Introduction: Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is valuable in the detection of biliary abnormalities. In this study, we aimed to investigate the diagnostic accuracy of IOC during LC for the detection of anatomic variations of the biliary system, as well as the visualization ability of IOC on determining the normal anatomy of the biliary tree. Materials and methods: This cross-sectional study was conducted on patients who were presented to the surgery outpatient clinic and were scheduled for elective LC for symptomatic cholelithiasis. Patients underwent intraoperative laparoscopic ultrasound (LUS) before the dissection of Calot's triangle and IOC video fluoroscopy examination of the extrahepatic biliary tree. Results: Our study enrolled 53 patients. No intraoperative complications occurred in all enrolled patients. LUS was successful in all 53 (100%) cases, while IOC was successful in 50 (94.3%) cases. IOC had accuracy rate of 100% (50 patients) in defining biliary ducts at the porta hepatis compared to 84.91% (45 patients) for LUS with a failure rate of 15.09% (p = 0.60). Concerning stones detection, LUS accuracy indexes were as follows: sensitivity = 80%; specificity = 95.83%; positive predictive value (PPV) = 66.67%; negative predictive value (NPV) = 97.87% 99; and diagnostic odds ratio (DOR) = 92. IOC accuracy indexes were as follows: sensitivity = 80%; specificity = 93.33%; PPV = 57.14%; NPV = 90%; and DOR = 56. Conclusion: The results of the current study encourage using IOC as an effective, accurate, feasible, and safe technique to visualize the biliary tree while performing LC.

Background: Traumatic spinal cord injury (SCI) may be a devastating life event. Motor and sensory recovery after 6 months post-injury is sparse, despite intensive neurorehabilitation. Long-term disabling consequences may further reduce self-supportiveness and the quality of life. A new surgical intervention, the Possover LION procedure (Laparoscopic Implantation of Neuroprosthesis), may improve long-term perspectives providing the patient with an implantable pulse generator (IPG), and leads to pelvic situated nerves (sciatic and femoral nerves) to regain substantial motor and sensory functions in lower extremities. Objective: To report from the surgical point of view, the experience of implementing an IPG system for direct nerve stimulation of pelvic nerves in a series of chronic traumatic SCI patients. Methods: From two substudies, a feasibility study and a controlled clinical study, data from 21 SCI patients with severe paraplegia who had undergone the Possover LION procedure were obtained. The Possover LION procedure was implemented in a surgical department with skilled surgeons in close collaboration with neurological expertise. The developer of the procedure performed the first operations and afterward provided guidance and collaboration. Results: Twenty patients (F = 3, M = 17, age = 36.9 ± 9.0, ISCNSCI AIS A = 19, AIS B = 1) with lesion between Th3 and L1 had IPG and four leads implanted. One patient had a “frozen pelvis” and could not be operated. During operation, severe bleeding was seen in one patient that could be stopped using on-site applied hemostats, with no need of transfusion. One patient had initial normalization of infection parameters postoperatively, but developed Staphylococcus aureus infection near the IPG, removal of IPG and leads was needed. Clinically significant dislocation of leads was seen in two patients and dislocation/tilting of IPG in one patient. Hardware problems with possible lead breakage were observed in one patient. Conclusion: Posttraumatic SCI patients with paraplegia can be elected for the LION procedure by a specialist team of neurorehabilitation experts (neurologists, PTs), and skilled surgeons in the neuro-pelvic area, with Possover LION expertise. Complication rates for the Possover LION procedure are comparable to or better than those seen with spinal cord stimulation, and the procedure is generally safe. We recommend the monitoring of implanted leads and IPG using CT abdomen.

