The field of minimally invasive surgery has witnessed numerous innovations that aim to improve patient outcomes, reduce operative time, and enhance postoperative recovery. One such advancement is the technique of performing cholecystectomy and appendectomy simultaneously using Mishra’s Knot, pioneered and popularized by Dr. R.K. Mishra. This combined procedure demonstrates the efficiency, safety, and versatility of modern laparoscopic techniques, allowing surgeons to address multiple abdominal pathologies in a single operative session.


Introduction to Combined Surgery


Cholecystectomy, the surgical removal of the gallbladder, is commonly indicated for gallstones, cholecystitis, or biliary dyskinesia. Appendectomy, the removal of the appendix, is primarily performed in cases of acute or chronic appendicitis. Traditionally, these procedures are performed separately; however, certain patients may present with coexisting gallbladder and appendix pathology or require prophylactic appendectomy during abdominal surgery. In such cases, performing both procedures laparoscopically in a single session offers significant advantages.


Dr. Mishra’s technique emphasizes precision, minimal tissue handling, and secure ligation using the innovative Mishra’s Knot, making the combined procedure safe and effective.


Mishra’s Knot: The Core Innovation

Mishra’s Knot is a specialized laparoscopic knot-tying technique developed by Dr. R.K. Mishra. It allows surgeons to achieve secure ligation of structures, such as the cystic duct, cystic artery, and appendiceal base, without the need for multiple instruments or extensive dissection. The knot is designed to be reliable under tension, reducing the risk of postoperative bleeding or stump leaks. Its application simplifies laparoscopic procedures, making combined surgeries like cholecystectomy and appendectomy more feasible.

Stepwise Surgical Approach

Dr. Mishra’s approach to performing cholecystectomy and appendectomy together is methodical and emphasizes patient safety:

Patient Preparation and Port Placement:

The patient is positioned supine, and standard laparoscopic ports are placed. Typically, a 10 mm umbilical port is used for the camera, while 5 mm working ports are positioned in the epigastrium and right abdomen. Proper port placement is crucial to ensure optimal visualization of both the gallbladder and appendix.

Laparoscopic Cholecystectomy:

The procedure begins with a standard laparoscopic cholecystectomy. The cystic duct and cystic artery are carefully dissected and ligated using Mishra’s Knot. Dr. Mishra emphasizes identifying the critical view of safety to avoid bile duct injury. The gallbladder is then detached from the liver bed and removed through the umbilical port or a slightly enlarged port if needed.

Transition to Appendectomy:

After completing the cholecystectomy, attention is shifted to the right lower quadrant. The appendix is mobilized, and the mesoappendix is dissected using energy devices or laparoscopic scissors. Mishra’s Knot is employed to ligate the base of the appendix securely. The appendix is then removed through one of the existing ports, minimizing additional incisions.

Closure and Postoperative Care:

Once both organs are removed, pneumoperitoneum is released, and port sites are closed. Dr. Mishra stresses meticulous inspection of both surgical sites to ensure hemostasis and prevent bile or fecal contamination. Postoperative care includes early mobilization, pain management, and monitoring for potential complications such as infection or bile leakage.

Advantages of the Combined Approach

Single Anesthesia Exposure: Performing both procedures in one session reduces the risks associated with repeated anesthesia.

Reduced Hospital Stay: Patients recover faster and spend less time in the hospital compared to undergoing two separate surgeries.

Cost-Effective: Combining procedures reduces operative costs, including operating room time, anesthesia, and hospitalization charges.

Minimized Surgical Trauma: Using existing ports for both surgeries limits additional incisions, decreasing postoperative pain and scarring.

Enhanced Safety with Mishra’s Knot: Secure ligation minimizes the risk of postoperative complications, making the procedure reliable even in complex cases.

Considerations and Limitations

While this combined procedure offers multiple benefits, careful patient selection is essential. Severe inflammation, adhesions, or anatomical variations may necessitate staged procedures or conversion to open surgery. Surgeons must also be skilled in laparoscopic techniques and proficient in using Mishra’s Knot to ensure safety and efficiency.

Conclusion

The technique of performing cholecystectomy and appendectomy together using Mishra’s Knot represents a significant advancement in minimally invasive surgery. It demonstrates how innovative surgical techniques can improve patient outcomes, reduce recovery time, and optimize operative efficiency. Dr. R.K. Mishra’s approach emphasizes meticulous dissection, secure ligation, and minimal trauma, making it a safe and effective option for patients with concurrent gallbladder and appendiceal pathology.

By integrating such advanced laparoscopic techniques into surgical practice, surgeons can provide high-quality care that is safe, efficient, and patient-friendly, highlighting the continuous evolution of modern surgery.