Learn the step-by-step technique of Extra Corporeal Mishra's Knot in this detailed video. Perfect for surgeons, trainees, and medical professionals looking to master this essential laparoscopic suturing skill.

Extra Corporeal Mishra's Knot is ideal knot for thick pedicles. We prefer to use a monofilament poly trimethylene carbonate absorbable suture for Mishra's Knot. It is very good knot for uterine vascular bundle, splenic artery, renal artery or In-mass Ligation in cholecystectomy. It combines excellent tensile strength with good handling properties. It has a good first-throw holding capacity and a smooth knot tie-down, which facilitates tissue approximation and reduces intraoperative knot repositioning, despite its relatively high memory. If a Mishra's knot has to be placed extracorporeally, we use a monofilament polypropylene or polygalactane suture as in conventional surgery. We prefer to use coated, braided polyester nonabsorbable sutures in sutured rectopexy also in Mishra's Knot.

Laparoscopic surgery has revolutionized minimally invasive procedures, allowing surgeons to perform complex operations through small incisions with precision and minimal patient trauma. One of the critical skills in laparoscopic surgery is intracorporeal and extracorporeal knotting. Among these, the Extra Corporeal Mishra's Knot stands out as a versatile, secure, and efficient suturing technique widely used in various procedures.

What is the Extra Corporeal Mishra's Knot?

The Extra Corporeal Mishra's Knot is a laparoscopic knotting technique developed to simplify suturing in minimally invasive surgeries. Unlike conventional intracorporeal knots that are tied inside the abdominal cavity, this knot is tied outside the body (extracorporeally) and then slid into place through a trocar. This approach reduces the complexity of knot-tying within the restricted laparoscopic field while maintaining strong and reliable tissue approximation.

Advantages of the Extra Corporeal Mishra's Knot

• Time-efficient: Faster than intracorporeal knotting for most laparoscopic procedures.

• Secure: Provides a firm, non-slipping knot that maintains tissue tension.

• Versatile: Can be used in various surgeries, including hernia repair, gastrointestinal anastomoses, and gynecological procedures.

• Ease of learning: Suitable for surgeons in training due to its straightforward technique.

Indications

The Extra Corporeal Mishra's Knot is commonly used in:

• Laparoscopic hernia repair (TAPP and TEP procedures)

• Laparoscopic cholecystectomy for cystic duct ligation

• Laparoscopic gastrointestinal surgery (anastomoses, perforation repair)

• Gynecological laparoscopic procedures (suturing of ovarian cysts, hysterectomy closures)

Step-by-Step Technique

1. Preparation

• Select an appropriate suture (usually absorbable for soft tissue approximation).

• Introduce the suture into the abdominal cavity via the trocar.

• Ensure proper laparoscopic instruments are in place (needle holder, grasper).

2. Forming the Knot Extracorporeally

• Outside the body, tie the Mishra's knot by creating a series of loops in a specific pattern to ensure a secure lock.

• Maintain the tail of the suture at an appropriate length to allow smooth sliding.

3. Sliding the Knot

• Use a knot pusher or the laparoscopic grasper to slide the pre-formed knot through the trocar into the surgical site.

• Advance the knot carefully along the suture to the tissue approximation site.

4. Securing the Knot

• Once positioned, tighten the knot gently to approximate the tissues without causing ischemia.

• Repeat additional throws if necessary to reinforce the knot.

• Cut excess suture, leaving an adequate tail to prevent unraveling.

Tips for Success

• Practice the knot externally on a training board before performing on patients.

• Maintain consistent tension while sliding the knot to prevent loosening.

• Use proper instruments to avoid suture fraying or slippage.

• Visualize the tissue carefully to avoid injury during knot placement.

Conclusion

The Extra Corporeal Mishra's Knot is a valuable technique in laparoscopic surgery, combining efficiency, reliability, and ease of learning. Mastery of this knot can significantly improve operative speed and confidence, particularly for surgeons performing minimally invasive procedures. Continuous practice on simulators and real-time surgical application ensures proficiency and optimal patient outcomes.