Description

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease, including acute cholecystitis. However, securing the cystic duct in cases of acute inflammation poses a technical challenge due to ductal edema, friability, and risk of slippage. While metallic clips and endoloops are commonly used, both have limitations in inflamed tissue. The Mishra Knot, a self-sliding extracorporeal knot, has emerged as a safe, cost-effective, and reliable technique for cystic duct ligation in difficult cases. The Challenge in Acute Cholecystitis The cystic duct is often thick, edematous, or fragile. Clip application may fail due to incomplete closure or slippage. Endoloops, though effective, can be costly and time-consuming. Surgeons require a secure, low-cost, and universally applicable method. The Mishra Knot Technique The Mishra Knot is a modified extracorporeal knot, specially designed for laparoscopic procedures where secure ligation is required. It is a slip knot with high holding strength. Can be tied extracorporeally and easily slid into place with a knot pusher. Provides strong, non-slipping ligation, even on thick or inflamed ducts. Application on the Cystic Duct After careful dissection of Calot’s triangle and achieving the critical view of safety, the cystic duct is isolated. A pre-tied Mishra Knot is prepared extracorporeally with absorbable suture (e.g., 2-0 Vicryl). The knot is introduced into the abdomen using a knot pusher. It is positioned at the base of the cystic duct, near its junction with the common bile duct. The knot is tightened securely and an additional knot can be placed for reinforcement. The cystic duct is divided distal to the knot. Advantages of Mishra Knot Secure: Provides excellent holding capacity, preventing bile leak. Cost-effective: Uses simple sutures instead of expensive clips or loops. Versatile: Works effectively in both normal and inflamed cystic ducts. Safe: Reduces the risk of clip slippage or incomplete closure. Reproducible: Easy to learn and apply in routine laparoscopic practice. Clinical Relevance In acute cholecystitis, where the duct is inflamed and thickened, the Mishra Knot offers an extra margin of safety. Its reliability has made it an accepted alternative to titanium clips and endoloops in challenging cases. Many surgeons trained in advanced laparoscopy and minimal access surgery now routinely use the Mishra Knot for cystic duct closure in high-risk scenarios. Conclusion The Mishra Knot represents a significant advancement in laparoscopic surgery, particularly in the management of acute cholecystitis. Its simplicity, affordability, and superior security make it a preferred technique for cystic duct ligation. By minimizing complications such as bile leak and clip failure, it enhances the safety profile of laparoscopic cholecystectomy, especially in difficult cases.