Description

Extracorporeal and intracorporeal knotting in laparoscopic surgery can be used in various situations and though it can be technically demanding, it can be overcome with repeated practice. Mishra's knot is a modification of the Roeder's knot or the Meltzer's knot. In the case of a wide cystic duct, where laparoscopic clips would not occlude the full width, an extracorporeal slip knot would be appropriate. Other advantages of applying Mishra knot include less expense and eliminating the risk of catching the common bile duct with the end of the clips. In step 1, interpose the stem of instrument A above the suture to prevent ‘cheese wiring’ the cystic duct on pulling through. remember to ‘snug down’ the throws that have been previously performed. Finally, push the knot down using a knot pusher as in step 6. Do not pull up like a lasso as it would saw through and tear the tissue.