This video demonstrate Two port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery.

In the realm of laparoscopic surgery, the management of the appendiceal stump is the most critical step of an appendectomy. While various methods exist—such as endostaplers, endoloops, or titanium clips—Mishra’s Knot has emerged as a gold-standard technique, particularly at institutions like World Laparoscopy Hospital.

Developed by Prof. R.K. Mishra, this intracorporeal knot-laying technique offers a secure, cost-effective, and elegant solution for ligating the appendix during acute appendicitis.

The Clinical Challenge: The Appendiceal Stump

In acute appendicitis, the base of the appendix is often inflamed, friable, or edematous. A secure ligation is vital to prevent:

• Post-operative leaks (fecal discharge into the abdomen).

• Peritonitis (infection of the abdominal lining).

• Intra-abdominal abscesses.

While mechanical staplers are effective, they are expensive and can sometimes be too bulky for a severely inflamed cecal base. Mishra’s Knot provides a customized, surgeon-controlled alternative using standard silk or synthetic absorbable sutures.

The Technique: Step-by-Step

Mishra’s Knot is a specific modification of the sliding knot, designed to be tied intracorporeally (inside the body) using laparoscopic graspers and needle holders.

1. Skeletonization: The mesoappendix is first dissected and divided to isolate the base of the appendix.

2. The Loop Formation: A suture material (typically 2-0 silk or vicryl) is introduced into the abdomen. The surgeon forms a specific configuration of loops that allow the knot to slide easily when pulled but remain locked once tightened.

3. Application: The knot is placed around the base of the appendix.

4. The Slide and Lock: Using a knot pusher or a secondary grasper, the surgeon slides the knot down to the base. Once the tension is reached, the geometry of the "Mishra's Knot" ensures it locks securely against the tissue, even if the tissue is slightly swollen.

5. Division: Once two or three knots are placed for security, the appendix is transected and removed via a retrieval bag.

Advantages of Mishra’s Knot in Acute Appendicitis

Feature	Mishra’s Knot	Traditional Staplers/Clips
Cost	Extremely low (cost of a single suture).	High (cost of disposable cartridges).
Adaptability	Can be adjusted to any thickness of the appendix.	Limited by the "jaw" size of the device.
Security	Excellent tactile feedback for the surgeon.	Mechanical; no "feel" for tissue tension.
Foreign Body	Minimal (small suture knot).	Larger (plastic or metal clips/staple line).

Training and Precision at World Laparoscopy Hospital

The execution of Mishra’s Knot requires a high degree of laparoscopic suturing skill. At World Laparoscopy Hospital, surgeons undergo intensive "Dry Lab" and "Wet Lab" training to master this specific knot.

Conclusion

Mishra’s Knot represents the perfect marriage of traditional surgical principles and modern minimal access technology. For patients undergoing appendectomy at specialized centers, it ensures a recovery that is not only fast due to the laparoscopic approach but also safer and more affordable due to the precision of the ligation technique.