1) The length of suture used in the extracorporeal knot for free structure is 75 cm.
2) Take the Bhandarkar Knot Pusher in left hand and pass 2cm suture through the eye in the tail end of the Bhandarkar knot pusher by right hand.
3) The knot pusher is now reversely feed in the 3mm reducer. Reverse feeding is important.
4) Once the reducer is feeded the thread is pull out from the eye of the tail of knot pusher. The job of the eye in the tail is just to pass the suture safely from the reducer.
5) Now the other end of the suture is passed through the eye of the head end using right hand.
6) Ask the assistant for a finger and the extracorporeal slip knot is tied.
7) There are three types of extracorporeal knot (A) Roader’s Knot (B) Meltzer’s Knot and the (3) Mishra’s knots. All the knots have different configuration.
8) The configuration of Roader’s knot is 1-3-1. In which the 1st 1 stand for the hitch, 2nd 3 stand for 3 consecutive winds and the last 1 stand for 1 lock (half knot). It is secure up to 8mm tubular structure.
9) The configuration of Meltzer’s knot is 2-3-2. As above the 2 stands for 2 hitch, 3 winds and 2 half knot consecutive lock. This knot is secure up to 12mm tubular structure.
10) The configuration of Mishra’s knot is 1-1-1-1-1-1-1. One hitch 1 wind 1 lock, 2nd wind second lock and again 3rd wind and the final lock. It is the most secure knot among the three for the structure up to 18mm tubular structure.
11) Make the diameter of loop 6cm by sliding the loop by right hands finger and thumb
12) After that hide the knot and its loop under the reducer 
13) Now the knot pusher and the reducer is introduced through the 5mm or 10mm port. If it is introduced through the 10-mm port additional 5 mm reducer should be introduce over 3mm reducer to prevent the leakage of the gas.
14) An Atraumatic grasper should also be introduced from the contralateral port.
15) The loop of the knot should go near the free structure.
16) The Atraumatic grasper should have introduced in the loop and after that it should hold the tip of the free structure over which you want to tie.
17) Now the knot pusher should go to feed the loop behind the structure. The same way like our hands goes behind when we put garland on someone’s neck.
18) The knot now can be slide to the desire place where you want to tie the knot by stablishing the knot pusher with left hand and pulling the suture with right hand.
19) It should be done in such a fashion that structure should not know that it is getting tied. Any traction of pulling and pushing should never be exerted over the tubular structure which you are ligating.
20) After tightening the knot consecutively three times the knot pusher and 3mm reducer is pulled and hook scissors is introduced from the same port and the suture is cut leaving 1 cm tail.
21) The extracorporeal knot is very strong knot and one knot is sufficient to tie any tubular structure like appendix, fallopian tube a piece of omentum small pedunculated myoma or paraovarian simple cyst.

World Laparoscopy Hospital 
Cyber City, DLF Phase II, Gurgaon 
NCR Delhi, 122002, India