Laparoscopic surgery is useful to deal with surgical diseases which in the past need open surgery, yet tying sutures within the abdominal or thoracic cavity is really a challenge for a minimal access surgeon. A knot is always in demand which should be strong enough to secure tissue approximation, which may be hand-made, secure on the vessels, simple, easy, quick, reliable, and extracorporeal without extra mechanical devices.

A knot with all these quality, was created and named the Mishr's knot. Extracorporeal Mishra's knot. Bring an extended suture into the laparoscopic field, leaving its tail away from port. Put the stitch; then bring the needle end out through the same port. Mishra's knot can be used over any tubular structere upto 22mm in diameter. Thorough knowledge of laparoscopic suturing by Mishra's Knot is of great importance towards the laparoscopic surgeon and gynecologists, especially throughout the performance of advanced laparoscopic procedures.

Intracorporeal and extracorporeal knot tying enhances the technical capabilities from the laparoscopic access, thus extending the spectrum of laparoscopic surgical and gynecological minimal access surgical procedures to that particular comparison of open surgery. We describe herein the above video extracorporeal Mishra's Knot applied over cystic duct. This knot is designed with a focus on simplicity and safety. A comparative study of the Mishra's knot, the Roeder knot, and the classical surgical knot, as the gold standard, using polypropylene, silk, catgut, polyglycolic acid, and Polyglactin 910, these of 1-0 caliber, was performed in animal model.

Measurements in this study were time for  to perform the knot by surgeons, slippage of knot, and breaking point which was measured having a manual high quality digital tensiometer. The Mishra's knot was significantly faster statistically to perform than the Roeder knot and more resistance against rupture and slippage. The slippage rate was significantly lower statistically within the Mishra's knot compared to the Roeder or Meltzer's knot when Polyglactin 910 and polypropylene were used.

The security of several kinds of laparoscopic and open surgical knots and varying suture materials was tested in laparoscopic laboratory environment in an attempt to improve suture and knot selection for advanced laparoscopic procedures. Six different types of knots and five different suture materials were tested. All sutures were of 2-0 size, and laparoscopic knots were tied utilizing a pelvic trainer. The laparoscopic trainee surgeons of World Laparoscopy Hospital were the subject. A typical number of throws as describe in various textbook for Roader's Knot, Meltzer's knot and Mishra's Knot was utilized for each suture. Stress was gradually used by withdrawing the ends of a manual digital tensiometer until all these knots slipped or the suture parted.

The maximum stress withstood by the knot-suture complex was recorded, as was whether the knot was secure and to see whether the different type o these laparoscopic knot held before the suture broke. Each knot type was tied five times, and each type was tied in random order by the same primary and assisting surgeons using a laparoscopic pelvic surgery training model. The data of this laparoscopic knot testing study were analyzed using analysis of variance of SPSS to compare the knot security of the several knot types and also the different sutures using a given laparoscopic knot. Mishra's knot has shown significant difference and was discovered better in security or stress resistance between laparoscopic roader and meltzer knot perhaps in the Dacron, polypropylene, and expand polytetrafluoroethylene (ePTFE).

Silk suture was considerably less secure than all the other sutures for all knots tested. The Roeder's and Fisherman's knots were the least secure of laparoscopic knots in most sutures tested, which was as secure as the extracorporeal and intracorporeal polyglactin knots. These experiments showed laparoscopic Mishra's knots to be as secure as open surgeons or square knots. Our data also suggest that silk is not as secure as other permanent suture materials for any extracorporeal knot.

Conclusion:

The Mishra's knot is the strongest laparoscopic slip knots and are the only slip knots similar in strength to multiple-throw square or surgeons knots which is used in open surgery.