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okay? Yeah. Hello. Good evening. And welcome to the Black Belt Academy of Surgical Skills. Wherever you are in the world, if this is your first time, Welcome. And if you're returning Thank you very much indeed. I'd like to thank the 3290 followers on Facebook and the 521 followers on Instagram. We're about to open a tiktok channel and hope to have something really exciting about not time on tiktok shortly. This evening is about time. Noxon and not enthusiasts would say that civilization is held together by knots and knots. Probably predate fire and even man himself. The animal kingdom, gorillas and primates make not to construct nests. Man was found to actually Tinel's about 300,000 years ago and 4000 BC Egyptian spindles have been found which demonstrated that the Egyptians were able to construct ropes because, of course, your rope, whether it's made of cotton or wool or acrylic, is a glorified length of knots and fibers woven together in 2218. Bee sting. The ropes were used by the Romans and they're crossbows and very successfully too. And in 100 80. Our weavers started using knots as part of their decorations. But knots have been embedded in many other things. In the Inca population, knots were used in creepers to store bureaucratic data. I suppose they didn't have bites. They had knots. Instead, think about it. All are woven garments, the knitting or all glorified knots. The cables for suspension bridges also not, and on the NASA explore a curiosity. The cables in that space vehicle a bundle together with grief, knots. You could say that not so threaded in the very fabric of our life, they appear in legends like Guardia's, who are traveling with his wife through unknown lands, now regarded as probably Turkey and Prophecy said that the first person to come through the gates of the city with an oxen cart would be king. He was crowned king, and he's the father of minus but in supplication, two zeros for this privilege. He tied his card to a post in the center with a Gordian knot. Another oracle said that the first person to undo the Gordian knot will become the ruler of the empire that stretched beyond the fridge in territory just so happened in 333 BC A Macedonian soldier walked into Guardia's the capital blue of Frigia at the time and wrestled in trying to get this knot undone but not finding a beginning and end. That was impossible. So this young soldier drew his sword and with a mighty blow cut the not in half. The rest is history. For this young soldier was Alexander the Great. And you know the amount of kingdom and territory that he ruled over not also have a spiritual element, and we find not many heraldic symbols, but the Celtic knot or time. The knot is the joining of hands that we now refer to as wedded or wedding hand fasting. Willing suitors having their hands tied. But we are surrounded by everyday knots. The knots that we tie to tie ties There are accounted 14 of them, depending on the occasion, depending on the size and flamboyancy they're not. We choose you're not accordingly, but of course, there's one several knots that you and I were taught to do in the first place, and that was your shoelaces. A half hitch with these bunny ears on either side that enabled you to pull it and come undone one of the most convenient knots that we use to date. But if you look closely, the bunny ears and the not in the right hand shoe here are across the shoe, indicating that this is a square uncrossed or grief not, and I'll demonstrate the importance of the moment. But this you the bunny, is I am the longitudinal plane of the shoe, and it's that, too, that will come undone. And if your shoelaces are coming and done, you haven't understood the principle of them. Not does. Paulson is a retiree in Ipswich, and he's the founder of the International Guilt of North Tires. And he has awarded an M B 1996 for his services to the road industry. And he said, Where would we be without knots, particularly with pajama bottoms? But where would we be a Sergent without not and there are some simple principles. First of all, it needs to be secure to It needs to actually be better down such that it doesn't strangulate but includes, and it needs the right tension and all these elements I've brought together in a series of exercises to demonstrate how to tie a knot too frequently. I see videos our surgeons rapidly tying knots and recall Steven Wester be turning to the system, saying, Please, could you squirt some water on my hands? Because my hands are going so fast with the implication, but also they're not going over each other or causing friction. That's not supposed to happen when you time. Not you do not want the not a thread to rasp over itself. It can damage the suture. So please don't. Certainly, when time not Mr Lincoln used to say, Sister, please, could you just squirt water on my hands? Because if you had blood on your gloves and you were tying a six or not, the six er might get stuck on dried blood on your gloves. Hair out of a crony vessel. There is a place for water. So what we mean by crossed and uncross marks, and this is the first principle. You'll see two knots on the table here and you'll see that one is sitting flat on the table and one is sitting proud. Now the simple right over left and left over right is a square reef. Not see to hitch is intertwined like that watch when I put my fingers in this and I pull and as I pull this is self tightening. So imagine you walking with a proper not on your shoe. Regular steps throughout the day will keep the not tight. There is a science in knots, and a lot of physics applied to the tension, and these are regarded as constrictor knots or self tie knots. By contrast, here we have across