Introduction: Laparoscopy has established its role (diagnostic as well as therapeutic role) in patients with nonspecific chronic pain abdomen. In case of diagnostic dilemma and uncertainty, use of laparoscopy can help to avoid unnecessary laparotomy, provides accurate diagnosis, and helps to plan for surgical intervention if required. However, the role of laparoscopy in nonspecific chronic pain abdomen is still debated. Aims and objectives: To assess the accuracy of laparoscopy in the diagnosis of nonspecific chronic pain abdomen and its ability to avoid unnecessary exploratory laparotomy with complications and limitations associated with laparoscopy including failure rate. Materials and methods: This prospective descriptive study was conducted for a period of 1 year in patients with nonspecific chronic pain abdomen for more than 3 months attending the outpatient department or emergency department when clinical features and investigations are not conclusive. Results: Sixty-two patients in age-group from 15 to 60 years were studied. Overall 85.48% of patients had resolution of pain after diagnostic laparoscopy with diagnostic accuracy in our study of 88.7%. Conclusion: Diagnostic laparoscopy should be considered as one of the gold standard tests for diagnosing the nonspecific chronic pain abdomen, when noninvasive diagnostic modality failed in diagnosing cause.

Background: In today's era of minimally invasive surgery, early postoperative pain reduction, early recovery, and return to normal activities are also important aspects. This study has been designed to analyze and compare the effect of laparoscopically administered transversus abdominis plane (TAP) block with port-site infiltration of long-acting local anesthetic agent (0.25% bupivacaine) in cases of elective laparoscopic cholecystectomy. Materials and methods: This is a comparative study carried out at St Joseph Hospital, Ghaziabad, from September 2019 to March 2020 on 154 patients who underwent standard four-port laparoscopic cholecystectomy. Seventy-seven patients in group I received TAP block with 0.25% bupivacaine and seventy-seven patients in group II received 20 mL of 0.25% bupivacaine infiltration over port sites, including 10 mL each at epigastric and umbilical port and 5 mL each at midclavicular line and anterior axillary line ports, respectively. Various parameters were assessed during the intraoperative and postoperative periods. The pain was analyzed using visual analog scoring (VAS) for the first 24 hours at an interval of 3, 6, 12, and 24 hours. A note was made of any additional analgesic requirement. Results: Postoperative pain at 3, 6, and 12 hours was significantly reduced in group I who received TAP block as compared to those who received port-site infiltration. Hospital stay duration was significantly shorter in group I. Conclusion: Laparoscopic-assisted TAP block significantly reduces early postoperative pain, shortens hospital stay after elective laparoscopic cholecystectomy, and is a safe and cost-effective method without any extra requirement of specialized equipment and skills.

Aim: We reviewed a retrospectively collected database of 64 patients undergoing two-stage hepatectomy for colorectal liver metastases with special attention to cases involving a laparoscopic first stage. Materials and methods: Three patients undergoing laparoscopic first-stage hepatectomy were analyzed and compared with 61 other patients who underwent two-stage hepatectomy using open surgery for the first stage. Results: In three patients with a laparoscopic approach, the first-stage operation was a laparoscopic lateral sectionectomy or resection of segment 3, combined with portal vein embolization via the iliac vein directed at the contralateral hemiliver. No postoperative morbidity or mortality resulted. After a mean interval of 37.3 days, second-stage hepatectomy was performed for clearance of tumors in the right hemiliver (two in an open approach and one in a hybrid laparoscopic and open approach), with morbidity in 67% of patients (Clavien–Dindo classes I and IIIb in one patient each) but no mortality. When these three patients were compared with 61 patients treated with an open approach, numbers of metastatic tumors tended to be less in patients with a laparoscopic first stage. Duration of the first-stage hepatectomy (p <0.01) and hospital stay after that hepatectomy were shorter in patients with laparoscopic resection than in patients with open resection (p = 0.03). Conclusion: Our preliminary data support the feasibility and safety of the laparoscopic approach for the first-stage resection during two-stage hepatectomy. Clinical significance: First-stage laparoscopic clearance for patients with relatively small numbers of tumors who are anticipating two-stage hepatectomy for bilobar metastases becomes a standard option.

