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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon in New Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh, and a visiting professor at Imperial College London. I'd like to thank you for joining us this evening and adding to the 1183 people who have viewed us over the past 18 months from 83 different countries. And I think we've got more than a dozen countries this evening. Thank you very much for joining us and thank you to metal for connecting us and making this possible. This is all free and available to on catch up and to emphasize that we are recognized and accredited by the Royal College of Surgeons of Edinburgh. So tonight, we're gonna be talking about ligation. Now, the other is from the Latin word, the gry to bind or to tie. And it's a medical term that you know, refers to the procedure of tying and literature tightly around a blood vessel or tube carrying fluids commonly to stop bleeding. And it was the principle attributed to prates in Galen. In ancient Rome, ligatures were used to treat hemorrhoids. And the concept of a ligature or tying something off was then lost for perhaps 500 years until Abdul Kim Kif in Al Abbas, Al Zahari, Al Ansari, otherwise known as Al Zahra who came from and which is the Iberian Peninsula, including Spain and Portugal. And he is considered one of the greatest surgeons of the middle ages. His principal work, the Kab Altaf translated literally as the arrangement of medical knowledge. For one who is not able to compile a book for himself or known as English. The Method of Medicine is a 30 volume Treat in Arabic encyclopedia that was then translated into Latin and was used as a standard textbook for surgery for 500 years, including the medical schools of Salerno and Pele. He reduced cat gut for internal stitches and his surgical instruments actually used today. What I liked his, his comment that before you practice surgery, you should gain knowledge of the anatomy and the functions of the organs so that you understand the shape connections and borders. You should become thoroughly familiar with the nerves, muscles, bones, arteries and veins. And if you do not comprehend the anatomy and physiology, one is likely to make a mistake which will result in the death of a patient. And he noted someone incised, the swelling of the neck, which turned out to be a carotid aneurysm and the patient bled to death. And in his book, he's depicted over 200 surgical instruments. Some of them, he created himself and he introduced techniques of cauterization and ligation and invented hooks, the double tips for use for surgery. We then move on another 500 years to 1510 and ambrosia pa who is a French barber surgeon who became the physician to the Kings Henry the Second Francis, the Second Charles the third or Charles the ninth, and Henry the third, he was an anatomist and he was known for his keen observation and perhaps did the first cohort study that we know of cos he was a battlefield surgeon and he noted that the soldiers who were wounded in battle were often treated with boiling alder oil and ca to their bleeding limbs. Not only did they scream with pain and it did not stop the bleeding. He then introduced an ointment made of rosewater eggs in turpentine. What he didn't know is the turpentine was probably a sterile agent. But after that decided not to cauterize anymore, but to ligate. And this was published in his book in 1545 or as a method of curing wounds by firearms. What he also noted during his work is that his patients often complained of phantom limbs and he deduced that this was not from the limb itself, but rather a perception of the brain. And that is what we think today, then we jump another 300 years to Jules Emil PM. And although pa described a, a hemostat a like a cruise be, it was actually Jules Il Pierre who introduced the common hemostat that we often use in theaters. Today, he was a follow of hygiene but actually disputed the work of Louis Pasteur. He refused to dissect corpses. And although he was an avid trainer, he was never actually made a professor who's the pioneer of the first vaginal hysterectomy for carcinoma. And you're the first to treat a diverticulum of the bladder. He also attempted a arthroplasty of a so a shoulder, the patient then died because of infection. But he popularized what we know today as the hemostat, he was elected to the Academy National of me and gained the rank of Commander Legion of Honor in 1893. So the importance of securing blood vessels have been known for a long time. And really that is taking a piece of rope twine crossing it and bring it through to form a loop. And as we watch many of the videos that are offered on youtube and how to tie a surgical. Not we see that trust and we don't understand or see the flick of the short end through the loop to tie the knot. Now the video is there on metal for you to look at, we put this to music and broke it down into seven steps and two standards that works with both right and left hand. But there are some fundamental principles to not tying that we'd like to go over and share with you again this evening. Remember what we're doing is crossing one piece of twine over another and literally flicking the short end through the loop is how you catch that short end and how you flick it through that I don't think is very well described in many of the videos that are offered online. So I'm gonna bring you overhead and, and there are some important elements that I'm trying to emphasize