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Right. 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 retired cardiac surgeon living in Yorkshire in the United Kingdom. The past director of the Faculty of Surgical Trainers and of the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College London. Thank you for joining us this evening from 14 different countries. It is much appreciated. Thank you to all the followers on Facebook and on Instagram do pass the word around we up to 622 on Instagram and 4230 on Facebook. This evening, we're going to be talking about knots and the knots are all around rope and twine. Now three ply cord or twine has been found in Neanderthal caves of 50,000 years ago or be it only a small fragment? But the fact that they had hump or was it animal skin or animal sines twisted suggested that the art of making rope and twine has been around for a long time indeed, 40,000 years ago in a cave in Southwest Germany, the whole fo caves, they found a piece of mammoth ivory with three holes in it with particular grooves designed for twisting and making twine or rope. I didn't know. And perhaps you didn't know when you look at a rope and look at the way it is actually twisted. If it is A Z, it has been twisted to the right and if it is an s it's been twisted to the left. And the tools for making these have been documented in hieroglyphs, an Egyptian pyramids and the Chinese have been making rope from hemp since 2800 BC. The Greek physician, her recla described the first knot and astronauts are trained in surgical knot tying as well. The thing about a knot, it has to be tied, it allowed to be tightened, but also it has to stay tight. And that is the principle of a knot. There's an International Guild of Not Tires that started in 1982 by a retail manager in Ipswich in the United Kingdom, Des Rason and a metropolitan police officer Jeffrey Bosworth. And they put together a guild of not tires to look at the research. And the Science of Knots produce periodicals and books. The most famous of which is the Ashley Book of Knots. Maintain a library, collect different Knots research and develop new lots. And there's a lot of science behind the tension of lots. But whenever you tire not, you're going to actually cause damage to the thread in itself. But they're also encouraged knots as a craft. And knot tying has been used as a physiotherapy for those people who have difficulty moving their fingers. What I was interested to read about is that there's the sixth knot challenge. Now, listen to this, this is tying six knots in a certain time that included a reef, not a sheet band knot, a sheep shunk, not a clove hitch, a round her 2.5 hitches and a Boline. Now, you wouldn't guess how fast they did that. The world record set by Clinton Bailey in 1977 was 8.1 seconds. Now, I recall the not tying and learning, not tying is really difficult and laborious exercise because nobody quite deconstructed it for me. And those recent surgeons were throwing knots furiously down on theater and said, sister get the syringe of water and they say why? Because my hands are working so fast and steam is coming off the knot. That is not what you're supposed to be doing because it needs to be deliberate, precise bed and down tightened and it should not come undone. The most common knot that you probably didn't realize you tie every day are your shoelaces. And the reason why your shoe laces comes undone is because you haven't done a proper knot. So if you take a length of cord like this and we fold it over to make a loop to make a, not we take it through the loop and bring it down in surgical terms for the one hand and surgical knot that's using two hands, that's the short end and that's the long end and effectively you've made a loop and it's your finger through the loop that flicks the short end through and you catch it and you catch it between two fingers and take it away. That is the first step towards making a knot. So let me show you again from a different angle. You a long hand and a short hand, we've crossed it over and your finger comes through the loop and you flick it with the back of your nail, catch it between your fingers and you take it away and there you go, you have your knot. So how does that actually work in the movement of fingers? And I emphasize that point because it's that flick with the back of the nail and catching it. That was never described to me when practicing nots. So let me explain the principles and will come down and look at this and we'll put a video up for you on the website and I tried to put it to music. One for a little bit of fun and two to try and reinforce the process. So you do not need a fancy plastic knot tying station. OK? I'm into sustainable surgery in practice and you do not need plastic simply get a book, a brick, a piece of wood, a couple of elastic bands and a couple of pencils and automatically you have you not tying jig. So let's come to this and see how we tie a one handed surgeon. Not, we have a long end that I'm holding up and your short end, I'm gonna hold, just make sure. And Gabrielle do say if I'm out of focus and out of picture, please will do. I'm holding between my index finger and my thumb and that's towards me. I'm now extending my three fingers and my hand and I'm gonna to supinate and by supinating, you can see I'm taking that string out, I'm then gonna cross the long over the short