Background: The gold standard for gallbladder (GB) surgery worldwide is laparoscopic cholecystectomy. At the same time, complications that may arise from performing cholecystectomy can be horrifying. This is because in some cases, the complex anatomy can predispose the patient to the dangerous arteriovenous and biliary injuries. A subtotal cholecystectomy (STC) can, thus, obviate these complications. Aim: To examine the clinical spectrum of STC and the postoperative turnout of this procedure. Materials and methods: Our health management information system was used to collate our 10-year data (January 2010–January 2020) from the secondary and tertiary health facilities owned by Ondo State of Nigeria. Information on patients’ biodata, indication for surgery, surgical approach, laboratory evaluation, and radiological assessment was entered into a spreadsheet and analyzed using Statistical Package for the Social Sciences (SPSS) version 20 (OBM Incorporation). STC occurs when there is a remnant of the GB after GB surgery exclusive of the cystic duct. Results: A total of 60 (15%) out of 400 patients underwent laparoscopic STC. Closely compacted, complexly crowded constituents and adhesions at the Calot's triangle were the main indications for STC. Ten patients (16.7%) had bile leakage after surgery. There were no biliovascular injuries, and 1-month mortality was zero. There was no case of surgical site infection. Over a consistent follow-up of 1 year, clinical examination, liver function test, and ultrasonography revealed no abnormality in any of the patients. Conclusion: STC is a rescue mission during difficult GB surgery. Early consideration for STC before conversion to open surgery is more acceptable. Intraoperative injuries are obviated, and the postoperative outcomes are satisfactory.

Aim: A randomized case–control study was performed to compare the traditional using a speculum vs vaginoscopic hysteroscopy in terms of pain score and procedure time. Materials and methods: A total of 100 patients aged 20 to 60 years old, including nulliparous, multiparous, and postmenopausal, were randomized in two groups: group A undergoing traditional hysteroscopy with speculum and vulselum (50 patients) and group B undergoing “no-touch” vaginoscopic hysteroscopy. Results: Vaginoscopy was significantly more successful than the traditional hysteroscopy. The total pain was calculated for each group, it was significantly lower in the vaginoscopic technique (p = 0.026). The mean time was 5.71 for traditional hysteroscopy and 4.44 for vaginoscopic hysteroscopy. The time taken to perform hysteroscopy was significantly shorter with vaginoscopic hysteroscopy. There was no difference in failure rates. Conclusion: The vaginoscopic approach is better tolerated, quicker to perform, less painful, and therefore, more successful than the traditional hysteroscopy using the speculum. It should be preferred in an outpatient setting.

Background: Laparoscopic surgery is gold standard for treating various abdominal diseases. Carbon dioxide, having high safety profile, is the most commonly used gas for insufflating peritoneal cavity for accurate visualization and operative manipulation. Despite the fact that CO₂ is naturally present in the atmosphere, i.e., 0.035% (350 ppm), it is one of the most overlooked toxic gases. CO₂ breathing causes numerous cardiorespiratory responses and psychological reactions, such as impaired vision, diminished motor control, slowed responses, disorientation, or reduced attentional capacities that may jeopardize a worker's health and safety. At high concentrations (8%), it has been shown to cause unconsciousness almost instantaneously and respiratory arrest within 1 minute. As laparoscopic surgeons are under constant exposure of leaking CO₂ gas, this study is taken up to evaluate the effects of CO₂ on them by a noninvasive technique that measures end-tidal CO₂ of operating surgeons at the beginning and end of laparoscopic surgeries. Objective: To evaluate the effects of leaking CO₂ gas on surgeons during laparoscopic surgeries. Methods: A Mini-Mental State Exam (MMSE) score and EtCO₂ levels (using a capnometer with 4 L of oxygen/minute) of operating surgeons were obtained before the start of surgery. After surgery, MMSE scores and EtCO₂ levels were again documented, compared, and analyzed using SPSS software. Results: The mean EtCO₂ before surgery was found to be 30.86 with standard deviation of 4.03 and that after surgery was 31.23 with standard deviation of 3.85 with mean duration of surgery being 73 minutes. Correlation of individual EtCO₂ values before and after surgery did not show significant changes (p value = 0.534). The difference in MMSE scale scores before and after surgery for all participated surgeons was insignificant. Conclusion: In healthy surgeons performing laparoscopic surgeries, there are no effects following exposure to leaking carbon dioxide.

