Page 13 - World Journal of Laparoscopic Surgery

WJOLS

Role of Mishra’s Knots in Various Surgeries in Laparoscopy
RESULTS CONCLUSION

Using a servohydraulic materials testing system (MTS A surgeon’s knot provides the best balance of loop secu­
model 858, Bionix, Eden Prairie, MN) to test the knot and rity and knot security within the knot configurations
loop security of each combination of the knots and suture tested. A sliding knot without RHAPs has both poor
types (Ethibond and FiberWire) and using 5N preload and loop security and knot security and should not be tied.
critical loop circumference of 30 mm, it was found that in The addition of three RHAPs improves knot security of
all cases, no knots failed by suture breakage, suggesting all sliding knots tested and improves loop security of
that all knots failed by a combination of knot slippage most of the sliding knots tested. The addition of three
and suture elongation. When tied with no. 2 Ethibond RHAPs improved the knot security of all sliding knots
suture or no. 2 FiberWire suture, the Weston knot pro­ to adequately resist predicted in vivo loads, and Mishra’s
vided the highest load to failure when compared with the knot has been proved to be one of the most secure, safe
other sliding knots. However, the maximum force of the extracorporeal knot in laparoscopy. It can be used for all
surgeon’s knot was significantly higher than the Weston continuous tubular structures of up to 22 mm diameter.
knot when tied with either Ethibond or FiberWire suture. The technique is easy to perform and can be done in
When the sliding knots were tied with three RHAPs minimal possible time. “This technique of the extracor­
using no. 2 Ethibond suture, the Weston RHAP, Roeder poreal knotting is simple, easy, and reproducible with
RHAP, Mishra RHAP, and SMC RHAP provided the good knot and loop security and can be used with any
highest force to failure. These forces were not significantly suture material of any size.”
different from the force to failure of the surgeon’s knot
tied with no. 2 Ethibond suture. REFERENCES
When the sliding knots were tied with three RHAPs 1. Akindele RA, Fasanu AO, Mondal SC, Komolafe JO,
using no. 2 FiberWire suture, the Weston RHAP provided Mishra RK. Comparing extracorporeal knots in laparoscopy
the highest force to failure. This force was not signifi­ using knot and loop securities. World J Laparos Sur April
cantly different from the force to failure of the surgeon’s 2014;7(1):28­32.
knot. In all cases, tying with either no. 2 Ethibond or no. 2 2. Stephen W, Eubanks ES, Lee L, Swanstrom MD, Soper NJ.
Mastery of endoscopic and laparoscopic surgery. 2nd ed.
FiberWire suture, the addition of three RHAPs after a base Lippincott Williams, Wilkins. 2004.
sliding knot significantly improved the force to failure. 3. J Indian Assoc Paediatric Surg 2010 Oct­Dec:122­126. Available
Of the sliding knots tied with no. 2 Ethibond suture, the at: http://www.jiaps.com
Duncan loop, Roeder knot, Weston knot, Mishra knot, 4. Nottage WM, Lieurance RK. Current concepts: arthroscopic
knot tying. Arthroscopy 1999;15:515­521.
and Tennessee slider, all provided similar loop circumfer­ 5. Weston PV. A new clinch knot. Obstet Gynaecol 1991
ences at 5N of preload, although the loop circumferences Jul;78(1):144­147.
associated with these knots were significantly larger than 6. Kim SH, Ha KI. The SMC knot: a new slip knot with locking
the loop circumference of the surgeon’s knot. When tied mechanism. Arthroscopy 2000 Jul­Aug;16(5):563­565.
with no. 2 Ethibond suture, the Roeder RHAP, Mishra 7. Chan KC, Burkhart SS. Arthroscopic knot tying. In: McGinty J,
RHAP, Duncan RHAP, and Nicky’s RHAP provided the Burkhat S, Jackson R, et al., editors. Operative arthros­
copy. Philadelphia, PA: Lippincott, Williams and Wilkins,
smallest loop circumferences and were not significantly 2004.
different from the surgeon’s knot. Similarly, when tied 8. Sami Walid M, Heaton RL. Laparoscopy­to­laparotomy
with no. 2 FiberWire, the Roeder RHAP, Mishra RHAP, quotient in obstetrics and gynaecology residency programs.
Duncan RHAP, and Nicky’s RHAP provided the smallest Arch Gynecol Obstet 2011 May;283(5):1027­1031.
loop circumferences and were not significantly different 9. Westerbring–van der Putten EP, Goossens RHM,
Jakimowicz JJ, Dankelman J. Haptics in minimally invasive
from the surgeon’s knot. surgery: a review. Minim Invasive Ther 2008;17(1):3­16.
Does securing a sliding knot with three RHAPs 10. Croce E, Olmi S. Intracorporeal knot­tying and suturing
decrease the loop circumference (improve loop security)? techniques in laparoscopic surgery: technical details. JSLS
With knots tied with no. 2 Ethibond suture, the addition 2000 Jan­Mar;4(1):17­22.
of three RHAPs decreased the loop circumference of the 11. Lieurance RK, Pflaster DS, Abbott D, Nottage WM. Failure
characteristics of various arthroscopically tied knots. Clin
Nicky’s knot, Mishra knot, Roeder knot, the SMC knot, Orthop Relat Res 2003 Mar;408:311­318.
and the Tennessee slider. No significant difference was 12. Hage JJ. How capsizing, flipping and flyping of traditional
found in the Duncan loop or the Weston knot when tied knots can result in new endoscopic knots: a geometric review.
with or without three RHAPs. When tying knots with J Am Coll Surg 2007 Nov;205(5):717­723.
no. 2 FiberWire, the addition of three RHAPs decreased 13. Burkhat SS, Wirth MA, Simonich M, Salem D, Lanctot D,
Athanasiou K. Knot security in simple sliding knots and its
the loop circumference of the Nicky’s knot, the Mishra relationship to rotator cuff repair: how secure must the knot
knot, and the Roeder knot. be? Arthroscopy 2000 Mar;16(2):202­207.
World Journal of Laparoscopic Surgery, September-December 2016;9(3):114-117 117