Page 10 - World Journal of Laparoscopic Surgery

WJOLS

RK Mishra et al 10.5005/jp-journals-10033-1286
OriginaL articLe

Role of Mishra’s Knots in Various

Surgeries in Laparoscopy

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1 RK Mishra, Sam Koruth, Nivedita Reshme
2
ABSTRACT INTRODUCTION
Introduction: In the present era of laparoscopy and its ever- “Minimal access surgery” (MAS) or the more Layman’s
expanding application to various different types of surgeries, the
art of suturing and knotting still plays a pivotal role in determining term keyhole surgeries has revolutionized the current
the success of any surgery as in case of open surgeries. Despite trends in all fields of surgery varying from single laparo­
the introduction of various energy sources as an alternative to scopic surgery to robotic surgery. The advantages of
suturing and knotting, the various complications associated with laparoscopy are that it is less painful, permits earlier
them and the cost limitations have to be considered.
Extracorporeal and intracorporeal knotting in laparoscopic return to work, provides better cosmesis, and is more
surgery can be used in various situations and though it can be acceptable to the patient than traditional surgeries.
technically demanding, it can be overcome with repeated practice. Advanced MAS requires that the surgeon should be well
Here we describe a new technique of knot which is simple, easy,
and a safe extracorporeal knotting technique which can be used versed at intracorporeal suturing and knotting. However,
for any continuous tubular structure up to a maximum diameter of mastering this skill is a very difficult process with a long
22 mm. This technique was introduced by Professor and Doctor and steep learning curve. Extracorporeal knots permit the
Mishra who has himself worked upon it in the last 2 years after trying
various other knots and modifying them to achieve better security. knot to be tied outside and then by using a knot pusher,
Technique description: Mishra’s knot is a modification of it is applied snugly inside the body. 1
the Roeder’s knot or the Meltzer’s knot. It’s a relative simple Some of the extracorporeal slip knots are: Roeder knot,
technique where we use 3 hitches and 3 loops alternating each Duncan loop, Nicky’s knot, Tennessee slider, SMC knot,
other. The modification aims to achieve better knot security by
application of a lock after every wind. Weston knot, Meltzer, Tayside knot, and others. The above­
Materials and methods: A literature review was performed mentioned knotting techniques are variations around the
using PubMed, SpringerLink, HighWire Press and search axis or the number of reversed half hitches on alternating
engines like Google and Yahoo. The following search terms post. Each technique has its proponents and some have
were used: Extracorporeal knot, Roeder’s knot, Meltzer’s knot,
Mishra’s knot. A total of more than 300 citations were found. been modified for improvement, but some of the disadvan­
Selected papers were screened for further references according tages with these techniques are in terms of size of suture
to our requirements. material, the numbers of knots that can be applied at once,
A list of 280 surgeries where Mishra’s knot was successfully and the ease of sliding in the extracorporeal knot.
used was given to us for study purpose by Professor Dr RK Mishra.
Conclusion: “This is a very simple and safe technique and has A good knot must fulfill the two basic qualities:
been successfully followed in more than 300 cases for tying an 1. The knot must be properly formed, so the suture does
extracorporeal knot. It’s a very safe and reliable knot even for not slip or cut into itself.
the critical structures like cystic duct, uterine artery, and various 2. It must be easily tightened to ensure maximum
arteries and we observed it to be very secure.” strength.
Keywords: Extracorporeal sutures, Mishras Knot, Sliding knot.
How to cite this article: Mishra RK, Koruth S, Reshme N. For a knot to be effective and strong without slippage,
Role of Mishra’s Knots in Various Surgeries in Laparoscopy. it must possess the attributes of both knot security and
World J Lap Surg 2016;9(3):114-117. loop security. 2,3
Source of support: Nil Knot security is defined as the effectiveness of the knot
Conflict of interest: None at resisting slippage when load is applied and depends
on three factors: Friction, internal interference, and slack
2,3
1 Professor and Head, Junior Consultant between throws. Loop security is defined as the ability
4­7
1 Department of Minimal Access Surgery, The Global Open to maintain a tight suture loop as a knot is made. Thus,
University, Dimapur, Nagaland, India any tied knot can have good knot security but poor loop
2 Department of General Surgery, Lourdes Hospital, Kochi security (a loose suture loop), and therefore it will be inef­
Kerala, India fective in approximating the tissue edges to be repaired.
3 Department of Gynecology, M S Ramaiah Memorial Hospital
Bengaluru, Karnataka, India DEFINITIONS
Corresponding Author: RK Mishra, Professor and Head
Department of Minimal Access Surgery, The Global Open University Postlimb: The straight portion of the suture limb purely
Dimapur, Nagaland, India, e-mail: md@laparoscopyhospital.com
defined as the suture limb under the most tension.
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