here. And what you have noticed is if we focus down, I have actually tied a knot with a 60 proline that's as thick as your hair and is a common suture that we use in cardiac surgery. My hands are not moving fast, but you'll see that I'm moving my hands back and forth like a loom. And the reason I do that is the first principle of what we're going to describe this evening. And the reason why your shoelaces come undone, this is as you know, a reef knot or a flat knot. You can see it sits flat on the table compared to was commonly called a granny. Not this is a flat knot and that is a crossed or not a flat knot. And the differences of demonstrated if I put my fingers in the hole and I'm moving in trying to undo this. Not the nature of the knot is such that it automatically tightens. Whereas if I put my fingers in the holes here and I work it, you can see that it comes undone. This is the reason your shoelaces has come undone. And I got the idea from a TED talk that was just telling us that we are tying our shoelaces incorrectly and we're tying our shoelaces incorrectly because we weren't tying a flat knot. So I'm gonna bring you down further right and show you the hand movement as demonstrated in the video for a flat knot, right hand and left hand. So, uh and I get it in camera for those who've previously mentioned, the camera work sometimes is awkward. I'm afraid it's just me so shorthand, longhand and what I'm going to do is supernate and holding the short end across my fingers. I'm going to cross the long end over that short end and here's my middle finger here to flick that shorten through the loop. Am I going to take it away from me and then taking it away from me? I'm now holding it between my middle finger and my thumb and I'm gonna put my index finger down to bed the knot down. I'm now gonna sweep my index finger round and hold it out and I've hoarding the short end out and crossing the long end over it. You see, I've created another loop or inverted figure four. And I'm gonna use the back end of my index finger to take it through and bring it towards me. And there you have got the square nah, and it's folding it over your fingers, creating the loop and using the back of your finger to take it through and note my hands are moving this way and that, and we have a series of flat knots. The same applies. That was the left hand and we're going to do it with the right hand. Now again, we take a short end and a long end. I'm holding the short hand between my index finger and thumb. I'm supernate to hold that short end out. I bringing the long end over the short end and I'm creating a loop. I'm now using my middle finger there to reach over and flick that short end and deliver it through the loop, holding it between my middle and ring fingers and I take it away and as I take it away, I'm applying my thumb to my middle finger. I'm extending my index finger to put my finger on the knot. I'm now gonna turn it out the index finger, extend that short end, cross the long over and I use the back of my index finger to flick it through and bring it towards me. And there, I've got a reef knot when I first started surgery, Mr William Water Frederick Southwood kindly stood opposite me all the time and called flat knot, cross knot and cross knot and looked at every single knot I did throughout that period. So that movement back and forth of your hands is vitally important to ensure that the knot stays squat. The next important principle is to ensure that the knot is bedded down. And when I say bed it down, note my index finger or my middle finger were pushing the knot down each time. But the first thing to realize is that when we're tying, we want to actually create a slip knot. And a lot of laparoscopic knots are preset slip knots that you literally push down and then secure. But this slip knot enables you to secure on the surface and then continue your time. And I'd recommend when you are starting to tie knots that you put a coat hanger on a surface and again, 12 and another through the same direction. And that gives me two half hitches really that I'm now holding down and I'm bending down on Cotana and I'm using the coat hanger and my finger down there because I don't want to be lifting the coat hanger off. And the problem is with not tying is if you do not apply the force across the knot, you will end up pulling it off what you're trying to ligate and at the bottom of a pelvis on a middle rectal artery that would be problematic. Now, I've set myself a challenge this evening because this kanga is square in cross section. So therefore to actually tie a tie to this, it is kind of difficult because it is a plus sign in cross section. So I'm gonna try it on here and hopefully demonstrate the point of one throw, second throw, same direction to bound to make sure it doesn't lip my finger is effectively on the knot, but it's actually across the knot, making sure that the tension across the knot is maintained and I'm not lifting it off. And what I want to try and do is time or not such that it is a cure and I cannot slip it along the plastic of this coat hanger. Once you've got the hang of that, then you can move on to using lots of other different materials because in surgery, we do have lots of different materials, essentially prayed and a monophylline suture. Now, the braided suture is a bit like string and it's relatively easy to tie. And you can see that it hasn't got a memory and it's like tying string. And as you learn to tie knots, I suggest you use the braided suture