Laparoscopic cholecystectomy (lap chole) is the gold standard treatment for symptomatic gallbladder disease, including cholelithiasis, cholecystitis, and gallbladder polyps. The critical step in this procedure is the secure closure of the cystic duct, which prevents postoperative bile leakage—a potentially serious complication. While conventional metallic clips are widely used, in certain situations, surgeons prefer suturing techniques. Among these, Mishra’s Knot—a specialized extracorporeal knot technique developed by Dr. R. K. Mishra—has gained recognition for its safety, reliability, and cost-effectiveness.

This article explores the technique of laparoscopic cholecystectomy using Mishra’s Knot, its indications, advantages, and clinical relevance.

Introduction to Mishra’s Knot

Mishra’s Knot is a pre-tied extracorporeal knot that is introduced into the abdominal cavity via a laparoscopic port and tightened over the cystic duct. It provides a secure ligation without relying on metallic clips. This technique is particularly useful in cases where:

The cystic duct is wide or inflamed, making clip application unreliable.

Resource constraints limit the use of disposable clips or staplers.

Surgeons aim for enhanced cost-effectiveness without compromising safety.

Dr. R. K. Mishra developed this knot to combine the simplicity of extracorporeal knotting with a reproducible method suitable for laparoscopic surgery.

Indications for Using Mishra’s Knot

While laparoscopic clips remain standard for most cases, Mishra’s Knot is preferred in the following scenarios:

Large cystic ducts (diameter >6 mm), where clips may not provide adequate closure.

Severe inflammation or fibrosis, common in chronic or acute cholecystitis.

Pediatric patients, where delicate tissue handling is required.

Limited resources where disposable clips or staplers are unavailable.

The technique is safe, reliable, and adaptable across a wide range of laparoscopic cases.

Steps of Laparoscopic Cholecystectomy Using Mishra’s Knot
Patient Positioning and Anesthesia

The procedure is performed under general anesthesia.

The patient is placed in supine position with reverse Trendelenburg and slight left tilt to allow bowel loops to fall away from the right upper quadrant.

Creation of Pneumoperitoneum and Port Placement

A 10 mm umbilical port is inserted for the laparoscope.

Two 5 mm working ports are placed in the epigastrium and right hypochondrium.

This setup allows for optimal visualization and instrument triangulation.

Dissection of Calot’s Triangle

The cystic duct and cystic artery are identified carefully.

The critical view of safety (CVS) is achieved by clearing fat and fibrous tissue around the cystic structures.

Preparation of Mishra’s Knot

A pre-tied extracorporeal knot is prepared using absorbable suture material, usually polyglactin 2-0.

The knot is loaded onto a knot pusher or laparoscopic grasper.

Introduction and Placement of the Knot

The knot is inserted through a working port.

It is looped around the cystic duct, and the knot pusher is used to advance and tighten the knot securely over the duct.

Usually, two knots are applied proximally for added safety, and one may be applied distally if required.

Division of the Cystic Duct

After the knots are tightened, the cystic duct is divided between the knots.

The gallbladder is then dissected from the liver bed using standard laparoscopic techniques.

Extraction and Closure

The gallbladder is retrieved via the umbilical port using a specimen bag.

Ports are removed under vision, and fascial and skin closure is performed to ensure optimal cosmetic outcomes.

Advantages of Mishra’s Knot

Secure Closure: Provides reliable ligation for wide or inflamed cystic ducts.

Cost-Effective: Avoids expensive disposable clips or staplers.

Versatility: Can be applied in standard, pediatric, and complicated cases.

Reduced Risk of Clip Displacement: Particularly in inflamed or friable ducts.

Educational Value: Improves surgeon skills in extracorporeal knotting, a valuable technique in minimal access surgery.

Limitations

Learning Curve: Surgeons require practice to master knot preparation and advancement through ports.

Time-Consuming: Slightly longer than simple clip application, especially for beginners.

Technical Skill Required: Precision is essential to avoid slippage and ensure complete closure.

Despite these limitations, Mishra’s Knot is a reproducible and safe alternative to clips, especially in challenging cases.

Clinical Outcomes

Clinical studies and experience from centers using Mishra’s Knot demonstrate:

Comparable operative times to standard clip techniques in experienced hands.

Low incidence of bile leakage and postoperative complications.

Excellent cosmetic results with minimal additional operative time.

The technique has been widely adopted in India and globally as a cost-effective, reliable method for cystic duct closure.

Conclusion

Laparoscopic cholecystectomy using Mishra’s Knot is an innovative, safe, and cost-effective technique for secure cystic duct ligation. It combines the advantages of extracorporeal knotting with modern laparoscopic principles, providing a reliable alternative to metallic clips in challenging cases. By mastering this technique, surgeons can enhance patient safety, reduce postoperative complications, and maintain the economic feasibility of laparoscopic surgery, particularly in resource-limited settings.