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Hello. Good evening. Good day. Good morning. Good afternoon. Wherever you are in the world. And welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College. I'd like to thank you for joining us this evening. And 3254 followers in 59 countries. We are represented this evening across the globe while you're following. And I'd also like to thank the 400 90 followers on Instagram if you're returning most grateful. And if this is your first time, welcome and spread the news. I put out an INSTAGRAM post or Facebook post saying that mastery is attained by focusing on the basics and has had 500 legs. There's no point focusing on the fancy if we can't get the basics right. And the idea about perfect practice makes perfect and you practice not until you get it right, but until you can't get it wrong. So I'm coming back to my favorite text The Book of Five Rings by me um, you to Musashi, that undefeated samurai of 16 43. And this is from his fire scroll chapter and called Becoming New when fighting with the enemies. If you get to feeling snarled up and making no progress, you toss your mood away and think in your heart that you are starting everything anew. As you get the rhythm, he discerned how to win. This is becoming new. Any time you feel tension and friction building up between yourself in yourself and others, if you change your mind that very moment, you can prevail by the advantage of radical difference. This is becoming new in military science. It is essential to understand becoming new. It is something that suddenly appears through a power of knowledge of martial arts. Now this rhythm and becoming new resonated with me. As in 13 days time, I undergo my third down assessment in karate, and we've practiced the basics again, again, again and again. And one has to learn the first seven cartons backwards and even after nine years in the art of martial arts, I recently realized in learning something backwards, a slight nuance in one of the first three counts as we learned that I hadn't realized, but only discerned because I was learning it backwards. And that was a complicated move of turning my Gary Guillain Barre you dokie and turning around again tomorrow. Mizuki. It was profound that a hadn't worked out that movement until the son of the instructor who is an instructor himself explained. To do that movement was simply to go up on the ball of the ones feet twist on the ball on your feet do the movement and and twist, and that simple explanation of onto the ball of the feet and during the turn on the ball of the feet made the whole movement a lot smoother. So this evening, we're going to be talking about the one hand surgeon, not, and the reason for the one hand surgeon not being useful is because one hand can get into smaller places and the index finger even further than two hands and the 200 not. But there are a number of principles involved in the not, of course, not have been around for thousands of years, and they use is underappreciated, have even been in prehistoric times, as people have learned to join things together in length together to make longer lengths. They've been used for decoration, especially an Elizabethan times, and we know not on a rope on a log blocked off the back of the ship with a zan timer used to measure knots. And, of course, the nautical not is 1.15 miles per hour or 1.85 kilometers per hour. And that's where knots through the see come through not only has been used for recording measurements, actually, in Babylonian times and knocks, it was used for recording information not Bitcoins, but not coins, so to speak. The knot itself has also become spiritualized in Tibetan Buddhism. The endless knots are part of the scrolls. The Celtic monks described their book of kills and decorated that with Celtic knots of 1200 years old. There's a whole science behind maths as well. Lord Calvin said that the atoms were not in the ether, but it was in 17 71 that a mathematician then emerge started describing the mathematics of a knot, which is the embedding of a circle in three dimensional Euclidean plane in space, and since then, six billion knots and links have been tabulated. That's awesome. But what's interesting that to secure knots that uncommon place. The first is your bowl. I'm not up through the loop around the stamp and back through the loop. Voila! And every climber and every sailor will appreciate the security of a borderline. Not, and you can see it tightens itself. And these are what's called constrictor knots, the other important not, of course, is your simple reef not right over left left over right. If I put my fingers in this whole and I stretch and stretch and stretch effectively, the knot is tying itself. And if you ever wondered why your shoelaces come undone, that is because you have not tied a square reef. Not, and you can tell the difference because the bo is across the plane of the shoe rather than down the plane in the shoe, because the common not that we do. Is this granny not or cross not, and you can see as a warrior it comes undone. And as I've been thinking hard about how to teach the one hand, did not I have wondered, what are the basic principles. So the first principle of any not You have formed a loop and you've