During Laparoscopic cholecystectomy, the cystic duct (CD) is ligated in one of two ways: by clipping or by creating a knot outside the abdominal cavity and then introducing it into the cavity. A new technique allows safe ligation of the CD intracorporeally before its division by tying the knot at the site with absorbable tie material. To build the knot, a loosely constructed surgeon's square knot encircling the CD is converted to a slip knot, which is then cinched and tightened. The tightening process of the slip knot is executed by winding the long tail clockwise around the left-hand needle holder (traction) while the right-hand needle holder winds the short tail counterclockwise (countertraction), The endpoint of the tightening is determined by feeling the amount of torque to both hands and by visual confirmation of the knot integrity. To prevent reverse slippage, three single, flat knots are tied in square fashion. The cystic artery has also been ligated intracorporeally during laparoscopic cholecystectomy using the same technique with the same positive results and without complications.
