Uterine fibroids, also called myomas or leiomyomas, are benign growths that frequently affect women during their reproductive years. Among the different types of fibroids, pedunculated myomas are unique because they grow on a stalk (peduncle) and extend either outward from the uterus (subserosal) or inward into the uterine cavity (submucosal). These fibroids can cause pain, pressure, abnormal bleeding, or complications with fertility. Laparoscopic surgery has become the gold standard for treating pedunculated myomas, as it offers a minimally invasive approach with faster recovery, less pain, and reduced complications compared to open surgery.

One of the most effective and innovative techniques for performing laparoscopic myomectomy on pedunculated fibroids is the use of Mishra’s Knot, a secure extracorporeal knotting technique developed by Dr. R. K. Mishra. This technique ensures reliable hemostasis (bleeding control) while maintaining surgical precision, making it particularly effective for treating pedunculated myomas.

Understanding Pedunculated Myomas

Pedunculated myomas are attached to the uterus by a narrow stalk. Depending on their position, they are classified as:

Subserosal pedunculated myomas – arising on the outer uterine wall and projecting into the abdominal cavity.

Submucosal pedunculated myomas – projecting into the uterine cavity and often linked to heavy menstrual bleeding and infertility.

These fibroids, due to their stalk-like attachment, are easier to excise compared to deeply embedded intramural fibroids, but they pose a risk of intraoperative bleeding. Effective ligation of the pedicle is therefore critical for a safe laparoscopic outcome.

Role of Laparoscopy in Pedunculated Myoma

Laparoscopic myomectomy offers several advantages over open surgery:

Minimally invasive: Small keyhole incisions instead of a large abdominal cut.

Faster recovery: Patients typically return to normal activities within a week.

Reduced adhesion formation: Important for women planning future pregnancies.

Better cosmetic results: Minimal scarring.

For pedunculated myomas, laparoscopy provides excellent visualization of the stalk and surrounding uterine tissue, allowing precise dissection and removal. The challenge, however, lies in securely ligating the pedicle to prevent bleeding or recurrence. This is where Mishra’s Knot becomes highly beneficial.

Mishra’s Knot: A Breakthrough in Laparoscopic Suturing

Mishra’s Knot is an extracorporeal knot-tying technique specifically designed for laparoscopic surgery. It allows the surgeon to create a secure slip knot outside the body and then introduce it through the trocar into the abdominal cavity. Once inside, the knot is tightened around the pedicle of the fibroid with controlled precision.

Key Advantages of Mishra’s Knot:

High security – The knot does not slip, ensuring reliable pedicle ligation.

Ease of use – Can be mastered with training, reducing operative time.

Tissue safety – Provides uniform compression without cutting through tissue.

Hemostasis – Effectively prevents intraoperative and postoperative bleeding.

Versatility – Useful not only for myomectomy but also in other gynecological and general laparoscopic surgeries.

Surgical Steps: Laparoscopic Myomectomy for Pedunculated Fibroid Using Mishra’s Knot

Patient Preparation – The patient is placed in the lithotomy position under general anesthesia. Pneumoperitoneum is created and laparoscopic ports are inserted.

Visualization of Fibroid – The laparoscope is introduced, and the pedunculated myoma is visualized. Its stalk and vascular supply are carefully identified.

Application of Mishra’s Knot –

An extracorporeal knot is created outside the abdomen using a suture.

The knot is loaded on a knot pusher and introduced through the trocar.

The knot is then carefully placed around the stalk of the fibroid and tightened to occlude the blood supply.

Excision of the Myoma – Once the pedicle is securely ligated, the fibroid is excised using laparoscopic scissors or energy devices.

Hemostasis and Inspection – The pedicle stump is inspected to ensure complete hemostasis. If necessary, additional sutures can be applied.

Specimen Retrieval – The fibroid is removed either by morcellation or through an extended port incision.

Closure and Recovery – Ports are closed, and the patient is moved to recovery.

Clinical Benefits of Mishra’s Knot in Myomectomy

Reduced operative time compared to conventional intracorporeal suturing.

Lower risk of hemorrhage, as the knot provides secure vascular control.

Shorter hospital stay and quicker return to normal life.

Enhanced fertility outcomes, as the uterus is preserved with minimal trauma.

Conclusion

Laparoscopic surgery has transformed the management of pedunculated myomas, offering women a safe, effective, and minimally invasive solution. Among the many techniques available, Mishra’s Knot stands out as a simple yet highly reliable method for securing the pedicle and ensuring hemostasis. It combines surgical innovation with practicality, making laparoscopic myomectomy more efficient and safer for patients.

By mastering techniques like Mishra’s Knot, surgeons can significantly improve surgical outcomes, reduce complications, and uphold the highest standards of gynecological care. For women suffering from pedunculated fibroids, this approach offers renewed hope for symptom relief, fertility preservation, and a healthier future.