got to take one end through the loop. And there you go if you have got it. So the neurons of doing this is with two hands is easy. You just take it through your fingers. But how do you flip that short and through and having flipped it through, how do you catch it to then take it away and make sure it is a square. The second thing is not only should be square, but you've got to make sure it bends down because the not need to be secure and very simply here, is it not tired on the balloon. There you go. Not very tight. And if that was the vessel, it just let out. Balloons and tying of balloons is a very good way of practicing or not time. And these are, if you are tired earlier there you see, I can put a lot of pressure on the, uh let's see. And only when I squeeze it hard, it goes down. So how do you get to a secure one handed? Not that stops your balloon going down Well, that is. This evening's lesson is, how do you do it? And as I described it, I'll try to point out that nuance that flip through the back of the nail that pick up and catch taking the through before holding it and securing it, and then bring it back the other way to make sure it's square a square reef, constrict or not. So I'm going to do that right hand and left hand on my union model that I've had for you this evening, and I'm then going to share with you some music I've put to this and ask you to tell me what you think. Let me take you down to a view with my focus camera, thanks to Edward's Life Sciences and Kevin Austin of Wet Lab. So we'll zoom in to try and give you an angle, and the principal is the same, whether I'm doing it with the right hand or the left hand, and I'll go to the opposite side of the table. So this is right hand. First, the short hand is towards me and I'm holding it between my finger and thumb. Extend right, two fingers and I super neat holding the string out over my ring finger and then I bring the long end over the short to form an inverted figure of four. Now, you see that loop where my middle finger is there? I need to get the short end with the AG let being held between my thumb and index finger. I need to get it through that loop where my middle finger is. I need to flick it with the back of my finger, catch it. And you see, I've caught it between my ring finger and my middle finger, and I'm going to take it away from me a note that that knot is flat. And as I've taken it away, I have now opposed my thumb with my middle finger. I'm now going to take my index finger extended, sweep out, turn it in and there I am, holding the short end out again. I'm crossing the long over the short and you see, I've got a whole I need to get the short hand that is held between my thumb and middle finger through that hole. And I do that by flicking it through with a bag of my nail of the index finger catching it between my ring finger, my middle finger and my index finger, and I'm now going to pull it towards me. And I hope you see, as I zoom in that that note is a flat, brief note. Sir, the movement was very, very simple. But the problem is that many of the descriptions that are out there showing you the fingers moving fast. And I remember the surgeon Mr Western, be asking the sister to squirt some saline on his hands. And she said Why? He said, Because I'm tying so fast, the knots are going down fast and the friction is causing heat. Never. If you're getting friction on one string down on the other, that is wrong. That is causing heat, but actually is freeing the suture. So that is a no no, thank you, Mr Recipe. So let's come to the opposite side on my urine and young model and on the opposite side. I got the short term towards me. I pick it up between my thumb and index finger. I extend my ring and middle fingers, I super neat. So take the short hand over the extended finger. I bring the long end up over to form a figure of four. You see, my middle finger is in that middle of four and I need to get that middle finger around the loop flick that short end through, catch it in between my middle and ring delivered through and I need to carry that away. And at the same time I'm putting my thumb on my middle finger. My index ring is free to bed down or not, Index finger now sweeps out turns in, holds the short end out as across the long over the short. And my index finger now has got a flick with the back of the nail that short end through that hole and I'm carrying it towards me Between my index fingers My ring briefly before I complete the not by holding it there And I use my extended index finger Sorry. Ring finger to bed to knock down and will zoom in again And I hope you appreciate it. That is another square. Not so. Let me see what this looks like as I put this very simple seven stage two stanzas element together to music. Now, if you like it, I'll complete the video and make that available to everybody everywhere all the time. So let's see what it looks like. And I'll get the music up. Here we go. I hope you like it. One hand. Surgeons know. Are you ready? Relax the shoulders down. You start checking down those sounds loose in those fingers. Are you ready? Here we go. Okay, Let's go. Hold the short with the first finger. Step two with extended drink figure stupidity can hold that short end up. Yeah, over the shore. Check it