Description

Laparoscopic cholecystectomy has become the gold standard procedure for the treatment of symptomatic gallstones and gallbladder diseases. One of the most critical steps in this minimally invasive surgery is the secure ligation of the cystic duct and cystic artery. Traditionally, metallic clips, harmonic scalpel, or endoloops are used for this purpose. However, the introduction of Mishra’s Knot, a secure extracorporeal knotting technique, has revolutionized this step by providing a safe, cost-effective, and reliable alternative. What is Mishra’s Knot? Mishra’s Knot, developed by Prof. Dr. R. K. Mishra, is a modification of extracorporeal knotting designed specifically for laparoscopic surgery. It is a self-sliding knot that ensures strong ligation, even in situations where tissues are slippery or thick, such as in an inflamed or fibrotic cystic duct. This knot combines the security of an intracorporeal knot with the simplicity and ease of extracorporeal application. Key Features of Mishra’s Knot: Provides superior holding strength compared to conventional extracorporeal knots. Resistant to slippage, ensuring safe closure of cystic duct and artery. Can be tied quickly and reliably, reducing operative time. Eliminates dependency on expensive disposable instruments like clips or staplers. Particularly useful in developing countries where cost-effectiveness is a major concern. Application in Laparoscopic Cholecystectomy During laparoscopic cholecystectomy, once the critical view of safety is achieved and the cystic duct and artery are clearly identified, the surgeon can apply Mishra’s Knot to secure these structures. Stepwise Technique: Identification and dissection: The cystic duct and artery are carefully dissected to achieve the critical view of safety. Preparation of the knot: An extracorporeal Mishra’s Knot is fashioned outside the abdominal cavity using a knot pusher. Placement: The knot is introduced into the abdomen through a trocar and positioned around the cystic duct or artery. Tightening: The self-sliding property allows the knot to snugly tighten around the structure, providing secure closure. Reinforcement: One or two knots can be applied as per the surgeon’s preference for additional security. Division: After secure ligation, the cystic duct and artery are safely divided, and cholecystectomy proceeds as usual. Advantages Over Clip Application Economic benefit: Reduces dependency on costly titanium clips or staplers. Safety: Lower risk of slippage compared to metallic clips, particularly in thick cystic ducts. Versatility: Can be used in both elective and complicated cases of acute cholecystitis. Biocompatibility: Uses suture material instead of metal clips, reducing foreign body complications. Clinical Impact Numerous surgeons trained at World Laparoscopy Hospital have successfully adopted this technique in their practice. Studies and clinical experiences demonstrate that laparoscopic cholecystectomy using Mishra’s Knot is equally safe and effective as traditional clip application, with the added benefit of reduced cost and enhanced security. Conclusion Laparoscopic cholecystectomy using Mishra’s Knot is a significant advancement in minimally invasive surgery. It provides surgeons with a reliable, economical, and safe method for securing the cystic duct and artery. By eliminating the need for expensive disposable instruments, this technique not only enhances surgical safety but also makes laparoscopic cholecystectomy more accessible worldwide.