Background: Gastric cancer (GC) is a crucial cause of morbidity and mortality worldwide. In Egypt, GC ranked as the 12th most common cancer. During the last two decades, laparoscopic gastrectomy (LG) has proved to be popular and effective. This study aims to compare the short-term outcomes of LG vs open gastrectomy (OG) in resectable GC patients. Patients and methods: This is a randomized controlled trial, where patients presented to Assiut university hospital with resectable GC, in the period from January 2017 to December 2019, were randomly allocated to OG (group A) or LG (group B). Results: During the study period, 46 patients were randomized: 23 patients for OG and 23 for LG. Advanced cases after exploration were excluded from both the groups ended up with a total of 36 patients (20 for OG and 16 for LG). The mean follow-up time was 5 months ranging from 40 days to 10 months. There were no statistically significant differences between the two groups in the baseline clinicopathological data. The mean operative time was longer in LG (260.6 ± 46.7 vs 191.0 ± 24.7 minutes in OG) with a p-value <0.001. The postoperative hospital stay was more in OG compared to LG (8.0 ± 4.1 vs 6.9 ± 2.6 days, p-value = 0.361). Postoperative complications were more among OG (4/20) compared to (2/16) in LG (p-value = 0.549). Just one mortality was reported in the OG. Conclusion: For GC cases, LG shows comparable outcomes to OG in short-term results, and it is a promising minimally invasive surgery in such cases.

Background: Hernia is defined as an area of weakness or complete disruption of the body wall's fibromuscular tissues. Structures arising from the cavity contained by the body wall can pass through, or herniate, through such a defect. The typical clinical finding is a bulged mass increasing in size when intra-abdominal pressure rises. The hernia is asymptomatic or may cause severe pain for patients. Arising of intra-abdominal pressure for each reason can generate anterior abdominal wall hernias; on the contrary, each synchronous surgically treatable intra-abdominal disease can be revealed with the same symptoms, and distinction of this disease prior to the surgery is important. Materials and methods: This study was conducted on 90 patients who were candidates for anterior abdominal wall herniorrhaphy. All patients were screened for the coexistence of intra-abdominal surgically treatable diseases using the abdominopelvic sonographic examination. According to our project, patients with a synchronous intra-abdominal illness were treated with single surgery for their hernia and surgically treatable disease. Other patients with the healthy sonographic report were only subject to herniorrhaphy. Results: The sonographic report was normal in 53 patients and abnormal (including cholelithiasis or any synchronous surgically treatable disease) in 37 patients. The study of the population using the Chi-square test to determine the need for further surgery (normal sonographic report rate) showed a statistical difference between hernia groups (p = 0.001). In the umbilical hernia group, the need for further surgery is significantly lower than that in the other groups (p <0.001). Conclusions: The coexistence of intra-abdominal surgically treatable disease with anterior abdominal wall hernias and their possible recurrence due to the remaining of the intra-abdominal illness as a source for intra-abdominal cavity pressure convinced surgeons to carefully check patients for each surgically treatable intra-abdominal disease before surgery.

