BASIC INFORMATION

Date & Time: March 31, 2026, 12:17 PM Indian Standard Time

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This document synthesizes a comprehensive series of lectures for postgraduate surgeons and gynecologists on the Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES). It outlines the core principles, standardized techniques, and performance benchmarks for the FLS manual skills tasks, including Peg Transfer, Pattern Cutting, Ligating Loop, and Intracorporeal/Extracorporeal Suturing. The discussion addresses the upcoming evolution to FLS 2.0, which will revise the cognitive exam and skills tasks. The handout also covers the FES certification, detailing its five skills tasks, the critical role of clinical experience over simulation alone, and strategies for loop prevention and reduction in colonoscopy. A key discussion addresses the observed performance disparity on the FES exam between male and female trainees, exploring ergonomic and pedagogical factors and proposing adaptive training solutions. The content provides a structured framework for achieving proficiency and certification in these essential surgical domains.

KEY KNOWLEDGE POINTS

• FLS and FES Certification: These are validated, mandatory programs for American Board of Surgery (ABS) eligibility, designed to establish minimum standards for basic laparoscopic and endoscopic skills.

• FLS Manual Skills: The five core tasks are Peg Transfer, Pattern Cutting, Ligating Loop, Extracorporeal Knot Tying, and Intracorporeal Knot Tying, each with specific proficiency goals and penalty criteria.

• Structured Practice: Optimal skill acquisition is achieved through distributed practice (short, frequent sessions) rather than massed practice (cramming), with an average of 10 hours of practice required for FLS proficiency.

• FES Skills Tasks: The five virtual reality tasks are Navigation, Loop Reduction, Retroflexion, Mucosal Evaluation, and Targeting.

• Clinical Experience in Endoscopy: A high volume of clinical cases, particularly colonoscopies, is the single strongest predictor of success on the FES skills exam.

• Loop Management in Colonoscopy: The modern paradigm has shifted from reactive loop reduction to proactive loop prevention through skilled scope advancement using torque, patient positioning, and water immersion.

• Ergonomic Disparities: A performance gap on the FES exam between male and female trainees is linked to ergonomic challenges and training methods, not innate ability. Solutions involve teaching adaptive techniques.

• FLS 2.0: The FLS program is being updated with a new, specialty-neutral cognitive exam and revised skills tasks, including the planned removal of the extracorporeal knot.

INTRODUCTION

Standardized competency-based training and assessment are cornerstones of modern surgical education. The Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES) programs, developed by SAGES in collaboration with the American College of Surgeons (ACS) and the American Board of Surgery (ABS), provide a validated curriculum to teach and evaluate the foundational knowledge and psychomotor skills essential for minimally invasive and endoscopic procedures. Certification in both is a prerequisite for ABS board eligibility and is increasingly adopted by other specialties, such as gynecology. This lecture series consolidates the critical knowledge required to master these tasks, emphasizing not only the "how" of each skill but also the "why," connecting simulation-based practice to safer, more efficient performance in the clinical environment.

LEARNING OBJECTIVES

• To understand the procedural steps, rules, and proficiency benchmarks for the FLS and FES manual skills examinations.

• To master key principles of laparoscopic suturing, including intracorporeal and extracorporeal knot-tying techniques.

• To learn proactive techniques for loop prevention and a universal method for loop reduction in colonoscopy.

• To identify the ergonomic and pedagogical factors contributing to training disparities in endoscopy and recognize adaptive strategies.

• To understand the upcoming changes in the FLS 2.0 certification program.

CORE CONTENT

1. FUNDAMENTALS OF LAPAROSCOPIC SURGERY (FLS)

1.1. Principles of FLS Training

• Distributed Practice: Training should be planned in sessions of approximately one hour per day, several days per week. This method is superior to prolonged "marathon" sessions as it minimizes fatigue and enhances motor skill consolidation.

• Proficiency-Based Goal: The objective is to achieve consistent, expert-level performance, not simply to log hours. An average of 10 hours of dedicated practice is typically required for a novice to become proficient in all five tasks.

• Ergonomic Setup: Before beginning any task, the camera must be centered and focused, and the monitor should be positioned below eye level to reduce neck strain.

1.2. FLS Manual Skills Tasks

• Task 1: Peg Transfer: Assesses ambidexterity and hand-eye coordination. Six pegs are transferred from one side of a board to the other and back again. Objects must be transferred mid-air. The proficiency goal is completion in under 48 seconds.