not see the roofs are crossed, and this will also colloquially referred to as a granny, not watch as I walk throughout the day in tension is to this. Yeah, it comes undone, and that is why your shoelaces come undone. So there's a simple principle required and not time. And there are many videos on YouTube about Hae to tie a surgeon's not. In essence, what we are doing is forming a loop and taking one end through the loop and taking it away as a knot and doing that again through the loop and taking it away as a reef. Not yeah, and that requires an understanding of how you move your hands. So let's take a look at how we can look and demonstrate no time. I always start off and suggest you start off with a bit of string or shoeless as I've got here. And you always start with a short end. I'll bring this up and I've asked Gabrielle to point out if we can't see so short end between finger and thumb and then you're gonna super late My hand such the short end is over my ring finger. I'm going to take the long end to form an inverted figure of four. And you see, my two fingers are through the loop of the floor. I can take my middle finger and literally flick that short end through and they're going to carry it away. And I've caught it between my ring finger and my forefinger. And as I carried away, I am going to catch it with my thumb and my ring finger, and I'm going to put my index finger down on the not itself. You're halfway there. I'm now holding the not between my thumb and my middle finger. I take my index finger around, I'm going to hold out the short end again when they extended ring finger and then across the long over the short, and I'm going to flick short, end through the long and bring it towards me. And there I have constructed every if not or a flat. Not so let's go back and we're going to do the same again for the opposite side, and I'll try it at a different angle. And the important thing is, as I'm tying it, I'm swapping the holding of the end between my ring finger and thumb, my middle finger and thumb. And I'm putting down the not, respectively, with the index finger or the middle finger coming to the other side again. Did you know the end of the shoelaces called an AG? Let this little plastic bit and there's a patent for that invented in 18 70. So short end, finger and thumb Super Nate and hold the short end out across those extended fingers. Bring the long end across the short end, and you see, I've created a loop. I'm going to use my middle finger to flick that through, catch it between my middle finger and ring finger. I'm taking it away as I take it away. I'm applying my thumb to that middle finger and I'm putting my index finger down on the loop. Now Take my index finger, sweep it out, turn it in to hold out the short end across the long over. The short as before, and I used my index finger come round four to get the short end. Flick it through, and I've caught it again between right index finger and ring, and I'm bringing it towards me, holding it now between my thumb and middle finger. And I'm using my middle sort of thumb and index finger and using my middle finger to put the knock down. Now when you're watching, not tying, and I'll try a different angle for both hands, because I can appreciate that. This can be awfully confusing and complicated. Try and give you a different angle. What, and the principle applies to the right and the left hand. The left hand finger and thumb holding the short end Super made out told the short end out towards me. Cross the long over the short. Use your middle finger to flip the short end through that whole carried away little finger green finger pressured thumb little finger and put your index finger on or not so you can Index, bring it out, turn it in, hold it out, cross the lung over the short. And now we're gonna flick and short end through the whole again and bring it towards you. Let's look at the other side. Same replies with the opposite hand. And I do recommend that you learned to tie knots with both hands. We've put this to a jingle and a video, which giving some animation at the moment and it will be out shortly. And I hope before Christmas. And that's the thanks to our sensei Gestapo in Ecuador. Finger and thumb. Short end soup in eight to hold it out, Cross the long over the short and you can see in inverted four I can take my middle finger to flick the short end Through the whole I've caught it as you see there between my middle finger and the ring. I'm taking it away and I'm doing that. I'm applying my thumb to the middle finger and my index finger to the Not now. I'm gonna sweep my index finger out, hold it out, cross the long over short and my index finger only is through there and I'm literally flicking short end through and bring you towards me. And there you go. We have now another reef, not. And that is exactly what we should be doing with our not all the time, because they need to bed down one south time. And I hope that all surfaces are going to be festooned with braids of not, as I have here with much. No time. So there's the next principle. You need to secure the not down, and to do that, we actually throw to half inch hitches and the two half hitches. You'll see Titan and we throw the to half features before we start alternating. So let's demonstrate that to you armor, a coat hanger on the table and the reason I'm using the coating on the table. I'll explain as we go. So short end short turned super need out there, and I got the fruit same again until two half inches down 3.5 inches down. I'm begging the not on the table Now. The reason to use a coat hanger in this instance is to teach you to make sure sure that your finger is across the knot and I actually say it's on the not because the Palpa