While bariatric surgery is regarded as the most effective treatment for people with severe and morbid obesity, its pathway is regarded as a complex one due to the multidisciplinary approaches required from presurgery education until long-term management. This is essential to maintain weight loss and improve the quality of life after bariatric surgery. Although these approaches are broadened, patient education, preoperative preparation, behavioural therapy, rehabilitation, and dietary changes are regarded as the main domains in such complex care. With the increase in technological adaptation in medical services, virtual reality (VR) has shown many benefits that can be utilized in the care of bariatric patients undergoing surgery. However, VR has not been innovated to be a multidomain care package in which bariatric patients could benefit throughout their journey from the pre-operative optimization, recovery, and long-term followup. This review aims to give a brief description of some of the applications of VR technology and question whether it has the potential to be considered as a virtual ecosystem to improve the bariatric patients' experience and pathway throughout surgery and follow-up.

Background: Laparoscopic cholecystectomy is commonly performed for cholelithiasis. In spite of strict aseptic technique and preoperative antibiotic prophylaxis, there is risk of port site wound infection. Aim: To study the incidence of positive bile culture and the most common pathogen involved after laparoscopic cholecystectomy in patients of cholelithiasis and its correlation with port site wound infection. Study design: Cross sectional study Setting and duration: Bahawal Victoria Hospital Bahawalpur, from 01-01-2019 to 31-12-2020. Method: One hundre patients of cholelithiasis between 18-75 years of age underwent laparoscopic cholecystectomy. Prophylactic antibiotic was given. Bile with gall bladder was collected and sent for culture. Bacterial growth was recorded as positive bile culture. Organism type was recorded. Stone/stones size was also measured. Data was collected on a proforma which included demographics details like name, age, gender, BMI, clinical features, size of calculi, culture report (positive bile culture if some bacteria is isolated and negative no growth) and type of bacteria isolated and frequency of port site wound infection. Data was analyzed on SPSS version 21. Results: The mean age of the patients was 42.44±16.58 years and male to female ratio of the patients was 1:1.8. The mean BMI of the patients was 25.93±4.67 kg/m2. Bile culture for bacteria was positive in 30(30%) patients and the most common organism was E coli 13(43.33%.78%). Positive bile culture was detected in 20 (20%) male patients and 10 female patients. There was significant correlation between positive bile culture and gender (p value < 0.001). Port site wound was infected in 6 (6%) patients and in all the patients bile culture was also positive. Conclusion: Bile culture was positive in 30% patients of cholelithiasis undergoing laparoscopic cholecystectomy and wound infection was present in 6% patients and all the 6% patients were bile culture positive . Keywords: Cholelithiasis, Culture, Organism, Laparoscopic cholecystectomy

Introduction: Gallstones are common in western countries. Usually in minimally invasive cholecystectomy, cystic artery and duct both are separately ligated using metallic clips and then divided. Harmonic scalpel is effectual, useful, and secure instrument regarding control of blood loss and dissection especially in laparoscopic procedure for cholecystectomy. Objective: To delineate outcome of totally clipless laparoscopic cholecystectomy with harmonic scalpels in gall stones disease.Materials and Method: This research (a retrospective case study) was done at surgical department, Lahore General Hospital, Lahore for 12 months. Total 195 patients fulfilling the above mentioned inclusion criteria were enrolled. Then patients underwent surgery under general anaesthesia. During surgery, operative time, gall bladder perforation and blood loss were noted. Patients were evaluated if conversion to open surgery was required. After surgery, patients were followed-up in OPD for 7 days for assessment of infection.Results: Mean age of patients was 45.75±14.98 years. Among patients 93(47.7%) were male and 102(52.3%) were female. Mean duration of gall bladder stone was 5.02±0.80 months. Mean time for operation was 50.27±12 minutes. Mean loss of blood was 73.11±20.46 ml respectively. There were 24(12.3%) cases who had perforation. Total 35(17.9%) patients suffered from infection post operatively. Conclusion: Total laparoscopic clipless cholecystectomy by harmonic scalpels is fully safe and useful technique in surgery for gall bladder stones.Key words: Total laparoscopic clipless cholecystectomy, harmonic scalpels (HS), gall bladder stones