out. Invert figure songs through the fall, but the nail and the middle finger your way Between that finger step sales, I'm hoping to show f seven bet down bit down the not an extended index finger And there we go. I'll play there now attention now it's dangerous. Extended in the extreme week out. Turn in long over the show. Check it out. I love it. Carry it to you. Easy. The punishment, The real thing. Thank you. I'm going to show up to the next 14. That job with the extended little finger. Okay. Do Atlanta do it slow. Here we go. Here we go. Hold the short with the first finger and four step to with extended green finger. Stupid age. Then hold out your end up, she question over the shore. Check it out and Virgil figure fall. Jump through the phone. The nail of the middle finger. Step five. It's either way. Mhm. Step six holding the shop in the middle and so seven pit down the north with extended index finger. And there we go all the way there. Now. Attention. Thank you. With the middle finish the rest Stand the index finger. Sleep out, Turn it along. All the shots, check it out. That's good. Yeah. Carrier to feel easy between the first and the ring thing that's cheating, holding the sure opportunity where it gets ignorant. Oh, chilly, Get down and down the mountain with the extended middle finger Sedation. Yeah, the throat area. So the pool is open, You decide. Did that make sense to you? And I hope that we have demonstrated that the same words apply to the movement of your right hand and your left hand. I hope that you appreciate what we actually did during that was flicking through with the back of the finger. Catch it between two fingers take it away before holding it again. And there was two stages, the first stage recorded between the middle and the thumb. And then we used the index finger to hold the short end out to create that figure floor. I use the figure floor because actually, when doing this, I'm not holding it tight. I drop it down so there's a loop to flick it through. But I usually inverted figure for to describe the position of long and short and bring it to the floor that your hands are moving consecutively like that all the time. And these are important principles to apply in or not. Because when I first started cardiac surgery back in 1987 my consultant, Mr William Water Frederick Southward, I'm just adjusting the cavern. Excuse me, stood there and with every not I tied, said square, not uncross not and square knot, and you can see the difference there. The reef not sits flat on the table, and it won't open, whereas the other not will come and done. But the thing is, one has to actually bed this down to start off with and to bed it down. We need to throw two throws the same direction, and I've got two half hitches here and you can see it throws down. And as I explained earlier, the most secure knots are called constriction lots, the first common one I showed you as the bow line. The second commonest one is the square knot, and the advantage of the square reef not is that you can undo it relatively easy. So the next part to understand is we need to be able to tie to something such that it doesn't move, because when we tank or not, we want to ensure that what we tang is not being pulled or distorted, and you're not pulling the not off. I know there's knots and knots, so to do that, I'm putting one throw in, and then I'm putting the second throw the same direction, and that's two half hitches and the two half hitches go down, and I need to pull those tight across the not across the not And if I know I'm pulling it across the not because I'm not lifting this coat hanger off the table. So I'm timing across the not equal and opposite forces tightening across the not I can now secure the not by continuing the movement. How many throws? Well, for a branded sitter I like five. And for mono filament, I like seven. What you need to do when trying these knots is say to yourself, crossed uncross Not each time. Another way of securing a not tight to the surface and particularly drains is to throw two throws one to the same direction and tie it down. And again. I'm holding across the not and I'm not pulling it off the table. I can then secure the not this way, and your instrument tying is very much the same to test if you're not as good, see if it moves okay, see if it moves up and down on that surface. So the this is one way to test insecure your notes. So how can we practice very easily Simple cotton and a light cotton. It comes in a real and a lot of nighttime is actually and Vicryl etcetera comes in a real The short end is held in your hand. I'm just gonna pan backwards the short end or the real is holding your hands and you hold the same principles, the entire too rigid surface and the thing about cotton in practicing. If you're too hard or too aggressive, the cotton will break, and we want to try and minimize the movement of the coat hanger on the table. Once you've tied to the coat hanger, use the power forceps to see if you're not moves, and it doesn't what you came in this to practice for mono filament. It's a simple bit of fishing line. A monofilament is basically a bit of plastic drawn out into a long thread, but you'll notice it has got memory. And because it is slippery and shiny, it'll