Ligation of a tubular structure is a fundamental step practised in any surgery. Laparoscopic knot tying is considered more complex as (a) it involves the use of two long instruments whose distant fulcrum poses certain ergonomic challenges, (b) the task needs to be performed by observing a two-dimensional image and (c) the cues obtained from the peripheral field of vision (as during open surgery) are absent when the endoscopic camera zooms in on the operative field. With the increasing number of Laparoscopic Cholecystectomy  being undertaken, in a proportion of cases the surgeon is bound to encounter a wide cystic duct that will require ligation. Extracorporeal Knotting is a widely used technique and very effective to perform laparoscopic cholecystectomy. At World Laparoscopy Hospital 750 Cholecystectomy is being perform in last 5 year by using extracorporeal knot and non of those patient develop hemobilia or any other knot related complication. A wide or enlarged cystic duct is a common encounter in laparoscopic cholecystectomy. Many techniques are used to secure its ligation; including internal intracorporeal or extracorporeal Meltzers knots and Roeder knot. A preformed knot can be used ib case of fundus first cholecystectomy e.g. the Endoloop.

The Endo GIA is also a useful stapling device which is used by some surgeons but is more expensive and not possible     in developing countries. Other simpler techniques which is practiced by some surgeons have also been described. The Dr R K Mishra, Director, World Laparoscopy Hospital has also developed his technique of laparoscopic  Mishra;s knot and he has also   developed a new, simple, safe and quick technique to ligate the wide cystic duct utilizing the commonly used multiple clip appliers. The technique does not need special skill for operating surgeon or instruments and ensures complete ligation of the wide cystic duct using overlapping of the clips.

Many authors consider acute cholecystitis with associated inflammatory edema and adhesions a relative or absolute contraindication to laparoscopic cholecystectomy. Extracorporeal knot can be very useful for those patients diagnosed as having acute calculous cholecystitis and were offered laparoscopic cholecystectomy as the primary surgical treatment. 

Laparoscopic cholecystectomy is now gold standard pri-mary medical procedures for patients with gallstone disease even if presenting with acute cholecystitis. Early intervention is essential for successful completion of the process. Ultrasonography will be the method of selection for early proper diagnosis of these cases due to its wide availability and great accuracy. The task ought to be attempted only by experienced surgeons. The tactic should be modified as required to gain a successful outcome. A decreased threshold for conversion to an open procedure is going to be there if extracorporeal knot will probably be ligated. Hemostasis will also be maintained. Current debts convert needs to be taken very less within the process of extracorporeal knot tying. The reason behind conversion shouldn't be a complication but rather to prevent one. The most crucial indication for conversion is the wherewithal to clearly and safely identify structures in the Calot's tri-angle.