Laparoscopic Hysterectomy by Mishra's Knot

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For Extracorporeal Knotting knot pushers are utilized. These knot pushers are of either closed jaw or of open jaw type.

Extracorporeal knot Ligation for continuous structure:

1. A push rod is threaded onto a length of ligature material approximately 1.5 m long.
2. A knot is tied at the conclusion of the thread as it emerges from the straight end of the rod.
3. The finish of the ligature emerging in the tapered end is grasped by atraumatic endoscopic grasper.
4. The grasper and catgut are then passed into an introducer tube
5. The introducer tube is then passed with an 11 mm cannula.
6. The grasper and ligature are extended to the cavity and passed to 1 side and behind the structure to become ligated.
7. A second grasper is introduced through a second port to grasp the ligature from the other part from the structure.
8. The very first grasper releases the ligature and the takes it back from the second while watching structure.
9. The very first grasper and ligature are withdrawn from the abdomen with the introducer tube as the second can be used to safeguard the structure in the suture.
10. Another slip knot is tied externally. The knot tied is dependent upon how big vessel to be controlled and also the material in use.
11. The knot is pushed into the abdomen through the push rod and positioned just before tightening.
12. The rod is withdrawn a little and scissors brought to cut the thread leaving a reasonably long end

Extracorporeal knotting is preferred within the following situations:

1. igature in continuity of large vessels
2. Suturing in areas of limited access where the working space is restricted
3. In the approximation of edges of defects where the force requires to approximate the edges is substantial

Rules governing external slip knotting

1. the kind of the thread should be 1.5m and also the guage ought to be 2/0 or greater
2. The type of slip knot selected depends on the ligature material being used. Certain slip knots provide sufficient holding strength with catgut although not with other materials.
3. For any ligature material, the holding force (potential to deal with reverse slipping) of any surgical slip knot varies directly using its caliber. Thus the holding strength of a 1/0 slip knot is roughly twice that of the 2/0 equivalent.
4. Stiff hydrophobic monofilament material ought to be avoided since it exerts a lesser frictional hold and it has a greater tendency to spill than braided.