Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis Laparoscopic Tubal Ligation by Mishra’s Knot
Gynecology / Dec 29th, 2019 4:26 pm     A+ | a-
Dr. Andi Setiawan Tahang Sp.OG, M.Kes, F.MAS, FICRS
Gynecology, December 23rd, 2019

Equipment needed:

1. Laparoscopic drapes, insufflators, light source, HD camera with a 30-degree telescope (10 mm), seven parameter monitor, LCD monitor.
2. Veres needle 12 cm with 10 ml NS syringe, and 10 ml xylocaine 2 % for subcutaneous injection before doing skin incision.
3. Two 10 mm and one 5 mm port.
4. 11, number scalpel.
5. The length of suture used in the extracorporeal knot for the free structure is 75 cm by no.1 vicryl.
6. Bhandarkar Knot Pusher.
7. Ligasure.
8. An Atraumatic grasper.


1. The procedure can be performed under GA or LA.
2. Put the patient in a supine position with 15 degrees head down.
3. Quadrimanometric device ready, the preset pressure should not be more than 12 mm, and the gas flow rate 1L/min.
4. Position of the surgical team: Surgeon on the left side of the patient and coaxial alignment with the target organ (the tubes) and the monitor at a distant about 5*diameter of the monitor and the table height 0,49* surgeon height.
5. Disinfect the abdomen from the nipple till the pubic symphysis line and to the level of anterior iliac spines laterally.
6. Xylocaine 10 ml is subcutaneously infiltrated around the umbilicus.
7. By the use of an 11 mm blade, 2 mm incision at the lower umbilical skin crease.
8. Verres needle is checked for valve action and patency by n/s irrigation.
9. Hold it like a dart and skin thickness is elicited by holding it at the level of the umbilicus and add to it 4 cm for needle tenting, the needle should be perpendicular to the abdominal wall and directed toward anus, left hand should hold the lower abdominal to make it 45 degrees toward the patient body.
10. Two clicks are heard at this time, during the rectus and peritoneum entry, then check by suction-irrigation test, hanging drop test.
11. The insufflator is switched on and connected to the veress needle.
12. Check the flow rate and the actual pressure at this time, the flow rate, not more than 1,5 L/min, the actual pressure increasing gradually, and not exceeding preset pressure.
13. When the actual pressure becomes equal to the preset pressure, take out the needle and do a 10 mm smiling incision in the lower umbilical crease.
14. Insert artery holding forceps to the incision to dilate the vitellointestinal duct and separate the recti muscle (Scandanavian technique).
15. Insert a 10 mm umbilical port and connect the insufflator and close the valve for continuous pneumoperitoneum.
16. Insert a 10 mm 30 degree telescope and take a panoramic view.
17. 10 mm port is inserted under direct vision in the left iliac fossa 7,5 cm lateral to the umbilicus and 5 mm port is inserted under direct vision in the right iliac fossa 7,5 cm lateral to the umbilicus according to Baseball Diamond Theory.
18. Prepare of the length of suture in the extracorporeal knot for the free structure is 75 cm by vicryl no.1
19. Take the Bhandarkar knot pusher in the left hand and pass 2 cm suture through. The eye in the tail end of the Bhandarkar knot pusher by the right hand.
20. The knot pusher is now reversely feed in the 3 mm reducer. Reverse feeding is important.
21. Once the reducer is fed, the thread is pulled out from the eye of the tail of the knot pusher. The job of the eye in the tail is just to pass the suture safely from the reducer.
22. Now the other end of the suture is passed through the eye of the head end using the right hand.
23. Ask the assistant for finger and make the configuration of Mishra’s knot is 1-1-1-1-1-1-1. One hitch one wind one lock, 2nd wind second lock and 3rd wind, and the final lock.
24. Make the diameter of loop 6 cm by sliding the loop by right hands finger and thumb.
25. After that, hide the knot and its loop under the reducer.
26. Now the knot pusher and the reducer are introduced through the 10 mm port. If it is introduced through the 10 mm, port additional 5 mm reducer should be introduced.
27. An Atraumatic grasper should also be introduced from the contralateral port (5 mm port in the right hand).
28. The loop of the knot should go near to the Right or Left Fallopian Tube.
29. The Atraumatic grasper should have to enter or introduced in the loop and catch the left fallopian tube.
30. Now the knot pusher should go to feed the loop behind the left fallopian tube. The same way as our hands goes behind when we put garland on someone’s neck.
31. The knot now can be slide to the left fallopian tube. By establishing the knot pusher with the left hand and pulling the suture with the right hand.
32. After tightening the knot consecutively three times, the knot pusher after that coagulation and cutting by Ligasure (Bipolar).
33. 5mm reducer is pulled, and hook scissors is introduced from the same port, and the suture is cut, leaving 1 cm tail.
34. The same is repeated on the right fallopian tube. Remove the applicator.
35. Take a 5 mm telescope after white balancing and fixation before insertion through the 5 mm port.
36. Prepare the veress needle and make a loop of thread (proline) to use it for the closure of the 10 mm port to prevent future hernia.
37. Close the umbilical 10 mm port and 10 mm second port in the left hand under direct vision by no.1 vicryl.
38. Deflate the abdomen gradually making jerky movement by the 5 mm telescope to avoid intestinal entrapment to the port.
39. Put a surgical dressing on the port sites.

Elaborated Steps of other technique

Position the patient in the supine position with both arms tucked.

Administer general anesthesia.

Place a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 1-2 additional trocars as required.

Identify the fallopian tubes.

Apply Mishra's Knot or

Use the bipolar cautery or monopolar cautery to coagulate the isthmic portion of the tubes.

Apply a second layer of cautery to ensure complete occlusion of the tubes.

Remove the laparoscope.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.
Dr. Anita Bansal
May 21st, 2020 2:22 am
Excellent information on Laparoscopic Tubal Ligation. Very good task analysis with a clear and simple explanation! keep up the good work!
Dr. Sweta Tiwari
May 22nd, 2020 4:36 am
This article is very well presented, which helped me to learn new knoting knowledge quickly. Thanks for published Task Analysis of Laparoscopic Tubal Ligation by Mishra’s Knot.
Sujata K
Apr 28th, 2021 9:57 am
Excellent Task Analysis of Laparoscopic Tubal Ligation by Mishra’s Knot. I read your article many times and enjoyed it. Now I wish I become a doctor.
Dr. Harish Mathur
Apr 28th, 2021 10:35 am
Thanks, I like this article, I wait for more, Thanks for posting of Laparoscopic Tubal Ligation by Mishra’s Knot.
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