come undone easily, and that's why they're not. Time likewise needs to be good secure, but you need to throw a lot more throws on it to secure it. Suffice to say that that knot there, it's actually quite a significant spike. And as I mentioned previously when securing monofilament inside tissues berry, they're not deep to the tissues because that will cause discomfort and pain, but likewise that not is a biofilm in the skin, and the night is for infection and again to test your not see if it moves up and down. But of course, a lot of what we do is tying a depth when you're tying your depth. One way to practice is to put a cup on a plate, attach it to the blue attack, and you need to now tie around good. The other thing I've used previously is dental floss. It's more expensive than cotton, but dental floss is also a very good way of practicing. Simple trick for passing suture material At depth is to hold it on a lady, hold the tip extended across the bow. Well, the bend. Hold it underneath, horse it underneath what you want to tie, let it go and pick it up as an assistant. If you can learn to do that, I can tell you the consultants surgeon would be significantly impressed. So we're going to tie this down. I'm going to put two throws the same day way, and the great thing about this model is that you can adjust the death. I've got this to fill MGs deep, but in essence, you want to push yourself to three phalanges deep, in other words, to the bottom of the cup. So he gets used to directing the force down the bottom. A note. I haven't got my finger beyond what I want to tie. It is beyond what I want to tie because my finger is on the not It's on the not, and I'm holding it there to making sure it bends down and when I have been teaching how to do it. Aortic valve replacements Securing the knots is important, and I and she count the knots and call out crossed are uncrossed. Now, using a pencil in this model, you can see there. I hope you appreciate that might not be secure in the pencil. And actually, I can move the pencil through the cup because my not is secure, and that's the type of not that you require. Of course, we said in the beginning we started with a balloon. There's a balloon. This is a vessel, so to speak. We're going to tie that balloon off Now. The thing about it is that is moving around the table like crazy, but I have to control it with my finger on the not David E. V. David David. Yes, Ahmed, ask. Is there any specific fishing line or just any generic? One will do any fishing line, Ahmed. It's basically practicing with a monofilament. All right, so any fishing line will do. But don't go on to your fishing line until you've actually mastered doing it with string. Okay, you've got to be able to excuse me. You need to actually understand the movement of your hands moving backwards and forwards catching it. Taking it away either away from you or towards you and using your index finger or your middle finger on the not the next step is to be able to do that without lifting the coat hanger off the table, and then you can start practicing at depth. Once you've mastered this with a bit of string, and you could understand and recognize the automaticity of that movement, you then progress to finer branded sutures. Vicryl more cotton and cotton is actually challenging because if you pull too hard, it breaks and then try it with fishing line. Fishing line is difficult because, as you know, it's a plastic and slippery, but it's also got a memory, which also makes it very difficult. This movement of crossed that line crossed is also important in instrument time, so when your time with an instrument, you'll have the same effect. Clockwise around the instrument will be away from you. Anti clockwise around the instrument will be towards you, and you need to actually get that movement there, too. And my fellow sense a Mr Caddy who likely pointed out that I didn't demonstrate that with closing of the skin last week. But it's all about not trying and what's interesting about notes. They need to be secure. And there's a sort of spiritualism that comes with this, uh, A. It will never come undone. So I suppose that's why when people say they're getting married, they tie the knot because it's not supposed to come undone. They have a couple of things, of course. Sorry. Um, Bobby says monofilament is a type of fishing line. You can get braided ones, too. So for constricting, it was twice with the ring finger manoeuvre. Then the index one thereafter. Yes, to actually bed it down, you put two throws the same direction. It's either two half hitches and the half hitches slide down on one another, and there you go. That's two half hitches, and that would slide down and then you lock it by doing square knots or you put two throws in the same direction on the same loop. And that's called the Adam, but not and that is the one that is fabulous for tying in drains because actually what it does. And I've used a bit of host pipe here for tying in drains. And there you go, that element, not it actually bites into the plastic. And that hasn't moved at all on the hose pipe because the last thing you want is for your brain to fall out, especially if it's a chest rain. And we'll be talking about chest rains at the end of the month because