Laparoscopic Appendicectomy By Mishra's Knot
Acute appendicitis is one of the most common surgical emergencies worldwide. Traditional open appendectomy, though effective, involves a larger incision, more postoperative pain, and longer recovery. The advent of laparoscopic appendectomy has transformed the management of appendicitis by offering minimally invasive access, reduced pain, faster recovery, and improved cosmetic results. Among the modern techniques in laparoscopic appendectomy, Mishra’s Knot has emerged as a safe and efficient method for ligating the base of the appendix, minimizing operative time and reducing the risk of stump complications.
Indications
Laparoscopic appendectomy by Mishra’s Knot is indicated in:
Acute Appendicitis: The most common indication, including early and uncomplicated cases.
Complicated Appendicitis: Cases with perforation, abscess, or localized peritonitis can also be managed laparoscopically with proper surgical expertise.
Incidental Appendectomy: Sometimes performed during other laparoscopic abdominal procedures.
Diagnostic Uncertainty: In cases where the diagnosis of appendicitis is uncertain, laparoscopy allows both diagnosis and definitive treatment.
Contraindications are generally limited to unstable patients with severe septicemia, extensive adhesions from previous abdominal surgeries, or contraindications to general anesthesia.
Preoperative Evaluation
A comprehensive evaluation ensures patient safety and optimal outcomes. Key preoperative steps include:
History and Physical Examination: Identifying classic symptoms such as right lower quadrant pain, nausea, and fever.
Laboratory Tests: Complete blood count, C-reactive protein, and renal and liver function tests.
Imaging: Ultrasound or CT scan to confirm diagnosis and assess complications.
Anesthesia Assessment: Ensuring the patient is fit for general anesthesia.
Patients are also counseled regarding the surgical procedure, possible complications, and postoperative care.
Surgical Technique
Mishra’s Knot is a specialized method for securing the base of the appendix using a laparoscopic extracorporeal knotting technique, which simplifies the ligation process and reduces operative time. The procedure involves several steps:
Patient Positioning and Port Placement:
The patient is placed in a supine position with a slight Trendelenburg tilt and left tilt to move the intestines away from the surgical field. Standard laparoscopic ports include:
10 mm infraumbilical port for the laparoscope
5 mm ports in the left lower quadrant and suprapubic region for instruments
Exploration and Appendix Identification:
The abdominal cavity is insufflated with CO₂ to create pneumoperitoneum. The appendix is identified, and adhesions, if present, are carefully dissected.
Mesappendix Management:
The mesoappendix, containing the appendicular artery, is coagulated and divided using bipolar cautery or an ultrasonic energy device, ensuring hemostasis while preserving surrounding structures.
Mishra’s Knot Ligation of Appendix Base:
The appendix is mobilized and delivered near the umbilical port.
A special extracorporeal knot, known as Mishra’s Knot, is prepared using absorbable suture. This knot is designed to securely ligate the base of the appendix with minimal slippage.
The knot is carefully slid down to the base, ensuring tight closure without injury to the cecum.
The appendix is divided distal to the knot, completing the excision.
Specimen Retrieval and Cavity Inspection:
The excised appendix is removed using a specimen retrieval bag to prevent contamination. The abdominal cavity is irrigated, and hemostasis is confirmed.
Port Closure:
The ports are removed, and the fascial and skin layers are closed with absorbable sutures or subcuticular closure, leaving minimal visible scarring.
Postoperative Care
Patients generally recover quickly after laparoscopic appendectomy. Key aspects of postoperative care include:
Early ambulation to reduce the risk of thromboembolism.
Oral intake is usually resumed within 6–12 hours.
Analgesics are administered for pain control, which is typically mild.
Wound care and monitoring for signs of infection or intra-abdominal complications.
Most patients can be discharged within 24–48 hours, with complete recovery in 7–10 days.
Outcomes and Complications
Laparoscopic appendectomy using Mishra’s Knot is associated with excellent outcomes. Benefits include reduced operative time, minimal postoperative pain, early return to work, and superior cosmetic results. The risk of stump leakage or infection is very low due to secure ligation. Complications, although rare, may include intra-abdominal abscess, port-site infection, or injury to adjacent structures. These risks are minimized by meticulous surgical technique and proper patient selection.
Advantages of Mishra’s Knot
Secure Ligation: Prevents slippage or stump complications.
Time-Efficient: Reduces operative time compared to intracorporeal suturing.
Minimally Invasive: Preserves the advantages of laparoscopy, including less pain and faster recovery.
Safe and Reproducible: Can be performed reliably by surgeons trained in the technique.
