Background Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. At times it is easy and can be done quickly. Occasionally it is diffi cult and takes longer time. But there is no scoring system available to predict the degree of diffi culty of LC preoperatively.

IntRoductIonOver the last 100 years, the anatomical location of Bowel Obstruction (BO) has remained unchanged; however, the aetiological factors in small and large BO have changed significantly. With advance of time more and more elderly patients are presenting with BO [1]. But still, BO continues to be one of the most common surgical emergencies [2] encountered in general surgery units and it continues to be a major cause of morbidity and financial expenditure [3]. Peritoneal adhesions and hernia were the most common causes of BO and contributing 42.3% [4]. All patients of BO are potential candidates for major abdominal surgery with long term morbidity and possible mortality. Hence, the decision of surgery and its timing is vital.Various factors are considered for taking the decision on operative or non-operative management. The factors considered are age of the patients, duration of obstruction, volume of nasogastric aspirate, findings on the radiological imaging, previous abdominal surgeries and malignancy. decision in Small Bowel obstruction (SBo)Clinical presentation of pain, vomiting, distension and constipation, laboratory and radiographic factors should all be considered when making a decision about treatment of BO [5]. One must rule out an abdominal wall hernia as a cause of BO, which is seen in 26.8% of cases in virgin abdomen [4]. Plain radiograph should be an integral part of management of patients with clinical suspicion of BO and gastrointestinal perforation [6] [Table/ Fig-1]. The diagnosis in most cases will be confirmed by further imaging studies such as ultrasound, contrast studies or most commonly in contemporary practice, the Computed Tomography (CT) [7].The CT scan, besides confirming the diagnosis of BO, it gives information on partial or complete obstruction, it location, it also provides specific type like closed loop type and helps in deciding early surgery. Contrast Enhanced Computed Tomography (CECT) give enough information on ischemic bowel and bowel oedema, which requires emergency surgery and luminal gastrograffin helps in relieving the BO [8,9].Surgeons find coronal images more helpful than axial images for management [10]. The radiographic transition zone alone does not increase the likelihood of surgical intervention or identify patients who will fail non-operative management [11]. The four cardinal features -intra peritoneal free fluid, mesenteric oedema, presence of the "small bowel faeces sign" and history of vomiting -are predictive of requiring immediate emergency operative intervention [5]. decision in large bowel obstructionIn Indian scenario, two common types of Large Bowel Obstructions (LBO) are seen. They are: (a) Acute obstruction due to Sigmoid volvulus (SV); and (b) Sub-acute or chronic obstruction due to cancer of colon. In suspected volvulus, plain X-rays may help with diagnosis but MRI is more reliable. However, flexible endoscopy is always diagnostic as well as therapeutic [12]. Once diagnosed flatus tube, hydrostatic enema or colonoscopic reduction attempt is th...

Paraduodenal hernia (PDH), a rare congenital anomaly, is a type of internal hernia which occurs due to a defect in the reduction and rotation of the midgut. On anatomical and embryological basis, PDH can be broadly divided into right- and Left PDH. Right PDH is rarer than its counterpart. We present two cases of Right PDH. The patientsy presented with a history of recurrent intestinal obstruction since childhood, which was managed conservatively, without a definitive diagnosis. Once they presented to us, a detailed clinical history and a barium meal follow- through clinched the diagnosis of PDH. Intra-operative findings correlated well with the clinical diagnosis. The jejunal loops had herniated through the fossa of Waldeyer. Reduction of hernia contents and excision of the hernia sac was carried out. Post-operatively, the patients are healthy and symptom-free at 4 and 3 years follow-up, respectively. The rarity of this condition and the need for early diagnosis, to prevent the high risk of bowel obstruction and strangulation, makes PDH one of the difficult challenges for the clinicians.

Emphysematous cholecystitis is an acute infection of the gallbladder wall caused by gas-forming organisms. It is infrequent with insidious onset and diagnosed by the use of radiographs detecting presence of air within the gallbladder wall or lumen. The report describes the case of a 42-year-old alcoholic male who presented with sudden onset of pain in the right upper quadrant of abdomen, fever and bilious vomiting of two days duration. The patient did not have symptoms of jaundice. Emergency partial cholecystectomy was done and the culture directed antibiotics were given. The patient was followed up for 4 years and he remained asymptomatic.

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