Suturing and knotting are among the most essential skills in laparoscopic surgery. While staplers and energy devices have expanded the surgeon’s arsenal, knot tying remains the cornerstone for securing tissues and vessels safely. One of the most widely practiced and reliable knotting techniques in minimal access surgery is the extracorporeal square knot. Dr. R. K. Mishra, a world-renowned laparoscopic surgeon and Director of World Laparoscopy Hospital, has been instrumental in teaching and demonstrating this technique to thousands of surgeons worldwide. His demonstrations provide clarity, precision, and practical tips that make the learning process seamless.

What is an Extracorporeal Square Knot?

An extracorporeal knot is a knot tied outside the patient’s body and then pushed into the abdominal cavity using a knot pusher. This contrasts with the intracorporeal knot, which is tied inside the abdomen using laparoscopic instruments.

The square knot, also known as a reef knot, is one of the most secure and fundamental types of surgical knots. It consists of two throws of suture, one placed in a clockwise direction and the other counterclockwise, ensuring that the knot lies flat and resists slipping.

Importance in Laparoscopic Surgery

The extracorporeal square knot holds a special place in laparoscopic surgery because:

It provides high knot security, ensuring tissues remain approximated during healing.

It is relatively easy to learn for beginners compared to intracorporeal suturing.

It is time-efficient, especially in long procedures where speed is important.

It can be used in a wide range of surgeries including hernia repair, bowel anastomosis, gynecological procedures, and hemostasis of bleeding vessels.

Demonstration by Dr. R. K. Mishra

Dr. Mishra’s demonstrations are highly regarded for their structured approach. He breaks down the technique into simple steps, making it easier for both novice and experienced surgeons to understand.

Step-by-Step Technique:

Suture Preparation

A suitable non-absorbable or absorbable suture is selected based on the surgery.

The suture is cut to the appropriate length and held outside the abdomen.

First Throw

The surgeon ties the first half-knot outside the patient using the standard square knot technique.

This ensures proper alignment and security.

Second Throw (Reverse Direction)

The second throw is tied in the opposite direction to complete the square knot.

Dr. Mishra emphasizes the importance of reversing direction to prevent slippage.

Loading the Knot Pusher

The knot is then loaded onto a specially designed knot pusher.

The suture tail is passed through the channel of the pusher, allowing it to glide smoothly.

Advancing the Knot

With careful control, the knot is advanced along the suture into the abdominal cavity.

The surgeon ensures that the knot slides down without jamming.

Securing the Knot

Once inside, the knot is tightened over the target tissue under direct laparoscopic vision.

The process is repeated with additional throws (usually 3–5) to strengthen the knot.

Final Inspection

The surgeon inspects the knot for security and the tissue for appropriate approximation.

Key Tips Emphasized by Dr. Mishra

Always reverse direction with each throw to ensure a true square knot.

Avoid excessive tension while sliding the knot, as this may cause suture breakage.

Use a high-quality knot pusher for smooth transfer.

Practice regularly outside the operating room to develop muscle memory.

Maintain proper instrument triangulation to prevent awkward movements.

Advantages of Extracorporeal Square Knot

High Reliability – Provides consistent knot security when performed correctly.

Accessibility – Easier for surgeons who are still mastering intracorporeal techniques.

Speed – Faster to execute, saving valuable operating time.

Versatility – Useful across multiple specialties.

Teaching Tool – An excellent starting point for training surgeons in laparoscopic suturing.

Clinical Applications

The extracorporeal square knot is widely used in:

Laparoscopic hernia repair – For mesh fixation and peritoneal closure.

Gynecological surgeries – For securing pedicles during hysterectomy or myomectomy.

Gastrointestinal surgeries – For anastomosis or controlling bleeding points.

Urology – For suturing renal or bladder defects.

Dr. R. K. Mishra’s Contribution

As a pioneer in laparoscopic education, Dr. Mishra has dedicated his career to simplifying complex surgical skills. His live demonstrations, video lectures, and step-by-step training modules have empowered surgeons from more than 138 countries to adopt safe and effective laparoscopic techniques. His teaching philosophy emphasizes clarity, repetition, and hands-on practice, making the extracorporeal square knot accessible to all levels of learners.

Conclusion

The extracorporeal square knot, when demonstrated by experts like Dr. R. K. Mishra, becomes more than just a technical exercise; it becomes a cornerstone in the training of laparoscopic surgeons. Its simplicity, reliability, and versatility make it an indispensable technique in minimal access surgery. With continued practice and guidance, surgeons can master this skill, improving patient outcomes and advancing the field of laparoscopic surgery worldwide.