Uterine fibroids (leiomyomas) are common benign tumors affecting women of reproductive age. They can cause heavy menstrual bleeding, pelvic pain, infertility, and recurrent pregnancy loss. Surgical removal, or myomectomy, is the treatment of choice for women desiring fertility preservation.

Laparoscopic myomectomy has emerged as a preferred minimally invasive approach, offering reduced postoperative pain, shorter hospital stay, faster recovery, and better cosmetic results compared to open surgery. One of the key challenges in laparoscopic myomectomy is securely suturing the uterine wall after fibroid removal.

Dr. R. K. Mishra, a pioneer in minimally invasive gynecology, introduced Mishra’s Knot, a laparoscopic suturing technique that allows safe, secure, and rapid closure of the myometrial defect. This innovation has simplified laparoscopic myomectomy and improved surgical outcomes.

Indications for Laparoscopic Myomectomy

Laparoscopic myomectomy is indicated for women with:

Symptomatic fibroids causing menorrhagia, pelvic pressure, or pain

Infertility or recurrent pregnancy loss due to fibroids

Submucosal, intramural, or subserosal fibroids accessible laparoscopically

Desire to preserve fertility or uterus

It is generally preferred for fibroids up to 10–12 cm, though multiple fibroids can also be removed depending on surgeon expertise.

Preoperative Considerations

Imaging: Ultrasound and MRI help determine size, location, and number of fibroids.

Anesthesia: General anesthesia is required.

Patient Positioning: Supine with slight Trendelenburg tilt for pelvic exposure.

Vasoconstrictive Agents: Injection of vasopressin in the myometrium reduces intraoperative bleeding.

Surgical Technique
Port Placement

A three- or four-port technique is commonly used:

Umbilical port (10 mm) for camera

Two accessory ports (5 mm) for instruments

Optional fourth port for assistant or morcellator

Myoma Identification and Enucleation

The fibroid is localized and incised using monopolar scissors or harmonic energy devices.

The myoma is carefully enucleated from the myometrium while preserving the endometrial cavity if possible.

Hemostasis is maintained using bipolar cautery.

Closure of Myometrial Defect – Mishra’s Knot

Closure of the myometrium is crucial to:

Prevent uterine rupture in future pregnancies

Reduce postoperative bleeding

Restore uterine anatomy

Mishra’s Knot is a modified extracorporeal knotting technique designed for laparoscopic suturing. Key features include:

Rapid formation: Knot is tied outside the abdomen and pushed into the peritoneal cavity using a knot pusher.

Secure closure: Provides strong tensile strength and prevents loosening.

Reduced suturing time: Especially useful for large or multiple fibroid beds.

Minimally traumatic: Preserves myometrial tissue and vascular integrity.

The technique allows layered closure of the myometrium with either absorbable barbed sutures or conventional sutures, ensuring hemostasis and structural integrity.

Retrieval of Fibroid

Fibroid tissue is removed using morcellation or contained extraction techniques to prevent spillage.

In-bag morcellation is preferred to reduce risk of tissue dissemination.

Final Hemostasis and Irrigation

Inspect the uterine wall for bleeding

Irrigate the peritoneal cavity to remove debris and blood

Remove ports and close the skin

Advantages of Mishra’s Knot in Laparoscopic Myomectomy

Time-efficient: Reduces operative time for suturing large defects.

Secure and reliable: Minimizes risk of knot slippage.

Fertility-preserving: Maintains uterine wall strength for future pregnancy.

Easy to learn: Standardized technique suitable for surgeons in training.

Reduced blood loss: Rapid and effective closure reduces intraoperative bleeding.

Postoperative Care

Early ambulation is encouraged.

Pain management with minimal analgesics.

Hormonal therapy may be considered to prevent fibroid recurrence.

Patients are usually discharged within 24–48 hours depending on recovery.

Follow-up imaging may be done to assess uterine healing.

Outcomes

Laparoscopic myomectomy using Mishra’s Knot has demonstrated:

Excellent hemostasis and minimal blood loss

Restoration of uterine anatomy suitable for conception

Shorter operative time compared to conventional laparoscopic suturing

Low rates of postoperative adhesions and complications

High patient satisfaction due to minimally invasive nature and faster recovery

Conclusion

Laparoscopic myomectomy using Mishra’s Knot represents a significant advancement in minimally invasive gynecologic surgery. This technique combines surgical precision, secure suturing, and efficiency, enabling safe removal of fibroids while preserving fertility.

For surgeons, mastering Mishra’s Knot enhances laparoscopic suturing skills and confidence in managing complex myometrial defects. For patients, it offers less pain, faster recovery, and optimal reproductive outcomes, establishing it as a standard in modern minimally invasive gynecologic surgery.