• Task 2: Pattern Cutting: Assesses precise, bimanual dissection. A circle printed on gauze must be cut out. The key to success is using the non-dominant hand grasper to apply constant, gentle traction, presenting a taut edge to the scissors. The proficiency goal is under 98 seconds.

• Task 3: Ligating Loop: Simulates ligation of a structure (e.g., appendix). A pre-tied loop is placed over a target on a Penrose drain, cinched, and the suture is cut. The proficiency goal is 53 seconds or less.

• Task 4: Extracorporeal Knot Tying: Assesses the ability to tie a knot outside the body and advance it internally with a knot pusher. A 90–120 cm suture is used to tie three alternating half-hitches (a square knot). A surgeon's knot is not used as it will not slide. This task is currently planned for removal in FLS 2.0.

• Task 5: Intracorporeal Knot Tying: Assesses advanced laparoscopic suturing. Using a 15 cm suture and two needle drivers, a surgeon’s knot (double throw) is placed, followed by two additional single throws in opposite directions. The needle must be passed between hands after each throw. The proficiency goal is under 88-112 seconds.

1.3. FLS 2.0 Updates

• Cognitive Exam: A new question bank is being developed with content focused on fundamental tasks rather than procedure-specific knowledge, making it more applicable across specialties like OB-GYN.

• Skills Exam: The extracorporeal knot-tying task is slated for removal. The committee is exploring the addition of new tasks, such as trocar insertion, to better reflect core laparoscopic skills.

• Virtual Proctoring: Accelerated by the COVID-19 pandemic, remote proctoring for both the cognitive and skills exams is becoming a permanent, more accessible option.

2. FUNDAMENTALS OF ENDOSCOPIC SURGERY (FES)

2.1. The Primacy of Clinical Experience

The FES exam is designed to assess genuine endoscopic skills. The most significant predictor of success is the volume of clinical experience, particularly in lower endoscopy (colonoscopy). While simulation is a helpful adjunct, it is not a substitute for hands-on clinical cases. The pass rate for residents with 0-24 lower endoscopy cases is 77%, whereas for those with over 200 cases, it is 97%.

2.2. The Five FES Skills Tasks (Virtual Reality)

• Navigation: Navigating a simulated lumen to align a halo with a series of cones.

• Loop Reduction: Managing and reducing loops that form in the colonoscope shaft. This is often considered the most challenging task.

• Retroflexion: Using a probe to touch a target while the scope is in a retroflexed position.

• Mucosal Evaluation: Systematically inspecting the simulated mucosa to identify and frame lesions.

• Targeting: Using a probe to touch designated targets in a forward-viewing position.

2.3. Principles of Loop Management in Colonoscopy

• Paradigm Shift: The focus is on loop prevention through skilled advancement, not reactive reduction.

• Proactive Techniques: Mastery of torque steering, dynamic patient positioning, minimal air insufflation, and the use of water for lubrication and stabilization are key to preventing loops.

• Patient Positioning: Dynamic positioning is a powerful tool.

  • Sigmoid: Left lateral

  • Splenic Flexure: Right lateral (to hang the transverse colon down)

  • Transverse Colon: Prone

• Universal Loop Reduction: When a loop forms, a simple technique is applied:

  1. Hook: Slightly withdraw to hook a haustral fold or flexure.

  2. Torque: Apply rotational torque to the scope shaft (clockwise or counter-clockwise).

  3. Withdraw: Continue withdrawal to shorten and un-twist the colon over the scope.

2.4. Performance Disparities and Training Solutions

• The Issue: A documented performance gap exists on the FES exam, with female trainees passing at a lower rate (72%) than male trainees (91%).

• Root Causes: This is not due to innate ability but is linked to the ergonomic challenges of standard endoscopes for smaller hands and pedagogical gaps in training. Novices often grip the scope too tightly and are not explicitly taught to use body mechanics for torque.

• Solutions: Training must include adaptive techniques such as fingertip control, alternative hand positions, and the use of whole-body motion to apply torque. Mentorship from female or smaller-statured endoscopists is highly valuable.

SURGICAL PEARLS

• Camera First: Always adjust and focus the camera before starting any FLS task. A well-centered image is foundational.

