LECTURE: Learning Laparoscopy Skills with Lap-Pack, Thursday, September 10, 2020

The Society of American Gastrointestinal and Endoscopic Surgeons designed the Fellowship in Laparoscopic Surgery [FLS] training program 1, 2. The program has well researched and validated tasks for skills training consisting of Peg transfer, Precision cutting, Ligating loop, and extra / intra corporeal knotting.
Dr. Elias EngleKing interviewed many rural surgeons from IFRS and ARSI in 2009 3. During the interviews the senior rural surgeons who started their training in the Operating Rooms rather than the younger trainees who have the opportunities for training in the simulators felt that they needed more training in the following areas:
1) Conversion for 3D actions from 2D images
2) Extra / intra corporeal knotting
3) Suturing

They did not have much difficulty in dissecting, cutting, coagulating etc.
The NIHR–GHRG project of the University of Leeds made an ultra–low cost simulator 4 that has the following advantages in addition to the low cost.
a) Easy accessible ports for introducing instruments.
b) Flexibility to modularly swap with silicon based abdominal skin for using with endoscopic camera.
c) Ability to be used with commercial smartphone/tablet/portable computer.
d) Easy assembly in 10 minutes.
e) Less expensive, tough, lightweight, portable design that folds into a small pack.
f) Validated with various FLS training module task (Peg Transfer, Precision cutting, Ligating loop, extra/intra-corporeal knot).

2) The Laparoscopic Needle holder
3) The Laparoscopic Maryland Forceps
4) Disposable gloves
5) Gauze pieces
6) Re–usable Needle
7) Ordinary thread / suture

This is a well-researched and validated training for converting the 2D images to 3D actions. It is useful to get one even if it is expensive. The idea is to pick a peg, transfer from one hand to the other and place it in the pole on the opposite side. After acquiring the skill for comfortably doing it the following could be carried out.

  • Use different sides of the triangle and different places to transfer
  • Use different hands to transfer
  • Keep the equipment at different places and different angles and also keep a gauze piece underneath to change the slope
  • Do it through the Single Opening in the front


The commercial Endo Loops are expensive. A low cost Endo Loop could be made using the pusher of the DJ stent and Prolene suture 5. The fingers of the Gloves could be used for practising knotting and cutting. Some cotton pieces or gloves could be placed inside the fingers of the gloves to make them a little more realistic.

To make the low cost endo loop the fisherman’s knot or the modified Roeder’s knot could be used and reverse threaded.

Initially the two ports on the top could be used. Later the single opening or port in the front could be used for practising single incision surgeries.


The poles of the Peg transfer equipment could be used for practising the extra corporeal knotting. This is possible by two methods.

The first method is to use the regular surgical knots and a pusher. We can start practising this outside first and then through the front opening.

In the above method after each throw the knot has to be pushed in. During GILLS single incision surgery it is important to remember to have the telescope about the threads and not to have any instruments obstructing on the way.

The second method is to use the fisherman’s or modified Roeder’s knot and push it inside at one go. The tips of the pushers used for the extra corporeal knots are different.

These are available readymade or could be made from Steinmann’s pin as we did.
Several techniques of intra-corporeal knotting is described 15. However we describe the methods that we found useful. The single opening in the front could be used to practice Single Incision knotting.

The first thing to do is to bring the shorter end beneath the longer end of the thread. The next step is to hold the shorter end and push it inside the loop that is formed so that the first throw of the knot is completed as shown in the figures.

For the next step the longer part of the thread should be brought towards you to form the “C” loop as shown in the figure and the right hand instrument should start from below the bend of the “C” loop that is formed.

The needle holder is then passed through to hold the shorter thread and complete the knot.

Sometimes the thread automatically falls in a way that it is easier for knotting as the following picture shows.

If that happens then the needle holder is passed through the bottom of the loop to pass through the ring and complete the knot.

This is a good skill to acquire and could be used for ligating the appendix if single incision surgeries are used. For the regular intra-corporeal knotting the top two ports could be used and the principles are usually the same.