in the first instance, the monofilament. So a bit of plastic that is drawn out into literally a single filament is not unlike fishing line. And if you can't get suture material from theater, and often if you go to the theater, you'll find suture material available that is unused during an operation. But you see the difference here, that is the VR and that is the monofilament. Look at the memory and look at the micro. Now, the monofilament requires that you put at least seven throws on. You're not. But there is a problem with that because you can see that is a stiff, little bit of plastic. Yes, it slides down very easily but it also and does very easily. The problem is with the VR uh the the monofilament is that multiple throws end up giving you and not, it is quite bulky. And if anywhere near the surface or any postal area that will cause a problem and press in and cause pain or protrude out and break through the skin. Although it is a monofilament, many people actually, when putting a monofilament in the skin, tie a knot and that is also a source of biofilms and infections. And I stopped using a knot in my molar filaments in the skin because of that and literally brought it in flush with the edge of the wound and put a clip on it to stop it coming out. The next important principle of your not tying is to secure a drain. Now, drains are made of plastic and the worst thing to happen in surgery is for a drain to fall out and you need to be able to secure it properly. This is where this next principal knot I believe is comes in and there is a tremendous use. This time, we take one throw and a second throw and pull it down flat. And you'll probably recognize this because you put two throws in your monofilament on a skin suture and then lock it before coming back to secure the knot. But this edin or not is extremely good at biting into plastic and holding your drain and position. So to do that, I've done this, you can see previously again using a bit of string, I've got a bit of hose pipe here. I'm gonna put one through two throws. I'm gonna pull it down square and as I pull it down, you can see it biting into the plastic and I was gonna hold there as I then complete this with flat knots and using a bit of hose pipe or a bit of plastic is very useful to practice the snot because you can test and see if you are secured it properly. And when you're tying that double knot, you can see the plastic being indented. That drain is not going to come out. Fortunately, the next important step is to practice tying knots at depth and to do that very simply get a cup with a bit of blue tag on a plate and put a pencil through. So I've got one here and one phalanx. We've got another here. Two felling deep and the third one is three phalanges deep there. So what we're going to do now is just use a bit of cotton. And this is another fine thread to use to practice sutures and introduce you to a new way of delivering your suture around something at depth. Often trainees are asked to pass the suture and they grab it with a forcep and they take loose end and dangle it, expecting the surgeon to pick it up. The best thing to do is to bowstring the suture across Roberts or LA. He like this. And in doing this, you can hold this with your left hand as a surgeon, you can hold it as the left hand as the surgeon with a bowstring. And therefore pass this underneath what you want to tie, pick it up with a forcep and release the LA and you've passed the suture around what you wanted to tie. Now, I haven't given myself enough space there to do that and I don't do that again. Cotton is also a very useful material to practice with because if you put too much force on it, it will break. And the thing with the 60 I demonstrated earlier, if you put too much force on that, it would break as well, which would not be a good idea if you're using six sos for your top ends for coronary bypass grafts. And that is essentially the first branch of the aorta. You can imagine if that came undone, you'd have one tremendous bleed. Now, the important thing in this exercise is to make sure your finger goes down on the knot. Because if you don't, you will start lifting the cup off the plate. So once you have secured, you are not the useful thing to do is to test it if it's secure by seeing if it moves on the pencil. And I should be able to get that note and move it and it doesn't slide along the pencil. And in fact, I could probably pull the cup off side to side, but it's not sliding. So that is secure at depth. We do the same again, but two flings deep. And these are simple, easy exercises that you can do at home and need to practice is being able to tie at depth. And this paper cup gives you visible feedback of what you're doing. Note that I'm using the leg here again to pass the suture around and take the leg off and a death two felonies now and got to extend my finger even further. And when teaching aortic valve replacement to my trainees, we used to put in 21 mattress sutures around 21 to 27 mattress sutures around the annulus. And the not time at the bottom of the aorta needs to be deliberate and the weight you put on it is akin to the weight that is required literally to dimple the forearm. I'm not putting a lot of weight on it. You just don't put your forearm that's how much weight you require. No more, no less. And in fact, you are feeling it down, listen to this as well exaggerated because of the cup. I hope you hear that rasping sound. I often hear that with beginners tying knots. That rasping sound is