Appendicitis is among the most common surgical emergencies worldwide, affecting both adults and children. The gold standard treatment for acute appendicitis is appendectomy, which can be performed either through open surgery or laparoscopic techniques. With the advent of minimal access surgery, laparoscopic appendectomy has become increasingly popular due to its advantages of reduced postoperative pain, shorter hospital stay, and faster recovery.

In the hands of laparoscopic experts like Dr. R.K. Mishra, innovative techniques such as the use of the Mishra’s Knot have further refined appendectomy. This extracorporeal knot-tying method provides a cost-effective and reliable alternative to expensive staplers, clips, or endoloops.

Acute Appendicitis: A Brief Overview

Acute appendicitis occurs when the lumen of the appendix becomes obstructed, usually by fecoliths, lymphoid hyperplasia, or infection. This obstruction leads to bacterial overgrowth, inflammation, and, if untreated, perforation and peritonitis.

Symptoms of Acute Appendicitis

Pain starting around the umbilicus and shifting to the right lower quadrant

Nausea and vomiting

Fever and anorexia

Tenderness at McBurney’s point

Guarding and rebound tenderness in advanced cases

Prompt diagnosis and surgical intervention are critical to prevent complications.

Laparoscopic Appendectomy: The Preferred Technique

Laparoscopic appendectomy has revolutionized appendicitis management by offering:

Smaller incisions and better cosmesis

Magnified visualization of abdominal organs

Less pain and quicker return to daily life

Reduced infection rates compared to open surgery

One of the key technical challenges in laparoscopic appendectomy is securing the appendicular base before division. Traditionally, this is achieved using staplers, endoloops, or clips. However, these devices can be costly, especially in resource-limited settings. This is where the Mishra’s Knot provides an excellent alternative.

Mishra’s Knot: An Innovative Extracorporeal Knot

Dr. R.K. Mishra, a pioneer in laparoscopic surgery, developed the Mishra’s Knot as a modification of extracorporeal knotting techniques. It is designed to be strong, secure, and easy to apply through small laparoscopic ports.

Key Features of Mishra’s Knot

Provides a sliding extracorporeal knot that can be tightened securely over the appendiceal base.

Eliminates the need for costly staplers or endoloops.

Can be performed with standard laparoscopic instruments.

Reliable in both inflamed and friable tissue conditions.

Step-by-Step Technique: Appendectomy with Mishra’s Knot
Patient Preparation and Positioning

General anesthesia is administered.

The patient is placed supine with slight Trendelenburg tilt and left tilt to move bowel loops away from the operative field.

Port Placement

A 10 mm umbilical port for the laparoscope.

Two 5 mm working ports placed in the left iliac fossa and suprapubic region.

Exploration and Identification

Laparoscope is inserted, and the appendix is identified in the right iliac fossa.

Adhesions, if present, are carefully released.

Dissection

The mesoappendix is dissected and divided using bipolar cautery or ultrasonic energy devices.

Care is taken to control the appendicular artery.

Securing the Appendiceal Base with Mishra’s Knot

A Mishra’s Knot is prepared extracorporeally using a standard suture.

The knot is introduced into the abdominal cavity through a 10 mm port using a knot pusher.

The knot is slid down securely onto the base of the appendix.

Usually, two consecutive knots are applied to ensure safety.

Division and Removal

The appendix is divided distal to the knots.

The specimen is removed using an endobag through the umbilical port.

Final Inspection and Closure

The stump is inspected for bleeding or leakage.

Ports are removed, pneumoperitoneum is released, and port sites are closed.

Advantages of Mishra’s Knot in Appendectomy

Cost-Effective – avoids expensive staplers and endoloops.

Secure – provides strong ligation, even in inflamed tissues.

Simple and Reproducible – can be learned easily by trained laparoscopic surgeons.

Versatile – can be used in other laparoscopic procedures requiring ligation.

Safe – minimizes the risk of stump leakage or slippage.

Postoperative Care

Children and adults undergoing laparoscopic appendectomy with Mishra’s Knot usually recover quickly.

Early mobilization, pain management, and return to oral intake within hours are encouraged.

Most patients are discharged within 24–48 hours.

Follow-up ensures proper wound healing and monitoring for rare complications like infection or stump appendicitis.

Conclusion

Appendectomy for acute appendicitis using Mishra’s Knot is a safe, economical, and effective technique that reflects the innovation in minimal access surgery. By combining the principles of laparoscopic surgery with cost-saving measures, this method ensures that patients receive world-class care without the burden of expensive consumables.

Dr. R.K. Mishra’s contribution through the Mishra’s Knot has empowered surgeons worldwide, especially in developing countries, to perform secure and efficient laparoscopic appendectomies. This technique continues to stand as a prime example of how surgical ingenuity can improve patient outcomes while making healthcare more accessible.