FLS stands for two different things depending on context. In surgery, it refers to **Fundamentals of Laparoscopic Surgery**, a certification program that tests surgeons’ ability to perform minimally invasive procedures. In bone health and fracture care, it stands for **Fracture Liaison Service**, a hospital-based program designed to prevent repeat fractures in people who have already broken a bone. Both are widely referenced in healthcare, so here’s what each one involves.
Fundamentals of Laparoscopic Surgery
Fundamentals of Laparoscopic Surgery is a standardized training and testing program for surgeons who perform laparoscopic (keyhole) surgery. Laparoscopic procedures use small incisions and a camera instead of opening the body with a large cut, and they require a distinct skill set. FLS was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to ensure surgeons can demonstrate competence in both the knowledge and the hands-on technique this type of surgery demands.
The program has two parts: a written knowledge exam covering topics like patient safety, instrument use, and how to handle complications, and a manual skills exam performed on a physical training box. The manual skills portion tests five specific tasks:
- Peg transfer: picking up small objects with instruments and moving them between pegs
- Pattern cutting: precisely cutting a circular shape from gauze using laparoscopic scissors
- Endoloop placement: securing a pre-tied loop around a structure
- Extracorporeal suturing: stitching tissue with a knot tied outside the body and slid into place
- Intracorporeal suturing: stitching and tying a knot entirely inside the training box using instruments
These tasks simulate the coordination challenges of operating through tiny incisions while watching a screen rather than looking directly at the tissue. Surgeons must pass both the written and manual portions to earn certification.
Who Needs FLS Certification
FLS certification is a requirement for board certification in several surgical specialties. The American Board of Obstetrics and Gynecology (ABOG), for example, implemented FLS as a requirement starting in the 2019–2020 academic year. Candidates must complete the program and submit documentation before their certifying exam application can be approved. General surgery boards have similar requirements, making FLS essentially a gatekeeping credential for new surgeons entering practice.
Fracture Liaison Service
A Fracture Liaison Service is a coordinated hospital program that identifies patients who come in with a fracture, evaluates their risk of breaking another bone, and connects them with treatment to prevent it from happening. The core problem it solves is straightforward: someone who fractures a bone, especially after age 50, has a significantly higher chance of fracturing again. Yet most of these patients leave the hospital without anyone addressing why the fracture happened or what could reduce their future risk. An FLS closes that gap.
The typical process starts in the emergency department. When a patient arrives with a fracture, the FLS team flags them, assesses whether underlying bone loss played a role, and invites them for follow-up that includes bone density testing, a review of fall risk factors, and medication if appropriate. The service is considered the most effective organizational approach for secondary fracture prevention, alongside specialized geriatric fracture care for hip fracture patients.
How an FLS Is Structured
Building a Fracture Liaison Service requires four pillars. The first, and most clearly defined, centers on leadership and coordination: a designated bone health leader, a dedicated coordinator (often a nurse or allied health professional who drives the day-to-day work), a multidisciplinary team, and a business plan to sustain the program financially. The coordinator role is particularly critical because without someone actively tracking every fracture patient who enters the hospital, patients slip through the cracks. The remaining pillars address patient identification systems, clinical assessment and treatment protocols, and long-term follow-up strategies.
Global Quality Standards
The International Osteoporosis Foundation runs a program called Capture the Fracture that rates FLS programs worldwide against 13 specific standards. These cover everything from how many fracture patients the service identifies and evaluates, to whether it screens for vertebral fractures, addresses fall prevention, initiates medication, and maintains a long-term follow-up plan. Each standard is scored at three levels: Bronze requires meeting roughly 50% benchmarks, Silver around 70%, and Gold around 90%. This framework gives hospitals a clear target and lets patients and health systems compare programs.
Cost and Impact
FLS programs pay for themselves. A modeling study from the University of Oxford estimated that in a country the size of the United Kingdom, implementing Fracture Liaison Services would prevent over 13,000 subsequent fractures and avoid nearly 121,000 hospital bed days over five years. That translates to 6,455 fewer surgeries and 3,556 fewer person-years of institutional care (such as nursing homes). The cost worked out to about £8,258 per quality-adjusted life year gained, which places FLS firmly in the “highly cost-effective” category by standard health economic thresholds. For hospitals weighing whether to invest in the program, the math consistently favors it.
Which FLS Are You Looking For?
If you’re a medical student or surgical trainee, FLS almost certainly refers to the Fundamentals of Laparoscopic Surgery exam you’ll need to pass for board certification. If you or a family member recently broke a bone and a doctor mentioned FLS, they’re talking about a Fracture Liaison Service designed to keep that fracture from being the first of many. Both programs exist to improve patient outcomes, just at very different stages of the healthcare system.