one thread, rubbing against another thread as a raided suture. And that is weakening your suture. I do recall Steven Wetherby turning to the scrub nurse and saying, sister, could you squirt my hands, please? And she'd say why? Because they're moving so fast, it's generating lots of heat. Well, yes, he was a very det surgeon, but the generation of heat is the friction of the suture running against each other and that should not happen. So there was the la he and now we're going for three felling Gs deep and again, deliberately putting my finger down as far as I can. My finger is on the knot and I'm holding it for that period on the knot so I can further the same direction, take it down and I'm holding it on the knot. And as that pause or finger on the knot at the bottom that secures they're not in place. It's a deliberate purposeful motion. And the idea behind this is I don't wedge my hand into the cup and I'm not lifting it off. Have I done it correctly? That's the thing about all the models that we try and introduce in the Black Beard Academy are models that you can test yourself. So I'm gonna get hold of that. And there you go. I hope you're satisfied that that is secure. And now it's not slipping along that pencil and that's tying a knot at depth. But of course, we want to be able to stop bleeding. One. What better thing to use? I used to use surgical gloves, but of course, they are expensive and not as much fun as a party balloon. So, the funny thing is I've been trying to get those elongated model balloons and I'm gonna have to order them because I can't find them in the supermarkets. But for now, a regular balloon partially grown up how by heat, just to show you that there you go. The heat is actually holding the air in as with the fluids. And the idea behind this is again to now finger on the knot and tired of, I'm just using a bit of cotton. I'm pausing at the bottom and maintaining the pressure on. They're not a braided suture. So I would only need to put five throws on it. And let's see. Um, a hip. You do agree. That is a secure knot. But of course, we gotta keep on practicing each and every time because that's one vessel, but we practice until we can't get it wrong. And I would like to see from you examples of your practice at home. I know when I started learning to tie knots that the arms of the chair, her right arm and the left arm of the chair were festooned with bits of string as I got to grips with flat uncrossed knots. It took weeks and I took a trainer to stand opposite me and say, cross uncrossed, crossed uncrossed. There you go. So far. So good. One of the best examples of innovative knot tying was sent to me by a gentleman who used some human hair. I think it was the long hair from his wife and he used that human hair to tie a knot. I was seriously impressed with this ingenuity and the ability to tie a surgical knot with something as, as fragile as a human hair. And he tied it to a rigid surface as well and it didn't break and like everything in surgery, there's no force involved and everything is about a technique. And if you get the technique right, the rest will follow. Ok. So finger on the knot, you see, my finger is actually below the knot and I'm pausing to make sure it's bedded down second through the same direction to give you that slip knot. And now I'm going to cross the knots, we square the knots for further five throws. Good. There you go. You can use anything string, cat gut. That cat gut here is not too dissimilar. This is not c got this fishing line is not too dissimilar to the 60 that I demonstrated in the first instance, I've previously also used dental floss and I like this because it actually comes in a real and a lot of ligature material does come in a real which you can keep in your hand. The anything with this compared to cotton, it is more expensive. And the idea behind what we're doing in the Black Belt Academy is introducing you to simple low fidelity models that will encourage you to practice at home. So the challenge is for you to come up with creative ways of practicing. And what we're going to offer is for the best three innovative examples of surgical practice, whether it's knot tying, scissors, knife skills, forcep skills on any model that you get in the supermarket or food market, take a picture, send it in to us at medal and the winners, the top three will get their own set of instruments and in this instrument pack, you got everything you need to practice at home. Remember, this is all done at an ironing table because you wouldn't iron up there and you wouldn't iron down there. Setting it up on an ironing board, gives you the perfect height. The other thing is you collapse it, put it out the way until you're ready to practice again. So Gabrielle, any questions from anybody so far, we don't have questions, but we have a comment that it was great. Good. Well, I hope it spurs you on. Ah I just remembered I've got one other important thing to show you coming back to the pian hemostats and how to apply them. And this is very important i in surgery and how you organize yourself as a surgeon and how your cyst now assume that this bit of rubber is a vessel. And I learned this as an sho when we put hemostat clips across all the mesenteric arteries, when you put your hemostat clips across the vessel, make sure there's a clear space between the vessel and the tip and make sure that the hemostats either side or where you're gonna divide are facing each other. You see that they're facing each other. And the reason