This video demonstrate Mucocele of Gallbladder with Impacted Stone at the Neck Performed by Mishra's Knot. A gallbladder mucocele is the distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow, decreased gallbladder motility, and altered absorption of water from the gallbladder lumen are predisposing factors to biliary sludge.

Mucocele of the gallbladder is a pathological condition characterized by progressive distension of the gallbladder due to chronic obstruction of the cystic duct, most commonly caused by an impacted gallstone at the neck of the gallbladder. The continuous secretion of mucus by the gallbladder epithelium leads to marked enlargement, inflammation, and increased risk of complications. Advanced laparoscopic techniques, including the use of Mishra’s Knot, have significantly improved the safety and efficacy of surgical management in such complex cases.

Pathophysiology of Gallbladder Mucocele

A gallbladder mucocele develops when the cystic duct becomes persistently obstructed. In cases where a stone is impacted at the neck:

• Bile absorption continues while mucus secretion persists

• The gallbladder becomes tense, enlarged, and thick-walled

• Chronic inflammation increases the risk of infection, ischemia, or perforation

This condition is often associated with long-standing cholelithiasis and may present diagnostic and operative challenges.

Clinical Presentation

Patients with gallbladder mucocele may present with:

• Right upper quadrant abdominal pain

• Palpable gallbladder mass

• Nausea and vomiting

• Features of chronic cholecystitis

• Occasionally jaundice, if associated with biliary obstruction

Diagnostic Evaluation

Diagnosis is primarily based on imaging:

• Ultrasonography reveals a markedly distended gallbladder with an anechoic or hypoechoic lumen and an impacted stone at the neck

• CT scan or MRCP may be useful in complex cases to assess anatomy and exclude malignancy
  Laboratory investigations are usually normal or may show mild inflammatory markers.

Surgical Management

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy remains the treatment of choice for gallbladder mucocele. However, impacted stones at the neck can obscure Calot’s triangle and increase the risk of bile duct injury.

Role of Mishra’s Knot

Mishra’s Knot is a specialized extracorporeal sliding knot widely used in advanced laparoscopic surgery. In cases of gallbladder mucocele:

• It allows secure ligation of the cystic duct even in edematous or thickened tissues

• It provides excellent knot security with minimal slippage

• It helps maintain precise control in difficult anatomy, especially when clips may be unreliable

The use of Mishra’s Knot enhances safety during cystic duct ligation and reduces the risk of bile leak.

Operative Technique Highlights

• Controlled decompression of the distended gallbladder, if required

• Careful dissection to identify cystic structures

• Extraction or milking of the impacted stone from the neck when feasible

• Secure ligation of the cystic duct using Mishra’s Knot

• Completion of cholecystectomy with meticulous hemostasis

Postoperative Outcome

Patients undergoing laparoscopic cholecystectomy using Mishra’s Knot typically experience:

• Reduced operative complications

• Minimal postoperative pain

• Early mobilization and discharge

• Excellent long-term outcomes with low incidence of bile leakage

Conclusion

Mucocele of the gallbladder with an impacted stone at the neck is a challenging surgical condition that requires expertise and advanced laparoscopic skills. The application of Mishra’s Knot offers a reliable, safe, and effective method for cystic duct ligation in difficult anatomy. When performed by experienced laparoscopic surgeons, this technique significantly enhances surgical precision and patient outcomes.