The low inguinal repair with a conical mesh plug is easily reproducible, elegant and probably the best method for femoral hernia repair.

Introduction Though, in developed countries, laparoscopy is now a gold standard for splenectomy, we are lacking in this aspect in the eastern world. Splenectomy has mostly been performed by open surgery in our region. This is our effort to introduce laparoscopic splenectomy in our country. Methods This is a retrospective cohort study done in patients presenting to hematology and surgery department of our hospital who underwent laparoscopic splenectomy for hematological diseases from January 2013 to December 2016. Results There were 50 patients (38 females, 12 males). The diagnoses were idiopathic thrombocytopenic purpura in 31, (steroid/azathioprine-resistant, steroid dependent), hereditary spherocytosis in 9, alpha-thalassemia in 3, beta-thalassemia in 2, autoimmune hemolytic anemia in 4, and isolated splenic tuberculosis in 1. Average platelet counts preoperatively were 62000 ± 11000/mm3 (range 52000-325000/mm3). The mean operative time was 130 ± 49 minutes (range 108-224 min). The mean postoperative stay was 4 ± 2.11 days (range 3-9 days). Laparoscopic splenectomy could be completed in 45 (90%) patients. Conclusion Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, especially if spleen is normal or only mildly enlarged, and is an advantageous alternative to open splenectomy. Absence of ideal resources has not limited our progress in minimal access approach.

Introduction. Recurrent incisional hernias are difficult to treat. There are many factors involved in the recurrence, and due to extensive dissections, the planes are fused with adhesions, and we may need a new plane for dissection and placement of meshes. Case Report. We report here three cases of recurrent incisional hernias which were dealt by a relatively new method to laparoscopy: the enhanced view totally extraperitoneal repair (e-TEP) retromuscular technique. There were three patients: one after an open onlay repair of lower midline incision, another after an onlay mesh repair of a subcostal incision for open cholecystectomy followed by an intraperitoneal onlay mesh hernioplasty (IPOM) repair, and another after IPOM repair of epigastric hernia. They were treated with the abovementioned technique with satisfying short-term results. Conclusion. The e-TEP technique is a relatively new method of providing minimal access surgery to these patients utilizing the previously unaccessed retromuscular (Rives and/or preperitoneal) space for the repair of these recurrent incisional hernias.

Introduction: Recently, endoscopic techniques have replaced surgery for management ofcommon bile duct stones. Surgery is mainly reserved for situations where endoscopicexpertise fails or is not available. We describe here our experience with laparoscopiccholedochoduodenostomy and its outcomes in patients with common bile duct stones.Methods: A retrospective chart review of all patients with common bile duct stonesundergoing the operation at Civil Service Hospital, Kathmandu, Nepal between October 1,2012 and September 29, 2022 was done. Clinical, laboratory and radiological data wasreviewed, along with the intraoperative characteristics, complications, hospital readmissionsand follow-up data were recorded.Result: Sixteen patients were operated; mean age of the patients was 49.86+9.28 years(range 37–68 years); there were 10 females (62.5%) and 6 (37.5%) males; most commonpresenting symptom was abdominal pain followed by nausea/vomiting, and fever. There waspast history of failed endoscopic intervention in 3 patients. The mean common bile duct sizeon MRCP was 18+4.3 mm (range 15-23 mm). Two patients (12.5%) needed conversion toopen operation. Mean operative time was 165.47+17.34 min (range 125-210 min), totalhospital stay was10.68+7.43 days (range 6-19 days). Morbidity occurred in 5 patients(31.25%). There was no mortality in the immediate postoperative period and no occurrenceof sump syndrome.Conclusion: Laparoscopic choledochoduodenostomy extends the benefits of minimallyinvasive techniques; though due to the unique sump syndrome occurring in this operation,other techniques have been also adopted, but they are more complex. Ultimately the choiceof biliary bypass depends on the experience and ability of the surgeon. The present serieshas provided acceptable outcomes in these patients, and this is a safe, effective and feasiblebiliary bypass procedure. This series will help us be more prepared for more increasingnumber of complex scenarios like after failed endoscopic interventions or in stones occurringafter Roux-en-Y gastric bypass.

Introduction: Intussusception is rate in adults and is usually secondary to a definable pathology. This study was designed to review adult intussusception, including presentation, diagnosis, and pathology. Methods: A retrospective study of 18 cases of intussusception in individuals older than 18 years of age visiting the department of surgery of Civil Service Hospital from 2010 to 2018 was done. Results: There were 18 cases of adult intussusception. The mean age was 49.2 years (range 19-84 years). Abdominal pain and vomiting were the commonest symptoms. The median duration of presentation was 5 days (range 20 hours to 10 months). Three patients (16.6%) presented with generalized peritonitis. There were eight ileocolic, seven ileoileal, and three colocolic intussusceptions. Two patients (11.1%) settled spontaneously. Twelve out of the 18 patients (66.6%) had leading lesions. Benign pathologies were seen in seven cases (38.8%) and malignant in five patients (27.7%). All malignancies were in the large bowl Conclusions: Adult intussusception is a rare entity, nearly one-third of their causes are malignant. Surgery is the best recommended treatment, with or without a primary reduction of the intussusception; the latter can result in more limited bowel resection.