my finger can feel the knot down. But I'm also got forced across the pulp on my finger because I'm not putting it off and then can continue my not time a note as I'm doing this, What's happening is my hands. We're going back and forth, back and forth and you end up with a nice braid. What kind of fun? Bit like limbo dancing is how short can you go on your not tying. When you get practiced, you'll be able to do this with the tip of your fingers and tie a knot with very short string. Now the disadvantage with hand lots is that by definition you're going to be using a lot of suture material. But the major advantages? I think I'm at the limit of time or not. The major advantage and that's important, particularly ringing down a whole is you can feel the knot your finger is on the not so just to show that again. Not that way. And we want two half hitches and make sure they go down and let's bed it down. Okay, so the two half hitches you can see that, as I've demonstrated here, is batting it down, and that's ensuring that the not is not slipping on that surface. So the other reason to use the coat hanger is Can you bend it down and tell you not without lifting they could hang up off the table? You can test with it not to secure simply by moving it along the access. Now, I would recommend that you stick to pieces of strength before you're going on to something thinner, and cotton is another very useful material to use as I'm timeless. I'm reminded that, um had kindly sent a wonderful picture of innovation where you used human hair to tie and not, and you see what happens when you put too much pressure on a bit of cotton. We'll do that again. If you don't tie it properly, would have cotton, and you pull too hard. You're not will break. So it's another reason for your finger on the not and it doesn't require a lot of brute force. It requires delivered finger on the Not again. You're gonna test this a little bit of movement on there by Pretty secure, and that's what not tying is. What about? How many throws do you throw? One or not? Really. Surgeons have a different number, but the fundamental differences that on a braided suture as we got here or break a bit of string, you need less switches less throat than on a modern filament. The mono filament is just a drawn out bit of plastic, so I like the number five. How long do you cut five millimeters cut? And it's a deliberate cut. Difficulty is, and I've used this previously is fishing line, and this fishing line is clear, and unfortunately, you will not see it on the camera. But the fishing line is akin to a monofilament that we use in theater. Now the two things with the modern filament because it's drawn out plastic. Any crushing due to that can damage it and compromise you're not. So here we go again. Same thing applies if you don't put it down. Stand proud. I mean the same principle. How many throws do you put on this one? I prefer seven since five and seven. Some people say six and eight, but what? I don't want to see our people throwing lots and lots of knots because you see that and I'll show it here on. But a prolene knots themselves. Can I have drawbacks? And if you look at that, not here carefully, your note then sticking up like a little spike. Yeah. Now, if that was on a surface in which you're lying down or sitting, that will be sticking out in thin people that not could even wear through the wound and you get a protrude been not so with these knots and all knots and closing the recommendation is to bury the not so you start from inside out and then tie the knot. So as you close the factory layers, the knot is buried because this can be very painful, problematic and the source of infection. The other thing is, is that these knots and mono filaments are often used to close the skin. These knots in the skin act as the surface on which biofilms can grow. And I noted in my practice that the knots of the monocryl at the top end of external wound were causing a bit of crusting, another little bit of bruising. I therefore stopped knotting the skin not and simply put, a liger clip on the end immediately, I cured the problem. There's another way of securing and not so we said, two half hitches to bed down. But something that's more important is securing of a drain. And as a surgeon, the last thing you want is a drain to fall out. And this is chest rain we've got here, and I've demonstrated using a bit of host pipe. In this situation, the best thing to do is to throw what's called the surgeon's not. You see that there are two throws in this loop. There's one have taken it through again and then pulling it down. It secures. We throw to throws with the mono filament when we instrument tie. An instrument tying is very useful on the skin because you can keep one end short and you're not using lots and lots of suture material. So let's come to a little bit of host pipe again with the string we're going to true, Why not to throws through the loop? See that I'm not taking it down and you'll notice as I tie this down. This is literally writing into that hose pipe. Yeah, and as secure as I continue to tie my knots in the other direction. Flat square reef not to secured and to test. If it's secure, they're good. That is not going to drop out with the drain, just to remind you we're not in drains. Always put the not on the deep pendant side or the patient, because if you put it on the top side, it will tear out and cause attraction injury on the skin. So when your place or not is important for your drains, of course. Now, when time nods, we often a depth in some of the places in survey that we've tied. Knots are really truly out of reach and the middle rectal artery, for example, and what I have here the plastic cup with a bit of blue tack and a