there's some fundamental principles that I've forgotten now. And Mustafa asks, What do you mean by uncrossed? Knots, Right. So the uncross not Mustafa, is I'll come down and just show you again the to uncross knots. Okay. And then we can bring you over the top and show you this essentially crossed and uncrossed applies to the concept of reef not or runny. Not so. There you go. That is a reef. Not that's right over left, left over. Right. Okay. Whereas the out cross not. Is that okay? There you go. You can see that is a reef not having a second. It's very difficult not to tie bad marks. Okay, that doesn't sit flat on the table, whereas it crossed flat. Not is a reef. Not. And that actually tightens itself. And it tightens itself as it's a restrict. Constrict or not, the granny not or cross not comes undone. Okay. And basically the flat not or if not or square, not sit square or flat on the table. Your shoelace. If it's a square, not the loops. Should come across the shoe rather than down the shoe. Does that answer your question, Mr For So did that answer my stuff's question? Um, well, I'm going to say yes, but he hasn't responded yet, so maybe there's a longer answer. Okay, so there you go. You can see the difference. The square flat? Not Yes. Thank you, Mr for. Thank you. How do you do The double half features with one hand, Bobby. Okay. So let me come back to my piece of strength with one hand. Well, let me come back to my not trying not to. I'm Jake. All right. And sorry. I'm just trying to get the focus here. I'm not sure where I am. There you go. So let Bobby let me come back and answer that question for you. So we've done that, and the song is really telling you how to flip it around, but to start off Really? What I'm doing is flipping it through the same way both times. You see that? Both times I've got two half hitches and now that can go down. Let me see if I can do it with this. Yeah, So I've set it up, I flick it through, take it through and I flick it through again with the middle finger and take it through And I've ended up with two half hitches. You see that to take it down, putting the tag in through the loop twice. Once 100 I pause, Bobby. So twice. 100. If you want to do that. Um, but not I've gotten through once. Okay. Twice. There you go. To throw those body says Sorry. I meant putting the tag end through the loop twice. One handed? Yeah, that's what it says. Either two half hitches or two throws through the loop, and I just pause and do two throws with my middle finger. All right, does that answer your question, Bobby? That was once, and that's twice so. Either do it through the same route twice, or you do the same throw twice. One gives you the area, but not any other gives you the slip knot. And both of those are useful for bending down. Okay, Bobby says he has a bit of string and practicing on his mug at the moment. Marvelous. So what? I suggest Bobby, that's great is put some hot cup of coffee on it, and then your factor is if you end up pulling the mug over and the hot coffee spills on you, you'll never do that again. But I don't want you to burn yourself and therefore delete that answer, because otherwise you'll come back to me and say, I caused the bone. But anyway, you practiced till you can't get it wrong. But the whole thing is, as Bobby is doing every surface you've got, even when you're sitting down watching telly and sitting on a tree, sitting on a chair with arms, and I remember as a young surgeon, every single chair, every single arm every single loop surface. I had it down. You can play games with yourself is how short can you get that short end and still extend it out and flick it through? It's a bit like limbo dancing. How low can you go? The important thing is, is that you rehearse in your mind the flat, not all the time and your hand doing that, so it becomes totally automatic. Remember, it is not. Speed is not. Sister can have some water on the strings because my hands are moving fast. I want accuracy. So with 28 sutures around an aortic aneurysm, I want finger on the not each time, and I want a square. Not so when the trainees actually throwing the knots they throw not, And if it's square and their fingers on it, I count one and then they can go again and count, too. And with the branded seizure, I would say no more than five throws that are accurate as soon as you start moving more throws onto that with 28 times excessive throws. That is actually adding to bypass time in his unnecessary wasted movement. And that's what I say about surgery It's not speed. There's no hesitation, deviation, interruption, repetition. But as mayor, more chemo shots, he says, don't do anything useless. So beyond what you need to do, then become superfluous and in excess. And that's all part of mastering the basics. And unless we get those right, the fancy stuff is never going to come. Any further questions, ladies and gentlemen, sue any questions I can't see from here? No, no questions. I just put up next week's event. But no, no questions at the minute. Well, ladies and gentlemen, thank you very much for joining the black part Academy of Surgical Skills. I really do appreciate the global reach. I hope it makes sense to spread the word, and I look forward to seeing you next week and be safe.