and crossing the long over short. I've made that loop and I look at this, I like straight lines as a figure of four. There's my middle finger. It's through the loop already and I'm gonna bring it round and I'm gonna flick that short end. That is hell between my thumb and my index finger. Flick it through the loop. I'm catching it between my ring finger and my middle finger and I'm taking it away. And as I take it away, my thumb is now coming to hold the end between my middle finger and my thumb. Note the switch, it went from between my thumb and index finger and now it's between my thumb and middle finger and now extend my middle finger, I sweep it out, turn it in and I'm holding that short bit away. I'm creating that loop as that figure of four. Again, the only finger I've got through that four is my index finger that I'm gonna take. Flick it through and catch between my middle finger and index finger and a bringing towards me note that as I did that, my hand went that way and then went this way. And if I zoom down on this, uh looking at the hitting the wrong button there, if I zoom down on this, you will see I have got a perfect reef knot and I'll just show you that is the commonest knot that we tie in daily practice and that is your shoe lace. I'll explain further in a moment. So what does that look like from the other hand? It's the same rules of play. And some of you have said that you are good at practicing with your left hand and others with your right hand and some with both again, start short and towards you holding between your thumb and your index finger. I'm extending my other fingers and I'm supinating to hold that short end out. I'm bringing the long across the short. And as you can see there, I've got an inverted figure of four or loop and through that loop, I've got my index finger and my ring finger, but it's my ring middle finger, uh uh sorry middle finger. And index ring finger and it's my middle finger that I'm going to take at and flip to the back of my nail that short end through the loop and catch it. There you go between my middle and ring finger and I take it away and by taking away, you can see that that is going down flat. I'm now holding between my thumb and my middle finger. I extend my index finger, I sweep it out, turn it in and hold that short hand away. I cross the long over the short and my index fingers through that loop and I flick it through, catch it and I bring it towards me. And there again, we have that reef. Not a lovely flat perfect knot. Now, why that is important in your knotty is as follows. It was fine where I am on the camera, please. There you go. That is a reef knot that is right over the left, left over right. And you will recognize that as a re not. And it sits flat on the table surface and then sitting flat on the table surface. If I put my fingers in here and I pull this, it is tightening. But if this was your shoelace, that is the loop, the short ends that's sitting horizontally across your shoe. By contrast, this knot is a crossed knot flat, uncrossed re knot crossed, colloquially called a granny knot. And you see now the short ends are in the vertical axis. And if I'm pointing at working my fingers in the loop, it doesn't take much time. And that's what happened to your shoelace during the course of the day with flexion of the talar part of your foot and that comes undone. So when we tie or not, it's important that we recognize that our hands are going back and forth, back and forth like this as we're alternating between the through, holding the index finger and the thumb and the middle finger. All right. And I remember it this way, I take it through and it's way for me, sweep it out, take it through and it's back to me. And that's the way I remember the movement at no time are my hands crossing. Now. It's all very well to do that. But what we need to do is make sure it beds down and it sits carefully and tidally on the tissue. And here we got one throw, one direction and the same throw again, ending up with two half hitches and the half pitches allow you to bed it down and maintain tension. And that bedding down and maintaining tension is very useful in tying knots, particularly with mono filaments to make sure they're bedded down. The other way to ensure that it's tight and bedded down is to use a surgeon's knot. So a surgeon's knot, that's one throw. It's through the same route. A second throw. And this is particularly useful with tying and rings. And I was using a bit of string earlier on to tie it onto a drain. And my hose pipe is a drain because your drains do not want to come out and you gotta be able to bite it into the drain and it should not move along the surface. So how do we practice these techniques? Well, I suggest that you take a Khan pop it on the table and remember the table height is important because your arms have to be working at a functional height. Use any piece of string you like entwine and we're going to put one through down and the second through the same direction and bed that down. And it's the extension of the finger at the end of each movement that beds the knot down. I say finger on the knot. But if you look carefully, my finger is just below the knot and I'm tension the suture or tension the string across the knot. And because of the cross a lot, I am not lifting the coat hang off the table having tension that I can continue. Now with my K not tying