Introduction: With laparoscopy being the surgeon's first choice even in difficult cholecystectomy, a need to objectively grade intraoperative difficulty during laparoscopic cholecystectomy (LC) is gaining popularity. The study was done to design a scoring system to predict the difficult outcome during intraoperative LC. Materials and methods: The study was done at the General Surgery Department in a tertiary level hospital among patients undergoing LC. The procedures that exceeded 70 minutes in duration and/or converted to open were considered the difficult LC. To develop the predictive score, an association of various factors with difficult cholecystectomy was identified by performing multiple logistic regression analysis, and receiver operating characteristic (ROC) curve was plotted to estimate the cutoff value for the scoring system. Results: We recruited 200 patients in this study, out of which 85 had difficult cholecystectomy procedures. Among all intraoperative predictors, adhesions, gallbladder (GB) condition, Calot's triangle status and abnormality, and the presence of pericholecystic fluid were associated with a difficult LC. Based on the odds ratio, a new scoring system was designed with a score ranging from 0 to 25. The grading score was created as easy (0–5) and difficult (6 or above) based on the intraoperative factors. At a cutoff score of 6, this scoring system had a sensitivity and specificity of 87.1 and 88.7%, respectively. Conclusion: This study demonstrates that an intraoperative scoring system can predict the difficult outcome of LC. This can help in minimizing the complication and conversion to open cholecystectomy, especially relevant for funds-limited settings like India.

Background: The optimal treatment for choledocholithiasis (CLT) is currently the subject of debate, as there is no clear evidence that a two-step (endoscopic plus surgical) approach is superior to a one-step surgical procedure. Materials and methods: We analyzed the results obtained from 101 consecutive patients diagnosed with CLT using magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT) scan undergoing cholecystectomy and laparoscopic exploration of the bile duct, carried out at our center between 2006 and 2019. In this analysis, special emphasis was made on the permanent resolution of the CLT and the associated complications. Results: The mean surgical time was 142 ± 36.7 minutes. In patients with a CLT diagnostic test more than 7 days previously, the presence of CLT was checked using intraoperative cholangiography (IOC), which was negative in 25% of patients, while in the rest, a primary exploration was performed using a choledochoscope via choledochotomy in 82.2% of patients and via the transcystic approach in two cases. A T-tube drain was inserted in 18.9% of patients. The conversion rate was 0.9%, due to a technical difficulty in removing the CLT in one patient. The laparoscopic approach treated the CLT permanently in 97/101 cases (96%), while four patients (3.9%) required postoperative endoscopic retrograde cholangiopancreatography (ERCP) due to residual cholelithiasis. A total of 15.8% of patients experienced a postoperative biliary fistula, which was resolved using conservative management in 86.7% of them, while two patients required surgical treatment and insertion of a percutaneous drain, respectively. The average postoperative stay duration was 6.5 ± 7.3 days. None of the patients showed signs of biliary stricture in the long-term postoperative follow-up. Conclusion: In our experience, the laparoscopic approach for one-step elective treatment of CLT is a safe option, with a very small number of complications and satisfactory short- and long-term results. Furthermore, despite preoperative identification of CLT, it helped to avoid unnecessary exploration of the bile duct in 25% of patients.

Introduction: Body image often improves after bariatric surgery; however, those who are depressed are more vulnerable to continuing to have body image concerns. Body image dissatisfaction and depression are associated with poorer quality of life, less weight loss after surgery, and poorer overall physical/mental functioning. Our study aims to determine whether antidepressants influence the improvement seen in body image after bariatric surgery. Materials and methods: Body-Esteem Scale for Adolescents and Adults (BESAA), a validated tool for trending body image, was administered preoperatively and at 3, 6, and 12 months postoperative follow-ups. Scores were compared for improvement, and linear regression models were used to determine the influence of medications and demographic factors on score improvement. Results: The study sample was consisted of 47 men and 57 women (22–72 years of age). Preoperative BMI was in the range of 35.87–75.66 (mean: 49.26). Sixty-nine percent (69%) were taking psychiatric medications and 57% of those medications were antidepressants (12 different antidepressants represented). Improvement in BMI was in the range of 1.44–30.77 points (mean: 15.08). The majority (98.07%) showed improved BESAA scores; two factors revealed statistical significance for influence on score magnitude. For every 1 point of BMI improvement, our sample increased BESAA scores by 0.68 points (p = 0.021). Those taking antidepressants scored an average of 8.55 points higher than those not taking antidepressants (p = 0.032). There were no significant differences found for age, gender, race, type of surgery, use of anxiolytics/hypnotics, or stimulants. Conclusion: Perioperative antidepressant usage is associated with a greater improvement in body image after bariatric surgery compared to those who are not taking antidepressants. Given the high comorbidity of depression in bariatric surgery patients, this highlights potential for improved outcomes with treatment of psychiatric comorbidities in this population.

