In this video, we will discuss that Knot-tying is a cornerstone skill in laparoscopic surgery, where precision, control, and reliability are paramount. Among the various extracorporeal knotting techniques, the Mishra Knot stands out for its simplicity, security, and effectiveness in a wide range of minimal access procedures. Developed by renowned laparoscopic surgeon Dr. R.K. Mishra, this knot has become a preferred choice for surgeons around the world. In this video, we offer a step-by-step demonstration of how to tie and apply the Mishra Knot, making it an essential learning resource for all laparoscopic surgeons and trainees.

What is the Mishra Knot?

The Mishra Knot is a sliding extracorporeal knot used to ligate tissue and secure sutures inside the abdominal cavity during laparoscopic surgery. Unlike traditional intracorporeal suturing, which requires tying knots within the body using laparoscopic instruments, the Mishra Knot is tied outside the body and then introduced through a trocar using a knot pusher. It is especially useful in deep pelvic or upper abdominal areas where maneuverability is limited.

When to Use the Mishra Knot

The Mishra Knot is particularly effective in:
Securing the base of the appendix during laparoscopic appendectomy
Ligation of cystic duct or artery in laparoscopic cholecystectomy
Vaginal vault closure in total laparoscopic hysterectomy
Tubal ligation or fimbriectomy
Hernia sac closure or peritoneal repair
Hemostasis of small pedicles or bleeders in gynecological and urological procedures

Step-by-Step Technique Demonstrated in the Video

Suture Preparation: Choose a non-absorbable or delayed-absorbable monofilament suture such as Ethilon or PDS. Cut the suture to an appropriate length (usually 90–100 cm).

Forming the Loop: Tie a simple loop using one end of the suture, leaving the longer end free for sliding. The loop acts as the locking point of the knot.

Creating the Wraps: Make 3–4 turns of the long (sliding) end around the fixed limb (post). These wraps should be neat, close, and symmetrical for smooth sliding.

Passing the End: Pass the working end of the suture through the loop created earlier and pull gently to lock the turns in place.

Advancing the Knot: Use a knot pusher to advance the knot carefully through the trocar or working port to the desired tissue site inside the abdomen.

Tightening: Once the knot reaches the target area (e.g., a pedicle or duct), apply steady tension to secure the knot tightly. Additional half hitches can be placed for reinforcement if needed.

Advantages of the Mishra Knot

High Knot Security: Resists loosening and slippage
Smooth Sliding: Easily passes through ports and reaches deep anatomical locations
Time Efficient: Faster than intracorporeal knotting
Versatile: Can be used in multiple laparoscopic specialties
Easy to Learn: Ideal for beginners in laparoscopic suturing

Common Mistakes to Avoid

Loose wraps or improper coiling
Incorrect suture material choice (use monofilament for best results)
Excessive force during knot advancement
Poor loop formation leading to unraveling

Who Should Watch This Video?

General surgeons, gynecologists, and urologists
Surgical residents and fellows in laparoscopic training
Trainers and educators involved in MAS skill development
Operating room assistants and laparoscopic technicians

Conclusion

The Mishra Knot is a valuable technique that enhances the efficiency and safety of laparoscopic suturing. By learning and practicing this knot, surgeons can confidently manage a variety of intraoperative scenarios requiring secure tissue ligation. This video offers a clear, step-by-step guide to mastering the Mishra Knot and integrating it into routine laparoscopic practice.

Watch the full video for a detailed demonstration and expert tips on tying the Mishra Knot effectively in laparoscopic surgery. Don’t forget to like, share, and subscribe for more surgical education and hands-on training content.