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.
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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