This video demonstrate how to tie extracorporeal Mishra's knot. Nowadays, laparoscopy has become an indispensable component of surgical training across the globe. Many complicated procedures are quite regularly performed by minimally invasive approaches. As such, acquiring proficiency in endoscopic suturing has virtually turned an obligatory prerequisite into safe execution of not only advanced but also basic laparoscopic. However, intracorporeal suturing is remarkably difficult to learn and at times quite frustrating and time-consuming. To attain that required dexterity, a needle-to driver shaft angle is generally recommended].However, as per the persistent observations made and experience gained by us over the last two decades, such a right angled grip is arguably supportive only in the most favorable circumstances wherein the tissue to be sutured lies on the “floor” of the monitor, is co-axially aligned with the needle holder, and is easily accessible; thus can it finally tied the knot. Etracorporeal knot does not has these problems. Extracorporeal surgeons knot is used widely to ligated big vessels like splenic artery, renal artery and vein. Uterine artery and partial cholecystectomy.

Laparoscopic surgery has revolutionized modern surgery by allowing surgeons to perform complex procedures through small incisions, reducing patient trauma, hospital stay, and recovery time. A crucial component of laparoscopic surgery is suturing, which requires precision, dexterity, and specialized techniques. Among these, Laparoscopic Mishra’s Knot has emerged as a reliable, efficient, and widely used knotting technique.

What is Laparoscopic Mishra’s Knot?

The Mishra’s Knot is a specialized extracorporeal knot designed for laparoscopic procedures. It is named after Dr. R.K. Mishra, a pioneer in minimally invasive surgery. This knot is known for its security, ease of tying, and adaptability in various surgical scenarios, including hernia repair, gastrointestinal surgery, and gynecological procedures.

Unlike traditional intracorporeal knots, which are tied inside the body using laparoscopic instruments, the Mishra’s Knot is tied outside the body (extracorporeally) and then pushed inside through a trocar using a knot pusher. This technique reduces operative time and enhances knot reliability.

Advantages of Mishra’s Knot in Laparoscopy

1. Secure Knotting: The Mishra’s Knot provides excellent tensile strength, minimizing the risk of suture slippage or loosening.

2. Time Efficiency: Extracorporeal tying outside the abdominal cavity speeds up the procedure compared to intracorporeal knots.

3. Versatility: Can be used in multiple types of laparoscopic surgeries including hernia repair, bowel anastomosis, and gynecologic procedures.

4. Ease of Learning: Surgeons and trainees find it easier to master compared to complex intracorporeal suturing.

5. Reduced Instrument Clash: Since the knot is tied outside, there is less interference between laparoscopic instruments inside the abdominal cavity.

Step-by-Step Technique of Laparoscopic Mishra’s Knot

1. Suture Preparation: Select an appropriate suture material and thread it through a needle suitable for laparoscopic use.

2. Extracorporeal Knot Formation: Outside the body, form the Mishra’s Knot by creating a series of loops around the standing end of the suture.

3. Use of Knot Pusher: Introduce the knot inside the abdomen using a laparoscopic knot pusher.

4. Tightening the Knot: Slide the knot down the suture to the desired tissue site and tighten securely under laparoscopic vision.

5. Final Adjustment: Ensure proper tension without causing tissue ischemia or damage, then cut the excess suture.

Clinical Applications

• Hernia Repair: Particularly in laparoscopic inguinal hernia mesh fixation.

• Gastrointestinal Surgery: For secure closure of bowel or gastric anastomosis.

• Gynecology: During procedures like laparoscopic hysterectomy or ovarian cystectomy.

• General Laparoscopic Suturing: Anywhere secure and reliable knotting is needed.

Conclusion

The Laparoscopic Mishra’s Knot represents a significant advancement in minimally invasive surgery, combining safety, reliability, and efficiency. Its extracorporeal nature makes it particularly attractive for surgeons looking to reduce operative time without compromising on the security of the suture. Mastery of this knot is essential for any surgeon aiming to excel in laparoscopic surgery.