Description

Extracorporeal knot tying is one of the most fundamental and widely practiced suturing techniques in laparoscopic surgery. It plays a crucial role in achieving secure tissue approximation while maintaining precision and safety within the minimally invasive environment. Dr. R. K. Mishra, a pioneer in laparoscopic education and training, has extensively emphasized extracorporeal knot tying as an essential skill for surgeons beginning their journey in minimal access surgery. In laparoscopy, suturing is technically demanding due to limited instrument mobility, loss of tactile feedback, and dependence on two-dimensional vision. Extracorporeal knot tying helps overcome these challenges by allowing the surgeon to create a knot outside the body, where hand movements are more controlled and familiar. Once formed, the knot is advanced into the abdominal cavity using a knot pusher, ensuring secure ligation under direct laparoscopic vision. The procedure begins with proper placement of trocars and selection of suitable suture material, usually a monofilament or braided suture depending on the surgical requirement. After passing the needle through the target tissue intracorporeally, both ends of the suture are brought outside the port. The surgeon then ties a standard surgical knot externally, commonly a square knot or surgeon’s knot, ensuring adequate throws for strength and stability. Once the knot is formed, a knot pusher is introduced through the trocar. The knot is carefully slid along the suture and guided down to the tissue level. Dr. R. K. Mishra stresses the importance of maintaining equal tension on both strands while advancing the knot to prevent loosening or premature locking. Under continuous laparoscopic visualization, the knot is seated firmly against the tissue without excessive force, which could cause tissue damage or suture breakage. Extracorporeal knot tying is particularly useful in procedures such as ligation of pedicles, closure of port sites, and suturing in areas where intracorporeal knot tying is technically difficult. Its advantages include reliability, ease of learning, and reduced operative time during the early learning curve. However, surgeons must also be aware of its limitations, such as restricted use in deep or angulated operative fields. In conclusion, extracorporeal knot tying remains a cornerstone technique in laparoscopic surgery. Through his step-by-step guidance, Dr. R. K. Mishra has simplified this skill, making it accessible and reproducible for surgeons worldwide. Mastery of extracorporeal knot tying not only enhances surgical efficiency but also contributes significantly to patient safety and successful laparoscopic outcomes.