alternating four hand throw, index do middle finger, throw my hands moving towards me. And when I look at it at the end, I should have a neat pattern are repeated. We not all the way up, but the important thing is is to learn to do it such that it does not slide along. Of course, we do not use string in theater. We use a finer material. You don't have to have suture material to do this. And I recommend using some cotton and cotton is a very good exercise to practice with. I'm just trying to get this center for you. It's always awkward watching the screen and trying to do the exercise at the same time without losing the focus. So there you go, Short hand finger and thumb, supinate out figure four. Take it through, take it away and my finger is on the knot. I'm going to put this through the same direction, says two half hits to take it down and tighten it to bed it down on that. Once I know it is bedded down, I can then continue my throws, being careful each the time to make sure I'm not moving the ger OK? How many throws you put on a braided suture? Well, because it's braided like cotton. I put five for the monofilament and the easiest thing to do is to use some fishing line. It's a monofilament. I would then use seven. There's no point putting any more than five or seven or six and eight. Whatever you feel your superstitious lucky numbers are, but those are the minimum and certainly two or three on a monofilament is extremely likely to come undone. I had a bit of blue monofilament on the table and that's is a bit of proline on this exercise, you can take it and see if you can move it across your co hang up. Do the same with a bit of fishing line or there's go to theater and ask the theater staff to keep some sutures for you. Often, there's a lot left over after an operation and if you go to your theater and ask them to keep them for you, I'm sure they'll be delighted to reduce the waste. Now, I caught that suture and that's not a good tie. So let's come around finger and thumb, supinate figure four through the loop. Take it away. You put another one on there, make your finger in the knot to put it down. And I'm either using my index finger or my middle finger extended to bed it down. So we're gonna put seven throws on here. I'm not sure if you're counting and we cut it four millimeters long depending on the thick thickness of the thread. And again, you should be able to tie it such that it doesn't move down. Now, what we did point out last week when we were talking about knots is that the actual knot itself stands quite proud and this is why monofilament in particular or all knots or in closing layers need to be buried because that ends up as a little spike. And if you're using a monofilament to close the skin, that knot will also be a nidus for infection. And certainly when I was closing sternotomies. Even with a Monopril, I wouldn't knot this at the top but bring it through and put a little leger clip on it and cut it off later. But that little spike itself will cause damage. So we now got finger on the knot to make sure it's bedded down. We now got to practice notting at depth. And what I've got here is I table in a bit is a plastic cup with a bit of Gluta and fixing it to the bottom. And I put a pencil through the plastic cup. Now, the pencil you can put through at one Pharynx, two phalanges or right at the bottom of the cup. And this is a good way to actually practice. You're not tying the pencil is useful because it's a bit like a coat hanger. You can assess at how well you've tied the knot by moving it along the pencil or not as the case may be. And you can assess how well you bet the not down because the idea is not to lift the cap off the table. So the way to pass a suture a depth, it's to put it on a Roberts or this is a lay and bo string it across and I'm bowing in lacrosse, you place it down below what you going to tie to pick the end up, let go. And you have passed your suture around something at depth. That's a neat little trick to do as an assistant, whether you right-handed or left-handed. So here we're going to actually tie the knot at depth and make sure our fingers on the knot and the duration your fingers on the knot should be the duration of you saying it. Now listen to this carefully. You might not hear, see that, hear that rasping that rasping of the one suture against the another is you often hear that when people are tying knots and that is fraying your suture. I would not encourage that at all because it's weakening the suture. This is where the consultant said sister, pass me a syringe of water squirt my house because of the steam. So there you go. I should be able to rather than not, that was one I did earlier as well and effectively hold that and it shouldn't move across da pencil two secure knots at depth. Now, you can practice yourself either one phalanx two family or right at the bottom. And if your hand is right at the bottom and tying it, make sure as you're doing it, you're not crinkling the cup but the cup remained stuck to the plate all the time. Now, a fun way of practicing not tying as well is balloons. And I've got a balloon here, put a clip on the end, but that gives you a lovely practice neck, put tying a knot. So let's have a go and of course, all our knots have to be secure. And if it can't hold the air in the balloon, well, is not gonna hold blood. And what I demonstrated there also is cotton is very