the technique described provides extracorporeal control of one limb of the suture and has the advantage of continuous tension application on both ends of the thread during knot formation .
it is easy to learn , fast to perform , and no new equipment is used .
the needle end is advanced through the trocar , and the free end is firmly grasped extracorporeally by the assistant .
the needle is passed through the tissues to be sutured and held with the right needle holder .
the left - hand instrument holds the filament about 5 cm proximal to the needle , thus resulting in a triangle formation , the apex of it being presented by the tissues to be sutured and the base by the segment of the filament between the left instrument and the needle holder ( figure 1 ) .
the needle is rotated around the free end of the filament , which is aligned and held in place by external traction ( figures 2 and 3 ) . as many turns as desired are thrown choosing the appropriate direction : for clockwise throws , the needle is grasped proximally and for opposite throws distally .
the surgeon prepares to rotate the needle around the limb of the suture for a first time .
accurate and safe tissue suturing is essential for advanced laparoscopic surgery . during the last decade , suturing devices such as clip applicators , staplers , and endo - loops have been developed .
extracorporeal knots are easy to perform and are usually created by multiple throws that are advanced intracorporeally with a knot pusher .
most important , tension can not be maintained while throwing turns , and the tying instruments before the next throw release the ends of the filament . on the other hand ,
sequential throw formation in opposite directions is technically demanding , resulting in an unsecured sliding sequence instead of a square knot .
another problem is tissue exposure to unnecessary manipulation and traction from pulling long lengths of suture through the needle track and pushing the knot into position .
intracorporeal knots seem to deal better with the last issue , and they have the advantage of focusing on the operative field during creation . however , a considerable degree of virtuosity is required , and these knots are not available as an option to occasional laparoscopists . on the other hand , the main problem of preserving ligature tension while forming the knot remains to be settled .
even though the technique is an intracorporeal one , continuous tension is guaranteed by providing extracorporeal control of one limb of the suture , thus allowing the manipulation of the needle end with both instruments . winding sequential throws in both directions
the procedure necessitates the presence of a curved needle and can be used for ligating tissues that must be securely approximated , as in gastric banding and nissen fundoplication .
the greek term for intracorporeal knot  is easy to learn and is secure and therefore presents an option not only to the laparoscopic surgeons but to other surgeons as well .
 accurate placing of securely tied knots in laparoscopic surgery is technically demanding and time consuming . 
 surgeons must face difficulties arising from 2-dimensional vision , spatial limitations , and restricted movement . 
 issues to be taken into account include security , virtuosity , and cost effectiveness . 
 the authors believe that in spite of advances in instrumentation and optics , training should aim at manual skill development and application of the basic principles of general surgery . 
INTRODUCTION
METHODS
DISCUSSION
CONCLUSION