Laparoscopic cholecystectomy has become the gold standard for the surgical management of gallstone disease and gallbladder pathology. Traditionally, titanium clips or other energy sealing devices are used to occlude the cystic duct during this procedure. However, in his lectures and surgical demonstrations, Dr. R. K. Mishra, a world authority in laparoscopic and robotic surgery, often emphasizes the technique of ligation of the cystic duct with intracorporeal knotting. This approach not only eliminates dependence on costly clips but also provides surgeons with an opportunity to refine their laparoscopic suturing and knotting skills.

Importance of Cystic Duct Control

The cystic duct connects the gallbladder to the common bile duct and is the key structure to be identified and controlled during laparoscopic cholecystectomy. Secure closure of the cystic duct is essential to prevent postoperative bile leakage, biliary peritonitis, or other complications. While metallic clips are widely used because of their convenience, they may occasionally slip or migrate, especially if the duct is wide or inflamed. Suturing and ligating the cystic duct, as Dr. Mishra teaches, provides a permanent and cost-effective closure.

Dr. Mishra’s Surgical Philosophy

Dr. Mishra’s philosophy in minimal access surgery is based on precision, cost-effectiveness, and safety. He stresses that every laparoscopic surgeon should master intracorporeal knotting and ligation techniques, as reliance only on clips or staplers may limit surgical versatility. In resource-limited settings where disposable clip applicators are costly or unavailable, knotting and ligation of the cystic duct is a valuable skill.

His teaching combines anatomical clarity, ergonomic principles, and stepwise demonstration of suturing techniques, making it easier for trainees to adopt the practice confidently.

Surgical Technique: Step by Step
Patient Positioning and Port Placement

The patient is placed in a supine position with reverse Trendelenburg and slight left tilt. Standard four-port placement is performed, including a 10 mm umbilical camera port, a 10 mm epigastric working port, and two 5 mm right subcostal ports.

Exposure of Calot’s Triangle

The gallbladder is retracted upward and laterally. Careful dissection of Calot’s triangle is done to clearly identify the cystic duct and cystic artery. Dr. Mishra stresses the importance of achieving the Critical View of Safety (CVS) before dividing any structures.

Dissection of the Cystic Duct

Once the cystic duct is exposed and cleared of surrounding tissue, its full circumference is visualized. A window is created behind the duct to allow passage of a suture.

Ligation Technique

A 2-0 absorbable suture, such as Vicryl, is introduced through a 10 mm port.

Using a laparoscopic needle holder, the surgeon performs intracorporeal knot tying around the cystic duct.

Typically, a surgeon’s knot followed by additional square knots is used to ensure secure closure.

The cystic duct is ligated at two points, close to the gallbladder side and toward the common bile duct side.

After ligation, the cystic duct is divided between the knots.

Completion of Cholecystectomy

The cystic artery is similarly controlled by ligation or clips. The gallbladder is dissected from the liver bed using electrocautery or energy devices. It is then retrieved in a specimen bag through the epigastric port.

Final Inspection and Closure

The operative field is checked for hemostasis and bile leak. Ports are removed, and the incisions are closed.

Advantages of Ligation Over Clips

According to Dr. Mishra, ligation of the cystic duct offers several benefits:

Secure Closure: Sutures provide stronger, permanent closure compared to clips, especially for wide or thick ducts.

Cost-Effective: Eliminates the need for disposable clip applicators, making the surgery affordable.

Skill Development: Enhances a surgeon’s laparoscopic suturing expertise, which is crucial for advanced procedures.

Avoids Clip-Related Complications: Prevents issues such as clip migration, stone formation around clips, or allergic reactions to metal.

Challenges and Learning Curve

While effective, intracorporeal ligation requires advanced laparoscopic skills. The learning curve can be steep, particularly for surgeons not accustomed to knot tying inside the abdominal cavity. Dr. Mishra’s teaching methodology simplifies this process by breaking down each step of knotting, demonstrating ergonomics, and using training models before live surgery.

Educational Value

In his lectures, Dr. Mishra not only demonstrates the operative steps but also shares tips on handling difficult situations, such as inflamed cystic ducts, short ducts, or distorted anatomy. His video-based teaching combines 3D animations, live surgical recordings, and practical discussions, making it highly effective for surgical trainees.

Conclusion

Laparoscopic cholecystectomy with ligation of the cystic duct, as taught and demonstrated by Dr. R. K. Mishra, is a safe, reliable, and economical technique. While clips remain popular worldwide due to convenience, mastering suturing and knotting offers surgeons greater flexibility and security, particularly in challenging cases or resource-limited environments. Dr. Mishra’s emphasis on this approach reflects his broader vision of empowering surgeons with versatile skills that go beyond reliance on disposables, thereby enhancing both patient safety and surgical confidence.