Fundamentals in Laparoscopic Surgery (FLS), and
Essentials in Minimally Invasive Gynecologic Surgery (EMIGS)
Passing the Fundamentals in Laparoscopic Surgery (FLS) cognitive and psychomotor skills examination is now a requirement for American Board of Obstetrics and Gynecology (ABOG) certification. The process was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) for general surgery trainees and adopted by the American Board of Surgery in 2010. The FLS website can be reached by clicking on the FLS Logo.
The EMIGS Option - Starting 2023
Starting in 2023, a gynecologic surgery-specific and ABOG-approved option for laparoscopic surgery training and testing became available. EMIGS (Essentials in Minimally Invasive Gynecologic Surgery) was developed and validated by the AAGL in conjunction with CREOG and ACOG. It comprises a high-stakes test, a training platform, and 80 video-based, didactic components available on the AAGL website. The AAGL distributed the laparoscopic components to all national residency training programs. By 2026, over 80% of US programs had converted to EMIGS. At this time, the hysteroscopic psychomotor component of EMIGS is not included for ABOG certification. For more information, follow the links that include the validation trial and links to ABOG and the EMIGS website. Check with the Program Director at your training center for details
The 5 FLS Psychomotor Tasks
The videos below are web-based material that we have reviewed and generally support. While times should be seen as aspirational, the goal is to be accurate and to complete the task within the maximal allotted time. It is better to be accurate than fast!
Task 1. Sleeve-Peg Transfer
Equipment:
Two graspers, pegboard, 6 objects (triangular sleeves)
Maximum Time Limit:
300 seconds
Proficiency Time: 48 seconds
The 6 triangular sleeves are placed on the left side of the pegboard. The peg transfer exercise requires you to lift the 6 sleeves with a grasper first in your non-dominant (i.e. left) hand and transfer the object midair to your dominant hand. Then, place each sleeve on a peg on the right side of the board. There is no importance placed on the color of the objects or the order in which they are placed. Once all six sleeves have been transferred, the process is reversed. Each sleeve is lifted using the dominant (eg. right) hand from the right side of the pegboard, transferred midair to the left hand and placed on the pegs on the left side of the board.
Timing for this task begins when you grasp the first sleeve and ends upon release of the last sleeve. This exercise is timed and a penalty is assessed for any sleeve dropped out of the field of view. This exercise tests eye-hand coordination, ambidexterity and depth perception.
Task 2. Pattern or "Circle" Cut
Equipment:
One Maryland grasper, 1 scissors, large clip, 4X4 gauze piece
Maximum Time Limit:
300 seconds
Proficiency Time:
98 Seconds
This cutting exercise requires you to cut out a circle from a square piece of gauze suspended between clips. One hand should be used to provide traction on the gauze using the grasper and to place the gauze at the best possible angle to the cutting hand. If you wish, you may exchange instruments at any time during this task.
Timing starts when the gauze is grasped and ends upon completion of cutting the marked circle. This exercise is timed and a penalty is assessed for any deviation from the line demarcating the circle. There are 2 layers of gauze, but the error scoring is based on the marked, top layer only. This exercise requires you to use both hands in a complimentary manner, using one hand to resent the other hand in the best possible way for the other hand to cut.
Task 3. Ligating Loop ("Endoloop")
Equipment:
Two Maryland graspers, 1 scissors, 1 large clip, 1 pre-tied ligating loop ("Endoloop"), 1 foam appendage.
Maximum Time Limit: 180 seconds
Proficiency Time:
53 seconds
In this task you are required to place a pre-tied ligating loop or endoloop around a tubular foam appendage on the provided mark.
Once you have positioned the loop properly, break off the end of the plastic pusher at the scored mark on the outside of the box. Then secure the knot on the mark near the base of the foam appendage by sliding the pusher rod down. A penalty will be assessed if the knot is not secure and for any distance that the tie misses the mark.
Timing begins when instruments are visible on the monitor and ends when the ligating loop suture is cut. This task tests familiarity with the such loop ligatures and requires bimanual skills.
Task 4. Extracorporeal Tie
Equipment:
Two needle drivers (or choice of 1 needle driver and 1 grasper), 1 knot manipulator, 1 2-0 silk suture with a swedged on 26 mm curved needle and 90-120cm in length, 1 scissors, Penrose drain with a longitudinal fenestration and a pair of black targets.
Maximum Time Limit:
420 seconds
Proficiency Time: 136 seconds
This suturing task requires you to place a simple stitch through two marks in a longitudinally slit Penrose drain. You are then required to tie the suture extra corporeally, using a knot-pushing device to slide the knot down. You must tie the knot tightly enough to close the slit in the drain. Be careful not to avulse the drain off the foam block. At lest three square throws are required to ensure that the knot will not slip under tension. Please watch the video for an illustration of how to properly tie these knots.
Timing begins when instruments visible on monitor and ends when suture material and needle are cut. This task tests accuracy of placement of the suture and knot tying skills. It requires ambidexterity and depth perception.
Task 5. Intracorporeal Tie
Equipment:
Two needle drivers (or choice of 1 needle driver and 1 grasper), 1 2-0 silk suture of 15 cm length with a wedged on 26 mm needle, 1 scissors, 1 foam dexterity block, 1 Penrose drain with a longitudinal fenestration and a pair of black targets
Maximum Time Limit:
600 seconds
Proficiency Time: 112 seconds
This suturing task requires you to place a suture precisely through 2 marks on a Penrose drain, that has been slit along its long axis. You are then required to form the knot using an intracorporeal tying technique. You must place at least 3 throws that must start with one double throw followed by two single throws on the suture. You must also ensure the knots are square and won’t slip. Please watch the video for an illustration of how to properly tie these knots.
Skills required include proper placement of the needle in the needle-holder, needle transferring, suturing skills and knot tying. A penalty is applied for any deviation of the needle from the marks, for any gap in the longitudinal slit in the drain and for a knot that slips when tension is applied to it. If the drain is avulsed from the block to which it is secured by double-sided adhesive tape, a score of "0" will be applied.
Timing begins when the instruments are visible on the monitor and ends when the suture material and needle are cut. This is a more complex task incorporating several skills including depth perception, eye-hand coordination, ambidexterity, and transferring skills.