pencil through blue pencil. Is it one funding steep and the red pencil of three phalanges deep, and it can go further to make it literally three from GS deep, in other words, simulating tying a depth. And the trick here for time empowers enough and often you asked to pass or not, I'll just show you this little trick is the holder, not don't pass the free end and say, Hold that, please come down and took it well past the free end with a pair of forceps into the wound. You're not going to be able to pick it up. Yeah, Not going to be put. Pick it up. So if you want to be clever in passing the future, the best thing to do is put it around a lady as I've got here and bolstering it across the curve of the instrument. Even a Roberts. Pass it under control. It's in depth underneath what you want. Release it and pick it up in a pair of forceps. Now, the not tying here is exactly the same everywhere else. And there's a finger on the lot to half features. Make sure you bend it down and I'm not lifting the cup off the table. Hi, David. We have a question from Chris. Katie, Um, could you please just repeat the name of the instrument I was using a lady, Chris. Thank you. We will. Actually, we'll be covering the lady in, uh, opinion with silicon issues putting together expert How protected Christopher, uh, new sets. Now I'm kind of the death now. Test is that a secure note? It is. Absolutely. This tried another death. The pencils at two. Different Induced to again. I'm something. Using coffee. Also very unforgiving. Okay, uh, tight. The Copaxone itself. Great. Here we go. Causing at least. Okay, so I do scientist. That's actually considerably. So the what? Send this out. Pasta. I'm serious. Uh, what we're doing with you here. Listen to this. I certainly find some springs. Uh, you don't want that? That actually how many said, Let's have a note now. All right. I'm gonna help me feel much that many of them. Uh, mhm. Mhm. So the simple mood is not really getting your fever or feel okay around you to understand, potential required. Um, mhm to make sure. Thank you. All right. There you go. Uh, progress. Okay. Devastate. Okay. Oh, I broke. That is good. Put them here, or you got to do It's true or not. In the first week that I described using. Okay, right? Sure. Actually, this time, uh huh uh, very unforgiving. Thank you. All right. See how we do? Yeah. So, again, simple time off. However, this material give you a feel I could see, but this one. Um, sorry, Christmas. Coming up, Mr Bill. There was a problem with the microphone, but it does sound better now, so I think it was fixed. Maybe. Okay. Thank you. Oops. Feedback. That's sort of cotton. I was pulling too tight. Okay, so here we go again. Yeah. Okay. And when coming in to cut sutras, come in deliberately and cut the suture and take your take Lots. And here we go again. I hope you would agree. That is a secure Not so you can at home very easily practice. You're not tired because as I've already said to you, you'll find knots in every aspect of our life. Fuck. And being able to do this confidently with both your right hand and your left hand is a vital importance to understand how to bed the not down with two half inches secure the not by alternating flat knots or reef knots that you only need five or six for raided future, but for mono filament, you need perhaps seven or eight. You can easily break the suture and even pull it off. So practicing you're not tying with a coating or a table will teach you to keep the not still and to make sure that the tension ing of the knot is across the not and usually because the not as small that tension ng is across the tip of your finger and doing so you can feel the knot back down. The other important thing with ligation is to ensure that when you dissect the vessel out, as we discussed last week with the scissors that you enter the right facial layer and you clean the vessel off such. There's no extraneous tissue in fat or other tissue within the not because that's going to compromise the security of that. Not as well. These simple principles practice with your right hand and left hand, and you, too, will become proficient. We're running a competition that closes on the 16th of December, where the Black Belt Academy will send you your own set of instruments. And what we're looking for is the most innovative model that you're using at home. To practice any of the surgical skills described to date, I introduced the incision, cake and layers of pasta. Ahmed has introduced time of the human hair. Do send a picture hashtag black about academy, a surgery, school skills and medal, and the winner will be sent the instruments from the competition last time. I know two people have received their instruments already, but I think the jury and Masan have not received them. Please let me know if you have. I hope this has made sense. Next week we're going to be talking about assisting and my son will join me, and I am going to help him operate and demonstrate to you that good surgeons make good assistance and good assistance. Make good surgeons in standing opposite. I'll be able to help him operate. I'll then be away for a couple of weeks. But of course the festive season will be upon us and we'll join you again in the new year. I like to extend my thanks again to medal, and Gabriel, who is behind the scenes in production and answering your questions. She is going to be running Black Belt Academy in Lithuania and is kindly putting together with Professor do Gara, a compendium of instruments, because understanding the instruments I think will engender respect for the instruments and knowledge on how to use them. Thank you very much indeed for your attention. Hope to see you next week. Uh, I wish you well and stay safe.