Laparoscopic cholecystectomy has been introduced without the caution normally accorded to a new technique and without a controlled study comparing it to the conventional operation. The overall safety of the procedure appears to be similar to that of conventional cholecystectomy but bile duct injury may be more common','. Two cases are reported to emphasize the importance of this complication and to stress the need for careful surveillance of the safety of the procedure. Case reportsPatient 1 A 59-year-old woman was referred with a biliary stricture which developed 3 months after laparoscopic cholecystectomy. At the original operation, the cystic duct was noted to be short and it was thought to insert directly into the right hepatic duct. It was dissected and titanium clips were applied. After operation the patient developed a biliary fistula which closed spontaneously after 2 weeks. Three months later she presented with right hypochondria1 pain and obstructive jaundice. A percutaneous transhepatic cholangiogram showed obstruction of the common hepatic duct and thereafter the patient became deeply jaundiced and febrile.Liver function tests showed a bilirubin level of 234 pmol/l, alkaline phosphatase of 1320 units/l and aspartate transaminase of 31 units/l. A second percutaneous transhepatic cholangiogram showed a tight stricture immediately below the origin of the common hepatic duct ( Figure 1 ) and a biliary leak from the previous cholangiography puncture site. Coeliac axis angiography excluded any hepatic vascular injury. At laparotomy, the peritoneal cavity contained 2 litres of bile. There were extensive adhesions, especially to the gallbladder bed. The stricture was identified just below the level of the biliary convergence and appeared to be related to a titanium clip. This Bismuth type 111 stricture was excised and a hepaticojejunostomy Roux-en-Y performed. The patient recovered uneventfully and was discharged 1 week later. A postoperative 99"Tc-EHIDA (iminodiacetic acid derivative) scan showed good biliary excretion with no anastomotic narrowing or leakage.Patient 2 A 33-year-old woman was referred for assessment and management of a persistent subphrenic bile collection 3 weeks after laparoscopic cholecystectomy. There had been difficulty in identifying the ductal anatomy and two ductal structures were divided which seemed to communicate with the gallbladder. The patient developed persistent right upper quadrant pain and ultrasonography showed a subhepatic bile collection which was drained and a biliary tree of normal calibre. Endoscopic retrograde cholangiopancreatography demonstrated a normal common bile duct and left hepatic ductal system. There was extravasation of contrast close to the clipped cystic duct which filled a large cavity and eventually opacified the right ductal system. The patient was referred with established sepsis.Results of liver function tests were normal apart from a raised alkaline phosphatase level (489 units/l). Coeliac axis angiography excluded any vascular injury. At laparotom...

Objective:To evaluate post-operative pain, recovery time and standard of living in patients undergoing LVHR in detail. Study design and Setting: This prospective cohort study was conducted at a tertiary care hospital of Karachi, Pakistan,after getting approval from the “National Medical Centre EthicalReview Board”, from January 2011 to December 2019, Methodology: Total n= 577 patients undergoing standard LVHR procedure (defect closed with non-absorbable monofilamentsuture, reinforced with intra-abdominal dual layer mesh, anchored with non-absorbable tacks & sutures). Patient demographics,perioperative & postoperative findings and post-operative pain analysis were investigated and presented as descriptivestatistics. Follow-up was carried out at 1stweek, 2ndweek, 3rdmonthly, 6 monthly and 12 monthly post-operative appointments. Results: During the study period of nine years (January 2011 to December 2019), 577 patients (primary ventral hernia n=232, recurrent ventral hernian=188 patients, incisional hernian=157) underwent LVHR. Mean post-operative hospitalstay was 1.53 ± 1.8 days. Mean post-operative pain assessment onvisual analog scale (VAS) after surgery (0-3days) wasreported to be 38.5±29 by 65 patients out of 577 (11.26%), which significantly decreased at the end of 1st week to 27.9 ± 25.6. Only 3 patients (0.51%) reported chronic pain during the span of 3-6 months. Conclusion: LVHR was associated with considerably less post-operative pain, shorter hospital stay and reduced time of convalescence. It is demonstrated that LVHR to be a safe and superior approach for the repair ventral hernias

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