Gallstones disease are the most common biliary pathology. Its prevalence in Nepal is found to be 4.87%. Giant/large gallstones have a higher risk of complications and presents technical difficulties during laparoscopic cholecystectomy. Open cholecystectomy is preferred in most of the cases with giant gallstones. With the availability of experience laparoscopic surgeon and modern laparoscopic equipment, laparoscopic cholecystectomy is also feasible in large/giant gallstones. We report 2 cases, one large gallstone in 51 years old female and one giant gallstone in 39 years old female each of which were successfully managed laparoscopically with uneventful post-operative period.

Background Gallstones disease (GSD) is the most common biliary pathology. GSD is one of the common surgical problems in which lead people admit to the hospital in Nepal. Its prevalence is found to be 4.87%. The size of a gallstone is important, as giant/large gallstones have a higher risk of complications and present technical difficulties during laparoscopic cholecystectomy (LC). Open cholecystectomy is preferred in most cases with giant gallstones. With the availability of experienced laparoscopic surgeons and modern laparoscopic equipment LC is also feasible in large/giant gallstones. In this case report, we report 2 cases of one large and one giant gallstone each which were successfully done laparoscopically.Case Presentation Case 1 A 51 years old female presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty food with no significant past medical and surgical history.Ultrasound abdomen showed normal gallbladder with multiple gallstones, largest measuring approximately 4cms. She was planned for elective LC. The gallbladder was removed out after extension of the infra-umbilical incision. On the cut section, we found multiple gallstones with one large gallstone measuring 4*3.3*3 cm and weighted 23.2 gm. Her post-operative period was uneventful. Case 2 A 39 years old female, known case of hypertension under calcium channel blocker(CCB) and angiotensin receptor blocker(ARBs) presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty foods with non-significant surgical history. Ultrasound abdomen showed a normal gallbladder with a single large gallstone (approximately 4.7 cm). Elective LC was performed and the gallbladder was removed out after extension of infraumbilical incision. On the cut section, we found a single giant gallstone measuring 5* 3*2.8 cm and weighted 24.7 gm. Her post-operative period was uneventful.Conclusion Large/giant gallstones are associated with a high risk of complications and cholecystectomy is warranted in symptomatic and asymptomatic patients. Even for large/giant gallstones, LC appears to be the treatment of choice over open cholecystectomy and should be performed by an experienced laparoscopic surgeon, taking into consideration the possibility of conversion to open in case of inability to expose the anatomy and any intraoperative technical difficulties.

Background Most of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy. Method This was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale. Results Out of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19–75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5. Conclusion Parkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery.

Journal of Surgery[ IntroductionMedicine is an ever-changing and ever-growing field where day after day and year after year new things are invented, applied for the treatment of various diseases. In the line of treatment, surgery has been one of the feared treatment options for most of the patients; therefore surgeons try to provide the patients with the best possible surgical treatment options. The best possible surgical option has always been the one with the lesser complications intra and postoperatively, wellcontrolled pain, less stay at hospital etc. Both doctors and patient don't want to maximize hospital stay as one study stated that extended hospital stay has been associated with increased incidence of hospital acquired infections, which causes further increase in morbidity and mortality [1]. One of the greatest achievements in the history of surgery has been evolved from open surgical techniques to the operative video-laparoscopy Acute appendicitis is one of the most common cause of acute abdomen and one of the most common surgical emergencies. Appendectomy for acute appendicitis is one of the most commonly performed surgical procedures [2]. The surgical technique of first open appendectomy (OA) was performed by Dr. Charles Mcburney in and this approach has not significantly changed in the last 1 century [3]. In 1983, Dr. Kurt Semm, performed first minimally invasive laparoscopic appendectomy, thereafter LA has become the standard of practice in uncomplicated appendectomies in most minimally invasive institution [4]. In the past few years of minimally invasive surgery, LESS, NOTES has gained popularity. SILA was first described in 1998 by Esposito and has gained popularity as a method with a concept of ''scarless'' abdomen [5]. While Pelosi in 1992 performed the first SILA for acute appendicitis [6]. Innovative methods such as NOTES (Natural Orifice Tran luminal Endoscopic Surgery) and single incision laparoscopy (SIL) have demonstrated promissory results in various surgical procedures, appendectomy among them [7]. According to a recent study, SILA resulted in faster recovery than conventional 3-port LA [8]. However in some other studies it has also been reported that SILS is associated with a longer operative time and higher postoperative pain scores, and that patients need more analgesics to feel comfortable [9]. NOTES, SILS, and robotic surgery do not constitute techniques, rather they are concepts, hence regarded as transitions from laparoscopic surgery to unknown fields of minimally invasive therapeutic modalities [10]. SILS was recommended as a possible alternative of the traditional laparoscopic surgery via four ports for the biliary tact by Navarra et al. [11]. With NOTES having a diminished success, because of the inability to find a clean site for access, thereby increasing the chances of intra-abdominal spillage or infection from the incision [12] increased interest has been seen in SILS. SILS occupies a space between NOTES and standard laparoscopy [13]. There have been several studies regard...

Background: Acute intestinal obstruction is one of the commonly encountered emergencies in surgical practice. Gynecological surgery, especially adnexal surgery and hysterectomy has a higher incidence of bowel obstruction as compared to bowel surgery. Conservative management can be done in patients with post-operative adhesive bowel obstruction if there is no evidence of ischemia, bowel necrosis, or perforation. Therefore, a correct diagnosis is essential for appropriate management. We conducted a study to evaluate the etiology, clinical presentation as well as management and outcome of patients presenting with Acute intestinal obstruction at our center. Methods: This was a retrospective study of all the patients with a diagnosis of Acute intestinal obstruction from January 2015 to December 2019. The diagnosis of Acute intestinal obstruction was made by a combination of clinical and radiological parameters. The data were analyzed using Statistical Package for Social Sciences (SPSS) for Windows version 16. The  data  were  expressed in  number and percentage. Results: During the study period, 178 patients were admitted with the diagnosis of Acute intestinal obstruction. Abdominal pain and vomiting were the main complaints seen in 98.3% (n=175) and 84.8% (n=151) respectively. Hernia (n=49, 27.5%) was the most common cause of acute intestinal obstruction in adults, and Intussusception (n=15, 8.4%) was the leading cause of Acute intestinal obstruction in a pediatric age group. Majority of the patients’ needs (n=148,83.1%) operative intervention to relieve the obstruction. The overall mortality rate was 6.7% (n=12). Conclusions: Hernia was the most common cause of Acute intestinal obstruction in adults while intussusception was the commonest in the pediatric age group.