It is important to remember to pull the thread towards the camera while starting and make loops. Similarly the throws in the opposite direction too is possible.

Suturing is another skill that needs practice. To practice suturing it is easy to use a gauze piece that is going across the field as shown in the picture.

A re–usable needle and ordinary thread could be used for practice. This could be used many times and the thread used hardly costs anything.

Unlike in open surgeries the difficulty in laparoscopic suturing starts with holding the needle with the needle holder. Because the monitor is 2D the appearances could be very deceptive. Since the needle holder is different and since we use Maryland forceps or other laparoscopic surgical instrument it is good to practice holding the needle and suturing outside first. Once we know the comfortable positions for holding then to shift to the simulator.

To hold the needle in the correct position the thread is held as close to the needle as possible with the left hand instrument. The position can be adjusted by keeping the needle down.

Once held in position it is a good idea to practice the insertion of the needle above the place where you are actually going to take.

It will save lot of time if the needle is held at the correct place while pulling out the needle. Since the needle comes out in the correct place and is held by the tissues [now gauze piece] it stays in the correct angle for holding. A little push after passing the needle helps a bit to hold in the correct position. Another option would be to lift the tissue [or gauze piece].

Another thing to remember is that while pulling the needle holder through the loop the thread often gets caught in the space that is there for the jaw of the needle holder to open. Usually the needle holder has one fixed jaw and the other one mobile. It is good to have the mobile jaw upward so that it is easy to see and there is less chance of the thread getting caught.

This suturing technique gives practice for tying knots too and then taking suture in the common direction that is necessary [example suturing the peritoneum after TAPP surgery]. While pulling the thread it is important to do it under vision which might mean pulling with the left hand instrument.

Towards the end of sufficient length of the suture is not there holding the needle near the tip helps and sometimes it is easier than holding the thread.

This is a low cost suturing and knotting practice that could be repeated many times and timed to see the progress.

The readymade material for precision cutting would be expensive. A simple but may be even a better way would be to pack some gauze pieces inside the glove and mark the place for cutting on it with a marker pen. Unlike the readymade ones the line would be in different depths and also we can learn to pull out the single gauze piece below it without disturbing the others to practice dissection using the instruments on both the hands.

Studies 6, 7, have shown that surgeons skill improve significantly with training.

The tasks that need validation are
1) PEG TRANSFER – 2 PORTS [Already done by FLS]
9) SUTURING ON GAUZE PIECE [Standardized knotting and number of bites (4)]
The Peg Transfer helps the surgeons learn how to do 3 dimensional tasks using the 2D images that are seen on the screen. This would help them take the instruments to the structures that are of interest to them and do Diagnostic Laparoscopies. The low cost endo loop training would help in starting minor surgeries like tubal ligation. The Single port knotting techniques would help when the trainees are able to do surgeries like Appendicectomies. The suturing would be necessary for advanced surgeries like Hernia repair by TAPP technique and if necessary for other surgeries where suturing is necessary.

The disposable items given for practice with standard trainer boxes or simulators are expensive and need to be purchased. They do come at a price that could be significant for the rural surgeons.

The disposables used here are much less expensive and are easily available to the rural surgeons like Gloves, gauze pieces, the re–usable needles and ordinary thread. The Peg transfer items are the hand instruments are given along with the Lap-Pack.

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J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope. 

References (click to show/hide)

  1. https://www.sages.org/projects/fls/
  2. https://www.flsprogram.org/
  3. Available from: http://india2005.org/UserFiles/study/Development_of_Laparoscopic_Surgery_in_Rural_India.pdf [accessed on May 20, 2020]
  4. Available from: https://ghrgst.nihr.ac.uk/lap-pack/ [accessed on April 14, 2020]
  5. Gnanaraj, J. (2017). Low cost endo-loop for rural surgeons. Tropical Doctor, 47(3), 275–278. https://doi.org/10.1177/0049475516686540
  6. Cooke DT, Jamshidi R, Guitron J, et al. The virtual surgeon: using medical simulation to train the modern surgical resident. Bulletin of the American College of Surgeons 2008; 93:26-31.
  7. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room

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