Task Analysis of Laparoscopic Procedures

Task Analysis of Mishra's Knot
General Surgery / Mar 2nd, 2018 2:47 pm     A+ | a-
Dr Ex Major Deepashree Patil
MBBS, MS(OBG), FAGE, FMAS ,
(DMAS feb 2018 batch)
Army  Medical Officer (Rtd)
Assistant Professor, Dept of OBG,
RIMS ,Raichur, Karnataka
captdeepashree31@gmail.com

INTRODUCTION:
 
It’s aptly said “NO FUTURE WITHOUT SUTURE” which emphasises on the importance of suturing & knotting skills in laparoscopy. DR.(Prof)R.K. MISHRA is the proponent of new technique of knot named after him as “Mishra‘s  Knot” in the year 2003 ;and since then many surgeons are using this knot.
 
REQUIRMENTS:
 
Structures : Continuous structure
Suture: Type: any type
Length: 90 cm preferrable, Needle: Endoski needle, Knot pusher: Bhandarkar’s knot pusher
Maryland-1
Needle holder-1
Scissor-1
Long reducer-1
Ports inserted-3 [1 Telescope & 2 side ports 5mm and 10mm]
Configuration of Mishra’s Knot
1-1-1-1-1-1-1
1 HITCH; (1-1)3   WIND AND half LOCK alternating for 3 times
 
PARTS OF SUTURE 
 
Short/ Anterior/ Long/Posterior limb           
Wrapping  /Working limb
 
PARTS OF KNOT
 
PARTS OF BHANDARKAR KNOT PUSHER 
 
MAKING OF ENDOSKI NEEDLE:
 
STEP E1 Hold the needle at swag end tip with needle holder .
STEP E2 Hold the lateral one third from tip of needle with curved artery    such  that convexity faces convex centre of the needle.
STEP E3 Bend from E1 such that it makes J shape. There should not be   curves/hemps. It should be smooth.
NEEDLE INTRODUCTION AND TAKING BITE:
1. Insert  Maryland in 5mm reducer and hold suture at tail end & pull suture out of reducer & stop till 6 cm of swag end seen
2. Re –introduce Maryland and hold suture 2 cm away from swag end and hide needle with suture in reducer with 5 mm reducer, introduce Maryland and suture both together through 10mm port
3. Introduce Maryland  grasper in 5 mm port
4. Make a window by dissecting the tissue plane over the suture to be tied.
5. Introduce needle holder from Rt. Side port and align the needle from Rt. Hand needle holder.
6. Take a bite /pass suture through the window and hold with Maryland or atraumatic grasper pull suture for 2 cm. Drop the needle
7. Hold the suture with the needle holder 2cm from the swag end of needle & feed the suture of 5 cm length for 4 times such that atleast 20 cm of suture is inside abdomen.
8. The telescope to be focused towards the cannula of the needle holder to show the suture. 
9. With the Maryland, hold 2 cm from sway end, pull the suture out of the reducer and cut the needle through 10mm port. 
10. Take care not to give more  pressure so as to avoid cutting of  tissue
11. Assistant finger placed over washer  of reducer in between the 2 suture to prevent gas leak
12. Tie Mishra’s  knot as illustrated( Follow steps H1-3 ;W1-3 ;L1-3 ;S1-3 ) 
 
Making a Hitch
 
H1 with left hand hold right long limb & right hand to hold short left limb of suture.Short limb of suture to cross over the long posterior limb such that the short limb is above the anterior limb.
H2 Intersection point of suture to be held between left index finger and left thumb opposed
H3 Pass the short limb in between loop from below upwards using thumb and middle finger of right hand the short limb should be pulled downwards  by thumb and index finger of right hand to make first hitch
Making a Wind 
W1 Hold short limb in right thumb and middle finger and pass over whole loop from below
W2.pull short limb from up by index finger and thumb of right hand 
W3 place the first wind over the first hitch without overriding.
 
Making a half Lock 
 
L1 Short limb to be passed inside the loop from below upwards using index finger and thumb of Right hand
L2 once short limb project up push it down by thumb inside loop to make half locking knot
L3 Pull tail from below to tighten knot repeat w1, w2, w3 for making 2nd wind
Repeat steps  w1w2w3 for making 2nd wind
Repeat L1 L2 L3 for making 2nd halflock
Repeat w1w2w3 for making 3rd wind
Repeat L1 L2 L3 for making 3rd half lock
Reconfirm Mishras knot configuration 1-1-1-1-1-1-1
How to Slide the knot
S1- suture should be neatly stacked one above the other in order. Avoid overriding ,check for knot configuration again
S2-check if knot slides easily over long posterior limb.
S3-cut the short anterior limb 1cm from knot.
 
Mishras knot is now ready for tightening.
 
14 feed the suture from head end and Bhandarker Knot Pusher and take out from the tail end.
15 3mm reducer reversely feed over Bhandarker Knot Pusher. 
16Assistant removes finger and now knot pusher and reducer is introduced inside 5mm reducer. Focus telescope to visualize the placement of knot slowly from cannula to the structure.
17-slowly push the Bhandarker Knot Pusher and shorten the loop.
18-keep the tip of  Bhandarker Knot Pusher  where the knot is required to be placed and pull the suture from left hand and push the knot pusher from right hand.
19 do not over pull the structure.Gently twist the Bhandarker Knot Pusher such that the knot will automatically slide to the site of desired structure.
20 after placing the knot and tightening;  Push and Pull 3 times ;push the knot pusher and pull the suture gently .
21-remove 3mm  reducer ,introduce scissors in same port and cut suture leaving 1cm from knot.
 
Advantages of Mishra’s Knot
 
  1. Simple
  2. Safe 
  3. Easy
  4. Quick
  5. Strongest knot strength
  6. Highest knot security
  7. For any continuous tubular structure upto 22mm diameter 
  8. Can be tied with any suture size.
  9. Disadvantage of Mishra’S knot:
  10. Whole suture length required for one knot.
     
Conclusion
 
Suturing and knotting is the most important skill every gynecologist must know.Mishra’s knot is SAFEST easiest and quick knot which can be tied with any suture material of any size and has got the highest knot strength and lock security. 
 
References 
 
1.Mastering the technique of laparoscopic suturing and knotting by Dr. R. K   Mishra ,Jaypee Publication 2013 report.
2.Role of Mishra’s Knot in various surgeries in lap pg 114,115 original article from World Journal of Laparoscopic Surgeons;10.5005/jp journal-1003-1286. 
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