? And he knew what I was up to. He knew that I was closing the wound with a self particular stitch, and I'm using a monofilament here, but I would use a absorbable PDS. The first thing to say is many people put the not in the skin. At this end, I don't I like those monofilament that actually had a clip on the end because the monofilament as a knot is a bio phone, and I've noticed it in my sternal wounds, a little crusting and infection at the top of the wound. And the secret behind the sub particular stage is that 90 degrees to go through sub particular cystic tissue, and to get 90 degrees, you come slightly back on yourself, and I prefer using a straight needle because I feel I have in my hands the curve needle for this gives me a crinkle cut effect, and I don't get that straight ladder appearance required to bring the two and just together. So I'm coming back slightly and myself into that load. Some particular layer there, careful not to button hold the skin, and what I'm trying to do is establish that suture is going across and I'm drawing rooms of ladders and I put it together and the two edges sit together nicely like that. But what I need to avoid is any lipping. See there there's a little bit of limping on that, and that means the two edges are not perfectly together. So when it comes to closing, I don't want people to say Hurry up, it's closing time or theater teams to tout their watches. I'd like you to think about the physiology or pathaphysiology of wound healing surgical technique, and do everything you can to make sure that when the infection is reduced to zero, because in clean operations I believe it is a preventable problem. I hope this is all made sense to you. I hope next time you make an incision because that's where the wound healing starts is with a good incision surgical technique. And I hope that you now will take more pride in closing your wounds. And if anybody start tapping their watch in saying, Hurry up, you're welcome to actually ask them to email me and we can discuss the importance of proper skin closure, I was asked previously, What do I think of Skin staples? Well, I'm not a fan at all because of the amount of pressure that it exerts on the skin edges. It does Evert, certainly, but taking them out causes a great deal of discomfort. The two wounds that I demonstrated to you were closed with four. Oh, pulling. You can hardly see it. And I'd like to thank Sanju, the plastic surgeon, and Jake who left me with two scars. Very happy to take questions or any observations. So do we have any questions from our audience? No. Chris is very happy with you, though. He says bravo and he's got love her eyes on his emoji as well. Well, Chris, I'm very conscious of the fact that a talented plastic surgeon is actually watching this. And I want to ensure that the skills of the plastic surgeon are translated to the everyday surgeon as it is more than skin deep. Any other observations, ladies and gentlemen? Well, I'd like to thank you very much indeed for joining us from around the globe. And I look forward to seeing you next week, and I believe we're talking about knots. Is that not right suit? Oh, you've got me now, haven't you? Yes, not. Are you square? That's right. Are you square? That's right. Oh, hang on. I do have a question. Yes, of course. Okay. Mustafa has said we usually use the staples in our practice for skin closure and amputations. What would be a good alternative. Oh, okay. Mustafa, I do not want to disrespect the surgeons that use them, but I personally would feel uncomfortable if you're amputating because of lack of blood supply. You already dealing with an ischemic limb and I would advocate interrupted monocryl sutures. The reason for interrupted Monica sutures is because if there is any infection, you can release a couple of stitches and allow any exudate or purulent fluid to discharge. It is time consuming. It does take longer, agreed. But what would you prefer and from removal? It is much easier than taking out than staples. And if it's a question of a big area, why don't you get two people to work from either side? Because these wounds are often irregular and you work towards the middle, adhering to the basic principles of stitching. As I described, two people doing the job have the time. Beautiful wound. That's what I prefer. Any other questions? Nope, I think that's it. I have put up next week's event in our chat so before, as people leave, they can click on that, and they can sign up for next week, too. Thank you very much indeed, too, and Thank you very much for joining us. I am pleased to have the approval of a plastic surgeon this evening. I wish you well be safe that