Conclusion
Laparoscopic appendectomy using Mishra’s Knot represents a modern, safe, and efficient approach to the surgical management of appendicitis. By combining the benefits of minimally invasive surgery with a secure and time-saving ligation technique, this method provides excellent outcomes, rapid recovery, minimal postoperative pain, and superior cosmetic results. It is now widely recognized as an effective technique in both routine and complicated appendicitis cases, offering patients a reliable and advanced surgical solution.
Indications
Laparoscopic appendectomy by Mishra’s Knot is indicated in:
Acute Appendicitis: The most common indication, including early and uncomplicated cases.
Complicated Appendicitis: Cases with perforation, abscess, or localized peritonitis can also be managed laparoscopically with proper surgical expertise.
Incidental Appendectomy: Sometimes performed during other laparoscopic abdominal procedures.
Diagnostic Uncertainty: In cases where the diagnosis of appendicitis is uncertain, laparoscopy allows both diagnosis and definitive treatment.
Contraindications are generally limited to unstable patients with severe septicemia, extensive adhesions from previous abdominal surgeries, or contraindications to general anesthesia.
Preoperative Evaluation
A comprehensive evaluation ensures patient safety and optimal outcomes. Key preoperative steps include:
History and Physical Examination: Identifying classic symptoms such as right lower quadrant pain, nausea, and fever.
Laboratory Tests: Complete blood count, C-reactive protein, and renal and liver function tests.
Imaging: Ultrasound or CT scan to confirm diagnosis and assess complications.
Anesthesia Assessment: Ensuring the patient is fit for general anesthesia.
Patients are also counseled regarding the surgical procedure, possible complications, and postoperative care.
Surgical Technique
Mishra’s Knot is a specialized method for securing the base of the appendix using a laparoscopic extracorporeal knotting technique, which simplifies the ligation process and reduces operative time. The procedure involves several steps:
Patient Positioning and Port Placement:
The patient is placed in a supine position with a slight Trendelenburg tilt and left tilt to move the intestines away from the surgical field. Standard laparoscopic ports include:
10 mm infraumbilical port for the laparoscope
5 mm ports in the left lower quadrant and suprapubic region for instruments
Exploration and Appendix Identification:
The abdominal cavity is insufflated with CO₂ to create pneumoperitoneum. The appendix is identified, and adhesions, if present, are carefully dissected.
Mesappendix Management:
The mesoappendix, containing the appendicular artery, is coagulated and divided using bipolar cautery or an ultrasonic energy device, ensuring hemostasis while preserving surrounding structures.
Mishra’s Knot Ligation of Appendix Base:
The appendix is mobilized and delivered near the umbilical port.
A special extracorporeal knot, known as Mishra’s Knot, is prepared using absorbable suture. This knot is designed to securely ligate the base of the appendix with minimal slippage.
The knot is carefully slid down to the base, ensuring tight closure without injury to the cecum.
The appendix is divided distal to the knot, completing the excision.
Specimen Retrieval and Cavity Inspection:
The excised appendix is removed using a specimen retrieval bag to prevent contamination. The abdominal cavity is irrigated, and hemostasis is confirmed.
Port Closure:
The ports are removed, and the fascial and skin layers are closed with absorbable sutures or subcuticular closure, leaving minimal visible scarring.
Postoperative Care
Patients generally recover quickly after laparoscopic appendectomy. Key aspects of postoperative care include:
Early ambulation to reduce the risk of thromboembolism.
Oral intake is usually resumed within 6–12 hours.
Analgesics are administered for pain control, which is typically mild.
Wound care and monitoring for signs of infection or intra-abdominal complications.
Most patients can be discharged within 24–48 hours, with complete recovery in 7–10 days.
Outcomes and Complications
Laparoscopic appendectomy using Mishra’s Knot is associated with excellent outcomes. Benefits include reduced operative time, minimal postoperative pain, early return to work, and superior cosmetic results. The risk of stump leakage or infection is very low due to secure ligation. Complications, although rare, may include intra-abdominal abscess, port-site infection, or injury to adjacent structures. These risks are minimized by meticulous surgical technique and proper patient selection.
Advantages of Mishra’s Knot
Secure Ligation: Prevents slippage or stump complications.
Time-Efficient: Reduces operative time compared to intracorporeal suturing.
Minimally Invasive: Preserves the advantages of laparoscopy, including less pain and faster recovery.
Safe and Reproducible: Can be performed reliably by surgeons trained in the technique.
Conclusion
Laparoscopic appendectomy using Mishra’s Knot represents a modern, safe, and efficient approach to the surgical management of appendicitis. By combining the benefits of minimally invasive surgery with a secure and time-saving ligation technique, this method provides excellent outcomes, rapid recovery, minimal postoperative pain, and superior cosmetic results. It is now widely recognized as an effective technique in both routine and complicated appendicitis cases, offering patients a reliable and advanced surgical solution.
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