• FLS Pattern Cutting: The non-dominant hand applying traction is the key to success. The scissors only cut the straight, taut edge created by the grasper.

• Intracorporeal Suturing: Use two needle drivers. To manage a short suture tail, grasp the needle body itself with the dominant instrument to gain effective length for wrapping.

• Colonoscopy Loop Prevention: Water is your friend. Use generous water irrigation in a dry or difficult sigmoid to lubricate and stabilize the colon.

• Endoscopy for Smaller Hands: Use your entire body to rotate and torque the scope, not just your hand and wrist. Relax your grip and use your fingertips for fine control of the angulation wheels.

• Situs Inversus: For a patient with situs inversus, "mirror" your standard approach. Begin colonoscopy in the right lateral decubitus position instead of the left.

ANESTHETIC AND PHYSIOLOGICAL CONSIDERATIONS

Managing Simulator-Induced Motion Sickness

This is a common barrier to training. Management includes:

• Incremental Exposure: Start with short 5–10 minute sessions and gradually increase the duration.

• Environmental Controls: A small fan blowing cool air on the face is highly effective.

• Breaks and Hydration: Enforce mandatory breaks every 15–20 minutes.

COMPLICATIONS AND THEIR MANAGEMENT

• Intraoperative (During Simulation/Procedure)

  • FLS Task Errors: Penalties are incurred for errors like dropping a peg out of view, cutting outside the lines, or creating an insecure knot. These are managed by practicing to avoid them.

  • Drain Avulsion (FLS Suturing): Caused by excessive tension. This is prevented by stabilizing the Penrose drain with the non-dominant instrument during needle passage and knot tightening.

  • Colonoscopy Looping: Leads to paradoxical movement and patient pain. Manage by de-sufflating and applying the universal reduction technique. A vasovagal response (bradycardia, hypotension) requires immediate withdrawal of the scope to release mesenteric tension.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

• Mandatory Certification: FLS and FES certifications are non-negotiable requirements for ABS board eligibility. Failure to pass can delay a surgeon's career progression and credentialing.

• A Standard of Competency: These programs provide objective, validated tools that institutions can use to credential surgeons for laparoscopic and endoscopic privileges, forming a critical component of patient safety.

• Training Equity: The FES performance disparity highlights the need for adaptive training programs to ensure all trainees can meet the single high standard of proficiency, rather than altering the standard itself.

SUMMARY AND TAKE-HOME MESSAGES

• FLS and FES are foundational curricula designed to establish and assess basic, not expert, laparoscopic and endoscopic skills.

• Proficiency is achieved through structured, distributed practice with a focus on proper technique, ergonomics, and understanding the core principles of each task.

• Clinical experience, especially in colonoscopy, is the most critical factor for success in the FES exam, underscoring the direct link between simulation and real-world performance.

• Effective endoscopy and laparoscopy require more than just hand skills; they involve body mechanics, strategic thinking, and adaptation to patient anatomy and ergonomic challenges.

• Surgical training is a dynamic field. Trainees and educators must remain aware of evolving certification standards, such as FLS 2.0, to ensure continued relevance and competency.

MULTIPLE CHOICE QUESTIONS (MCQs)

1. According to the lectures, what is the recommended practice schedule for FLS training?

   a) A single 10-hour session before the exam.

   b) Four hours continuously, one day a week.

   c) One hour per day, for several days a week.

   d) Thirty minutes only on the day of the exam.

2. For the FLS Pattern Cutting task, what is the most critical action for a successful outcome?

   a) Cutting as quickly as possible.

   b) Using the non-dominant hand grasper to apply constant traction.

   c) Making long, sweeping cuts with the scissors.

   d) Cutting through both layers of the gauze simultaneously.

3. The knot configuration required for the FLS Intracorporeal Suturing task is:

   a) Three consecutive single throws.

   b) Two surgeon's knots.

   c) A surgeon's knot (double throw) followed by two single throws.

   d) A slip knot followed by a square knot.

4. Which FLS manual skills task is planned for removal in the upcoming FLS 2.0 update?

   a) Peg Transfer

   b) Intracorporeal Suturing

   c) Pattern Cutting

   d) Extracorporeal Knot Tying

5. What is the single most significant predictor of success on the FES skills examination?

   a) Hours spent on a virtual reality simulator.

   b) The number of clinical lower endoscopy (colonoscopy) cases performed.

   c) The trainee's final score on the FLS exam.

   d) The trainee's glove size.