for that is one, it helps you organize that side and that side because all the clips on this side are on the right. All the clips on this side on the left and that's curving in and that's curving in. The important trick to learn. I bring my hand in is when you asked to take off a hemostat with your left hand that is somewhat difficult in no time holding it. This is my non dominant hand. I'm holding it my thumb and three fingers. I am going to turn it around, lift it up so the surgeon can get it and turn it back towards me. So the three movements we're taking off the hemostat is lift it up so you can get it round a suture around the tip, turn it away and then turn it towards me and often you might be asked to ease and squeeze. So you let go slightly and you put back on as the ligature ties around the vessel. And there's that lifting to enable the surgeon to put the suture around and turn it towards yourself to expose the area where the not is going down. That is important. And certainly with a non dominant hand, I found when I was practicing surgery as a junior, this was difficult until I was instructed to hold it upside down. And now I can actually take the clip off with my left hand like that. Do that. Next time you're in theater, exposing and helping the surgeon get the ligature round the tip, they will be seriously impressed, lift the tip up and rotate it such they can clearly get it round and then take it off. Remember that ease and squeeze obviously, in large diamond of vessels as this would be a simple ligature might not do the trick. And in bigger vessels, you'd pass a needle through and do a stitched knot through the vessel and then tired to secure it to stop it. Dropping off. Remember a simple trick are putting your hemostats facing each other. We do have some questions now. Mhm. Well, the first one is more of an sharing, I guess. So, Kevin is saying that I'm glad to say I have a practice with long hair. It teaches you how much tension you should put and prevent you rubbing against the material. Um If it rubs the hair will break. I don't know if you want to comment anything on that. Yes, the hair is actually good. II wouldn't go that for starting out to practice. To be honest, Karen, simple cotton, simple cotton will do because that will break very easily if you do not apply the right tension and force. Remember the force that you're putting on is literally just dimpling. It's not more than that. So just put your finger against your forearm. That's how much pressure you need. You don't have to push hard. There's no force involved, it's feeling it down and that's the pressure you need no more than that. And certainly with cotton, if you start putting more pressure on than that, you will start breaking the suture. But the important part of the knot tying is actually to have the knot stable as you're tying it that you're not pulling across the knot. And this is particularly important when tying at depth. Remember also that arteries of more than I would say 1.5 millimeters or even more than a millimeter best not diathermy them or cauterize them, learn the lessons of ambrose per and secure them with a ligature. Remember, cautery also increases the amount of dead tissue about. So if you're really wanting to think about your surgical technique and reducing infection, consider ligation more than Cautery and certainly ligate all your veins. Veins do not cauterize cos the vessel walls are not thick enough. And of course, veins particularly around exocrine glands, the thyroid, the adrenal are numerous and variable. And if you do not attend to identifying them carefully and tying them off carefully, you'll run into trouble. Meticulous attention to detail is required. But that also means meticulous attention to putting your finger on the knot. Ok. Thank you. And then Rinker is asking why is it hard to do an Aberdeen's knot on monofilament versus? Oh, well, it it it isn't basically the Aberdeen knot is one throw, second throw and it probably is harder because a monofilament has got memory and it's the memory that makes tying with monofilaments particularly awkward. But if you know that and practice with fishing line, uh large real like this, I think this was couple of pounds. But look how thin that is. That's almost as thin as the hair. You can barely see it on the camera. But that is good stuff to use to practice your not time. And certainly in cardiac surgery, as I said, the 60, I always used for top ends and that's stitching a vein directly to the aorta and you can't afford for that not to come undone. Of course. Ok. Thank you. So that pretty much covers everything and we do have a lot of thank yous coming in, John. Thank you, particularly enjoyed historical introduction and Yeah, I would like you to join us next week. Next week, we're going to combine what we have learned about scissors and knife skills and we're coming up to Christmas. So I'm going to be dissecting a turkey leg as I found previously, the femoral canal of the turkey leg is quite fun to dissect out. It's a part of our festive period. Coming up. A turkey leg will be part of our dissection next week and we'll talk you through the tips and tricks and techniques to find the planes and secure hemostasis. Thank you very much indeed for joining the Black Belt Academy. Look forward to seeing you next week and Gabrielle and Meador, thank you for bringing the globe online to learn skills. And I look forward to hearing from you about your examples and we'll announce the competition in a formal poster.