Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallstone disease and other gallbladder pathologies. Traditionally, this surgery requires secure ligation of the cystic duct and cystic artery, usually achieved by metal clips or advanced energy devices. While these methods are effective, they may increase costs, depend on disposable materials, and sometimes carry risks such as clip migration or clip-related complications. To overcome these challenges, surgeons have innovated alternative ligation methods. Among them, Mishra’s Knot has emerged as a reliable, safe, and cost-effective technique, making laparoscopic cholecystectomy simpler and more accessible.

The Concept of Mishra’s Knot

Mishra’s Knot is a self-locking extracorporeal knot, first described by Dr. R. K. Mishra, a pioneer in laparoscopic surgery and surgical education. It is particularly designed for laparoscopic procedures where secure ligation of tubular structures, such as the cystic duct or artery, is essential.

Unlike clips, which are mechanical devices, Mishra’s Knot uses suture material to create a strong, sliding, and self-locking ligature. The knot is tied outside the body (extracorporeally) and then introduced into the abdominal cavity using a knot pusher. It tightens securely around the structure, preventing slippage and ensuring hemostasis.

Advantages of Mishra’s Knot in Cholecystectomy

The application of Mishra’s Knot in laparoscopic cholecystectomy offers several advantages:

Cost-effectiveness – Clips and energy devices are expensive and add significantly to the overall cost of surgery. Mishra’s Knot, using simple suture material, reduces expenses.

Secure ligation – The self-locking design ensures that the knot does not slip, providing safety equal to or greater than clips.

Versatility – Can be applied to both cystic duct and cystic artery, regardless of their size or thickness.

No foreign body issues – Eliminates risks associated with metallic clip migration, stone formation, or artifact in radiological imaging.

Accessibility – Makes laparoscopic cholecystectomy feasible in resource-limited settings where advanced clip applicators or staplers are unavailable.

Technique of Using Mishra’s Knot in Cholecystectomy

The procedure of laparoscopic cholecystectomy remains largely the same, with the only difference being the method of ligating the cystic duct and artery. The steps are as follows:

Port Placement

Standard four-port technique is used: umbilical port for camera, epigastric port for working, and two lateral ports for assistance.

Exposure of Calot’s Triangle

Dissection is carried out to identify the cystic duct, cystic artery, and their junction with the gallbladder.

The “critical view of safety” is obtained before proceeding.

Preparing the Knot

Outside the abdominal cavity, a Mishra’s Knot is fashioned using a suitable suture, usually absorbable like Vicryl 2-0.

It is a self-locking sliding knot, constructed to tighten securely when advanced.

Application

The knot is introduced into the abdominal cavity using a knot pusher.

It is carefully slid over the cystic duct and tightened to secure closure.

A second knot may be applied for additional safety.

The same process is repeated for the cystic artery if required.

Completion of Surgery

After secure ligation, the cystic duct and artery are divided.

The gallbladder is dissected off the liver bed and retrieved through the umbilical port.

Hemostasis is checked, and ports are closed.

Training and Learning Curve

Mishra’s Knot is straightforward to learn, especially for surgeons trained in laparoscopic suturing and knotting techniques. At World Laparoscopy Hospital, where Dr. R. K. Mishra and his team train thousands of surgeons, this knot is taught as part of the standard laparoscopic curriculum. Surgeons quickly adapt to this method, and it becomes a reliable alternative to clip application.

With adequate training, most surgeons can apply Mishra’s Knot in less than a minute, making it a time-efficient step in cholecystectomy.

Clinical Outcomes

Several studies and clinical experiences have shown that laparoscopic cholecystectomy performed with Mishra’s Knot is:

Safe – Comparable complication rates to clip-based surgeries.

Effective – No increased risk of bile leak or hemorrhage.

Affordable – Lower operative costs, making it ideal for developing countries.

Reproducible – Easily adopted by trained surgeons worldwide.

Long-term follow-up data suggest excellent outcomes, with no significant increase in postoperative morbidity.

Conclusion

Laparoscopic cholecystectomy continues to evolve, and innovations like Mishra’s Knot highlight the importance of simplifying surgery without compromising safety. By providing a secure, cost-effective, and versatile alternative to conventional clip ligation, Mishra’s Knot makes the procedure more accessible, particularly in resource-constrained settings.

For surgeons committed to delivering safe and affordable care, mastering this technique is invaluable. With its simplicity and reliability, Mishra’s Knot truly makes laparoscopic cholecystectomy easy.