6. Which of the following is NOT one of the five FES hands-on skills tasks?

   a) Loop Reduction

   b) Retroflexion

   c) Polypectomy

   d) Navigation

7. What is the modern paradigm for managing loops in colonoscopy?

   a) Identifying each loop by name before attempting reduction.

   b) Proactive loop prevention through skilled scope advancement.

   c) Using a variable stiffness scope as the primary strategy.

   d) Advancing forcefully to overcome paradoxical movement.

8. For navigating a difficult splenic flexure during colonoscopy, the recommended patient position is:

   a) Left lateral decubitus

   b) Prone

   c) Supine

   d) Right lateral decubitus

9. Data on FES exam pass rates revealed a disparity between:

   a) Rural and urban trainees (80% vs 90%).

   b) Male and female trainees (91% vs 72%).

   c) US and international trainees (95% vs 75%).

   d) General surgery and OB-GYN trainees (88% vs 82%).

10. The root cause of the FES performance disparity is thought to be related to:

    a) Innate ability and spatial reasoning.

    b) A combination of ergonomics and pedagogical gaps in training.

    c) A lack of interest in endoscopy among certain groups.

    d) Differences in residency work-hour restrictions.

11. What is a key adaptive technique for endoscopists with smaller hands?

    a) Relying exclusively on the control knobs for steering.

    b) Gripping the scope handle as tightly as possible for stability.

    c) Using whole-body motion to apply torque to the scope.

    d) Requesting a pediatric scope for all adult procedures.

12. A major change in the FLS 2.0 cognitive exam is a shift to:

    a) An essay-based format.

    b) Questions focused on advanced robotic surgery.

    c) More task-specific content applicable to multiple specialties.

    d) A verbal examination with a proctor.

13. What is a recommended strategy to manage simulator-induced motion sickness?

    a) Practicing in a dimly lit room.

    b) Using a small fan to blow cool air on the user's face.

    c) Increasing practice duration to build tolerance quickly.

    d) Consuming a large meal before training.

14. What is the recommended initial patient position for colonoscopy in a patient with situs inversus totalis?

    a) Left lateral decubitus

    b) Prone

    c) Right lateral decubitus

    d) Supine

15. In FLS intracorporeal suturing, what action is mandatory after each throw to form a square knot?

    a) Cleaning the instrument tips.

    b) Passing the needle to the opposite hand.

    c) Re-centering the camera.

    d) Applying a small amount of tension.

16. The universal technique for reducing a colonic loop involves which primary actions?

    a) Advancing, torquing, and insufflating.

    b) Suctioning, stiffening, and applying pressure.

    c) Hooking a turn, applying torque, and withdrawing/shortening.

    d) Changing position to prone and jiggling the scope.

17. The average time a novice requires to achieve proficiency in all five FLS manual tasks is approximately:

    a) 2 hours

    b) 5 hours

    c) 10 hours

    d) 20 hours

18. What is a common suboptimal training method in endoscopy identified in the lectures?

    a) The attending pushing the scope while the resident only turns the knobs.

    b) Residents practicing on simulators before clinical cases.

    c) Using water immersion for lubrication.

    d) Having the resident perform the entire procedure from the start.

19. A key advantage of using two needle drivers for intracorporeal suturing is:

    a) They are required by FLS rules.

    b) They provide a more secure grasp on both the needle and suture.

    c) They allow for faster cutting of the suture.

    d) They are easier to clean than a Maryland dissector.

20. The final FLS score for a skills task is calculated based on:

    a) Time only.

    b) A subjective assessment by the proctor.

    c) Time minus a score deduction for penalties/errors.

    d) Number of errors only.

Answer Key:

1.c, 2.b, 3.c, 4.d, 5.b, 6.c, 7.b, 8.d, 9.b, 10.b, 11.c, 12.c, 13.b, 14.c, 15.b, 16.c, 17.c, 18.a, 19.b, 20.c

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

The surgeon's greatest instrument is not the one held in the hand, but the disciplined mind that guides it. Cultivate this mind with relentless practice, for it is in the quiet hours of preparation that the confidence for the critical moment is born.

May your dedication to mastering these fundamentals build a career defined by excellence and unwavering patient safety. My best wishes are with you on your surgical journey.