1) The length of the suture for Extra Corporeal Knot for the Continuous structure used is 90 cm.
2) Before start tying extracorporeal knot for continuous structure make a Window by dissecting tissue plane where you want to ligate this extracorporeal knot.
3) Hold one end of the 90cm suture with the Maryland and then feed and hide 1/3rd of the Maryland and suture in the 5mm reducer and introduce Maryland and suture both togetherthrough 10 mm port.
4) Introduced Atraumatic grasper in another 5-mm port.
5) The suture should pass through the window and should be hold by the atraumatic grasper.
6) The job of the camera person is crucial here. The light cable should be towards the right and should flyover towards the window/target to show the tip of Maryland to the surgeon.
7) The suture which is held by grasper is now transfer back from the grasper to the Maryland.
8) The suture is now feed inside the abdomen minimum four timesby atraumatic grasper to bring 20cm suture length inside abdomen.
9) During the process of feeding the camera person should focus the telescope towards the tip of the cannula.
10) At each feeding minimum of 5cm length of the suture should be pulled inside.
11) Once feeding of suture is complete bring the grasper back again in between the suture loop and tissue.
12) With the help of the Maryland the suture should be taken out keeping the grasper in between the loop and tissue.
13) While taking out the suture grasper should have kept steady between the suture so that the tissue does not get cut through due to shearing effect.
14) Once tail end of suture is out through the reducer, ask the assistant to keep the finger on the washer of reducer in between the two suture to prevent gas leek. 
15) Now tie extracorporeal knot and the assistant finger should cover the reducer so that the gas leak can be prevented.
16) You can use any of the extracorporeal knot slip knot (Roader’s, Meltzer’s or Mishra’s knot) depending upon diameter of structure and quality of your suture material.
17) The suture is feed from the head end of the Bhandarkar knot pusher and is taken out from the tail end of the knot pusher.
18) The knot pusher is now reversely feed in the 3mm reducer.
19) The knot pusher and the reducer is introduced inside the 5mm reducer by asking the assistant to remove finger from reducer and knot pusher is pushed in the abdomen under vision.
20) Knot pusher is pushed and the suture is pulled to make loop shorter.
21) Keep the tip of the knot pusher where you want to tie the knot.
22) The knot will automatically slide to the desire place where you want to tie the knot and where tip of the knot pusher is kept.
23) Pushing of knot pusher and pulling of the suture should be done in such a fashion that structure should not know that it is getting tied.
24) After tightening the knot consecutively three times the knot pusher and 3 mm reducer is pulled and hook scissors is introduced from the same port and the suture is cut leaving 1 cm tail.
25) The extracorporeal knots are very strong knot and one knot is sufficient to tie the continuous structure like cystic duct, cystic artery, renal artery, splenic artery.

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