Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure worldwide and has become the gold standard for treating symptomatic gallstones and gallbladder disease. One of the critical steps in this surgery is the secure closure of the cystic duct and cystic artery, which prevents bile leakage and bleeding. Traditionally, this is achieved using titanium clips, polymer clips, or endoloops. However, in many resource-limited settings or for surgeons seeking cost-effective and equally reliable alternatives, the Mishra’s Knot, a laparoscopic extracorporeal knotting technique, has gained recognition as an innovative solution.

Understanding Mishra’s Knot

The Mishra’s Knot is a modification of the traditional extracorporeal surgeon’s knot designed for laparoscopic surgery. It is a three-turn knot (similar to a modified Roeder’s knot) that offers high security, minimal slippage, and ease of application. It was introduced by Dr. R. K. Mishra, a pioneer in laparoscopic techniques, to provide a dependable alternative to expensive disposable clip applicators.

Key features of Mishra’s Knot include:

High tensile strength – prevents loosening under tension.

Non-slippage design – suitable for both cystic duct and cystic artery ligation.

Cost-effectiveness – uses standard suture material, eliminating dependence on costly clips.

Versatility – applicable in a variety of laparoscopic procedures beyond cholecystectomy.

Indications for Using Mishra’s Knot in Cholecystectomy

While laparoscopic clips are widely used, certain circumstances favor the use of Mishra’s Knot:

Low-resource settings where clip applicators are not available.

Wide cystic ducts that may not be adequately secured by clips.

Surgeon preference for knot-based closure due to reliability.

Situations requiring cost-effective solutions without compromising patient safety.

Surgical Technique
Patient Preparation

The procedure follows standard laparoscopic cholecystectomy protocols. The patient is placed under general anesthesia in a supine position with slight reverse Trendelenburg and left tilt to optimize exposure of the gallbladder.

Port Placement

A four-port technique is most commonly employed:

Umbilical port for the laparoscope.

Epigastric port for dissecting instruments.

Two lateral ports for retraction and assistance.

Dissection

The gallbladder is retracted to expose Calot’s triangle.

Careful dissection identifies the cystic duct and cystic artery.

Critical View of Safety (CVS) is achieved before ligation.

Application of Mishra’s Knot

An extracorporeal knot is prepared outside the abdomen using a long suture (usually 2-0 polyglactin or silk).

The knot is designed as a slip knot with three turns to maximize holding strength.

The preformed knot is loaded into a knot pusher and introduced through a port.

The suture is looped around the cystic duct or artery, and the knot is advanced securely into position.

Two knots are typically applied on the proximal side and one on the distal side to ensure complete closure.

After confirming hemostasis and ductal security, the cystic duct and artery are divided.

The gallbladder is then dissected from the liver bed and removed through the umbilical port as in a standard cholecystectomy.

Advantages of Mishra’s Knot

Secure closure – Its unique structure minimizes the risk of knot slippage.

Cost-effective – Eliminates the need for disposable clips and applicators.

Versatility – Useful not only for cystic duct and artery ligation but also in appendectomy, bowel anastomosis, and other laparoscopic procedures.

Adaptability in wide ducts – Particularly beneficial in cases with dilated cystic ducts where clips may fail.

Resource-friendly – Makes laparoscopic cholecystectomy more accessible in low-resource settings and teaching institutions.

Postoperative Care

Postoperative management remains similar to standard laparoscopic cholecystectomy:

Early mobilization and resumption of oral intake.

Pain is mild and managed with simple analgesics.

Discharge within 24 hours in uncomplicated cases.

Follow-up ensures wound healing and checks for complications like bile leakage.

Patients treated with Mishra’s Knot closure typically experience outcomes comparable to, or in some studies better than, those treated with clips.

Outcomes and Safety

Several clinical studies and reports confirm that the use of Mishra’s Knot in laparoscopic cholecystectomy is safe and effective. Success rates are high, with a negligible incidence of bile leak or hemorrhage. Long-term outcomes are comparable to clip application, with the added benefit of reduced cost.

Surgeons trained in knot-tying techniques find Mishra’s Knot both reliable and easy to perform once mastered. It is especially valued in surgical training programs, where learning knot security is crucial.

Limitations and Considerations

Despite its benefits, certain considerations must be noted:

The technique requires training and practice, as improper knot placement may lead to complications.

Operative time may initially be slightly longer compared to clip application.

In very inflamed or friable tissues, clips may still be preferred by some surgeons for speed.

Nevertheless, with adequate skill, Mishra’s Knot stands as a dependable alternative in all settings.

Conclusion

Laparoscopic cholecystectomy using Mishra’s Knot is a safe, effective, and economical alternative to conventional clip-based techniques. By providing strong, reliable closure of the cystic duct and artery, it ensures surgical safety while significantly lowering costs, making minimally invasive surgery more accessible worldwide. With growing emphasis on cost-effective healthcare and skill-based surgery, Mishra’s Knot represents an important advancement in laparoscopic practice and continues to serve as a valuable tool in the surgeon’s repertoire.