unforgiving. If you do not put the right tension in it and hold it properly, it breaks. And that is true of many fine sutures that you really do have to put just the right amount of tension on the suture to hold it. Ok. And let's see if this is secure or not. There you go. No, you too can easily do this at home. Well, it's moving down, isn't it? But it's not leaking there. It is. I did not cheat. But that was putting an enormous amount of pressure on the knot. Let's have another go. Uh, so next time somebody has a party offer to blow up the balloons and you've got a substrate then for lots and lots of practice when I've taken trainees through an aortic valve replacement. We've got anywhere between 21 and 28 ses, each of them have to be tied when you're doing an aortic valve. And cardiac surgery is the only operation against the clock. You got to work with a clock if you put more throws on than necessary. And we're using a Ron a breaded suture. So I say five throws, each 678 throws, not only include increases the length of the knot, but increases the time because you're multiplying that by the number of sutures you've got around the Aorta Gauss. It's an unnecessary repetitive movement. And there you go, try it yourself with different sutures, different experiments, different materials. But that to me is the simplest and easiest way to practice on low fidelity models. Get used to tying with both your right hand and your left hand. I had a rugby injury when I was younger and therefore prefer not to use my left hand. The other thing about na time, which I'll demonstrate is for those who have used scissors before and are holding them on the ring finger, you can bury the scissors and still have three fingers to tie the knot. And that is quite a useful exercise and used to do it a lot as a general surgeon, but not as a cardiac surgeon because you can't afford to have your hands full of instruments catching on thread. But let me show you what we used to do, come back down again. So I've buried, I'll take these scissors, bat them in my hand and I can still through and not and bring the scissors out and cut it. And I suppose we'll talk about scissors next week, but that is why I've put and hold my scissors on my ring finger because it allowed me these three fingers to actually throw the knots. Now, as you practice, I want you to try when sitting down in front of the telly or on an arm chair to tie your knots in the right arm and your left arm of the chair with your right hand and left hand, each time you got to say to yourself is the knot flat. And that is achieved by moving your hands back and forth. Like that. Move on former piece of shoe lace and string to fine a sutures. And one of the best examples sent to me by one of the followers in the Black Belt Academy was a not high with a length of hair and was a beautifully tied knot and in cardiac surgery and a microsurgery. Seven Os and eight Os are as thick as your hair. It all starts by practicing with a bit of rope and it only comes with deliberate practice. Your hands are moving like that. Your extended finger is bedding it down and you're holding the tension across the knot. I hope this makes sense. Enjoy the video. Very happy to answer any questions Gabriel, do we have any questions? We don't. Uh But we do have quite a lot of people logged in. So if anyone has any questions, uh just to remind that you can pop them. Um Delighted, delighted to ask, answer them when I first started surgery. It, I only remember in 15 years of training three consultants who had a significant impact on the way I practice surgery. And the first was Mr William Walter Frederick Southward. He would watch my knot time and in those days back in 1987 w tied with silk sutures and silk ties. But he was very diligent in watching every through saying crossed, uncrossed, crossed, uncrossed. Nobody ever done that before. And it thanks to him that I look at my sutures even to this day and I'm thinking crossed and uncrossed. So talking out aloud to yourself and thinking about the movement of your hands, see crossed, uncrossed, say finger on the knot because saying it out loud as you're practicing, it is reinforcing the action and will help you remember these techniques and saying it out loud does become important and form part of your tea cup tcup thinking critically under pressure because during your career, you will be exposed to quite traumatic, scary moments where you think gosh, what am I going to do? But they have a sound basis of thinking critically under pressure, making sure your technique is accurate and precise is going to make all the difference. You can always fall back on good technique. And that's why he established the Black Belt Academy of Surgical Skills. Bruce Lee said he's not worried about the person who can do 10,000 kicks. He's more worried about the person who's done one kick 10,000 times. And there's the Japanese art of making pots, you have to make 100 parts perfectly. If 99 fails, you start again because the whole thing about practice is you practice until you can't get it wrong. Thank you very much for joining the Black Bart Academy. We look forward to seeing you next week. We'll be talking about the use of the scissors and how you can use them to separate and define tissue layers. Thank you very much and I wish you well and thank you Gabrielle and Medal for supporting the Black Belt Academy Surgical Skills.