Laparoscopic cholecystectomy is the gold standard procedure for gallbladder removal and has revolutionized the management of gallstone disease. However, anatomical variations, particularly a short cystic duct, pose technical challenges during surgery. The cystic duct connects the gallbladder to the common bile duct, and when it is very short, conventional clipping or ligation may increase the risk of bile duct injury, leakage, or accidental damage to the common bile duct.

Dr. R. K. Mishra, a pioneer in laparoscopic training and surgical innovation, has developed a unique solution to this problem through the use of Mishra’s Knot. This extracorporeal knotting technique provides secure closure of the cystic duct even in difficult anatomical conditions, making laparoscopic cholecystectomy safer in patients with a short cystic duct.

Anatomical Challenge of a Short Cystic Duct

In a standard patient, the cystic duct measures 2–4 cm in length and provides ample space for clip application or ligation. However, in some patients, the cystic duct is very short or merges directly into the common bile duct. This variation creates several challenges:

Difficulty in applying clips securely without risking slippage.

Limited space for dissection and knot placement.

Higher risk of common bile duct injury during clipping or cutting.

Increased chance of bile leakage postoperatively.

Such situations demand a safe, reliable, and technically adaptable method of duct closure.

Introduction to Mishra’s Knot

Mishra’s Knot is a modified extracorporeal knot designed specifically for laparoscopic surgery. It is easy to learn, reproducible, and provides strong and secure ligation. The knot is created outside the body using standard sutures and then pushed into place using a knot pusher.

The advantages of Mishra’s Knot include:

High security: It holds tight without slipping.

Low cost: It eliminates the need for expensive clips or staplers.

Versatility: Can be used in a wide range of laparoscopic procedures beyond cholecystectomy.

Ease of use: Even in narrow or difficult anatomical spaces, it can be applied safely.

In the context of a short cystic duct, Mishra’s Knot provides a safe alternative where clips may fail.

Surgical Technique
Patient Preparation

The patient is placed under general anesthesia in a supine position, with slight reverse Trendelenburg and left tilt to allow the bowel to fall away from the operative field.

Port Placement

A standard four-port laparoscopic setup is used. The surgeon stands on the patient’s left side with the monitor placed opposite.

Dissection and Exposure

Careful dissection of Calot’s triangle is performed to achieve the critical view of safety. The cystic duct and artery are identified and skeletonized. Special attention is paid when the cystic duct is unusually short.

Application of Mishra’s Knot

A length of absorbable suture (usually 2-0 or 1-0 polyglactin) is prepared extracorporeally into Mishra’s Knot.

The knot is mounted on a knot pusher.

The suture loop is carefully placed around the short cystic duct.

The knot is tightened securely, ensuring complete closure of the duct.

A second knot may be applied for added safety.

Division of the Cystic Duct

Once the duct is secured, it is divided carefully with laparoscopic scissors. The closure is checked to ensure there is no leakage.

Completion of Cholecystectomy

The cystic artery is controlled with clips or another knot if required, and the gallbladder is dissected from the liver bed and retrieved via an endobag.

Advantages of Using Mishra’s Knot in Short Cystic Ducts

Safety: Reduces the risk of common bile duct injury compared to clip application in a tight space.

Reliability: Provides a secure closure even if the duct is very short or inflamed.

Cost-effectiveness: Avoids expensive disposable staplers or clip applicators.

Reproducibility: Easy to teach and adopt for surgeons at all skill levels.

Versatility: Can also be used when clips are contraindicated, such as in cases of clip allergy or limited supply of consumables.

Potential Challenges

While Mishra’s Knot is highly effective, it requires:

Proper training in extracorporeal knotting and use of a knot pusher.

Careful dissection to avoid placing the knot too close to the common bile duct.

Vigilance to check for bile leakage after duct division.

With adequate training, however, these challenges are easily overcome.

Outcomes and Clinical Significance

Studies and practical experience at World Laparoscopy Hospital demonstrate that the use of Mishra’s Knot significantly decreases the risk of bile duct injury and postoperative complications in cases with a short cystic duct. Surgeons trained in this technique report high confidence in duct closure, reduced conversion to open surgery, and excellent long-term outcomes for patients.

This innovation emphasizes Dr. Mishra’s philosophy that laparoscopic surgery should not only replicate open techniques but also offer improved safety and cost-effectiveness through creative solutions.

Conclusion

Laparoscopic cholecystectomy for patients with a short cystic duct presents unique technical difficulties. Conventional clips may not always provide safe closure, leading to the risk of bile leakage or duct injury. Mishra’s Knot, a secure and simple extracorporeal knotting technique, provides a reliable alternative for cystic duct closure in such challenging cases.

Dr. R. K. Mishra’s contribution through this technique has provided surgeons worldwide with a safe, reproducible, and cost-effective solution, ensuring that laparoscopic cholecystectomy remains the gold standard even in anatomically complex situations.