1) Take suture length 90 cm for Extracorporeal square knot
2) The Endoski needle are generally preferred than the curved ones.
3) For making an Endoski needle, the needle is hold at the 1/3rdfrom the tip by the needle holder and slightly away from that by the base of artery forceps.
4) This will give you an Endoski needle in which 2/3rd of the needle is straight and 1/3rd is curved.
5) Now insert the Maryland in the reducer completely.
6) Catch hold the tail of the suture and bring it out through the reducer.
7) Re-introduce the Maryland in the reducer by the side of feeded suture and catch the suture near the needle and hide the needle in the reducer.
8) Now introduce the Maryland and the reducer together in the abdomen with suture held near the needle.
9) Drop the needleover the tissue in a way that tip should be left and the tail should be right
10) Align the needle by the Pressing the needle by upper jaw of the needle holder at the junction of one third and two third.
11) Stabilize the tissue by the left hand and prick the tissue by the needle and by rotating the tip of needle to keep it perpendicular to the tissue.
12) Bringing the tip of the needle 1/3rd out and catch it with left hand instrument and keeping the convex end of the instrument towards the tissue.
13) Now take another bite and hold the needle with the Maryland.
14) The suture is now feed inside minimum for the four times.
15) At each feeding minimum of 5cm length of the suture should be inside.
16) During the process of feeding the camera person should focus the telescope towards the tip of cannula.
17) With the help of the Maryland the suture should be taken out.
18) While taking out the suture needle holder should support between the suture so that the tissue does not get cut through.
19) Ask the assistant for the finger on the reducer and take a half knot, apply an artery forceps in the tail end and keep the needle end straight.
20) Keep the Clark Knot pusher near the knot and hook it forward.
21) Slide the knot keeping the needle end of the suture straight and tail end of suture loose.
22) Sliding process should be continuous, any stoppage or withdrawal of Clark knot pusher can make the knot pusher disengaged with the suture.
23) Once Clark knot pusher reaches to the tissue do the past pointing to tighten the first half of square knot.
24) Now again bring the Clark knot pusher out and make another half knot and slide it.
25) While sliding second time, take care that the same needle limb of suture should have to be straight and tail end is sliding.
26) Past pointing is important to make the sliding knot to convert into square locked knot.
27) Now finally take a third time the half knot in similar fashion and each time do past pointing.
28) Once the knot is tightened bring out the knot pusher and take curve scissor and cut the suture.
29) It is basically used for the tissue which are under tension and strong enough to tolerate the past pointing.
30) You should never use extracorporeal square knot for any tubular structure and blood vessels.
31) This knot is useful for Vault closure in TLH, Myomectomy, Fundoplication and Herniorrhaphy.

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