Background: One of the major global health burdens is type 2 diabetes mellitus (T2DM). Laparoscopic sleeve gastrectomy (LSG) has recently been shown to be effective and safe for T2DM management. Laparoscopic mini-gastric bypass (LMGB) was introduced as a simple (one anastomosis) operation combining both restrictive and malabsorptive functions thus suitable for obese patients with metabolic derangements like T2DM. This study aims to compare the effect of LSG and LMGB on T2DM in obese patients. Materials and methods: A cohort study was carried out on obese patients with T2DM submitted for LSG or LMGB in the department of surgery at Suez Canal university hospital and Suez Canal authority hospital, Egypt, from June 2018 to September 2020. The patients were followed up for 12 months. Results: A total of 20 patients were allocated to each group. The change in the mean body mass index (BMI) was significantly higher in the LSG, compared to the LMGB group (p<0.05). Both groups exhibited a significant reduction in the HbA1c at the end of follow-up 12 months after surgery; however, the reduction was significantly higher in the LMGB group (p<0.05).Among the LSG group, 75% of the cases showed complete diabetic remission, 15% showed partial remission, and 10% showed improvement in their glycemic control at the end of follow-up. Among the LMGB group, 85% of the cases showed complete diabetic remission and 10% showed partial remission. The difference between the study groups was statistically significant. Conclusion: The study showed good improvement for T2DM and a great response in losing weight with a significant superiority of LMGB over the LSG.

We have observed that the falciform ligament can appear prominently as a vertical lucent artifact making cholangiography difficult during laparoscopic cholecystectomy. Our suspicion is that this is due to the pneumoperitoneum, and once the pneumoperitoneum is released, this artifact disappears. We have presented images displaying this phenomenon that we feel would be useful for general surgeons operating on the gallbladder.

Ovarian dermoid cysts, also known as mature teratomas, are one of the ovarian numbers that can develop into malignancy and are mostly found in women aged 20–40 years. Most cases of teratoma mature cystic were discovered accidentally through the imaging examination. We reported a 31-year-old woman with complaints of bleeding from the birth canal for 16 days and accompanied by sharp pain during menstruation. The general condition is good and other vital signs examined were within normal limits. Abdominal ultrasound examination showed a mass in the right adnexa with a size of 12 × 10 × 8 cm and there were longitudinal thin white lines. Laparoscopic right ovarian oophorectomy was performed. After removing the mass was opened and there was a lot of hair in it. There are no complications during surgery and after surgery. The results of the histopathological examination were by the dermoid cyst.

Aim and objective: The aim and objective of this article was to focus on long-term complications after bariatric surgery, which are usually managed by general surgeons in the emergency department. Background: Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed bariatric techniques in the world. Gastric remnant complications after this procedure are infrequent and poorly known. Furthermore, the diagnosis of this pathology may be challenging. Case description: We present the case of a 54-year-old woman with intense epigastric pain and history of uncomplicated laparoscopic RYGBP 18 years ago. After clinical, laboratory, and radiological examinations, the patient was diagnosed with a gastric remnant perforation. Laparoscopic surgery was performed, and the perforation was successfully repaired with primary suture and omental patch. Conclusion: Gastric remnant perforation after bariatric surgery is not frequent and usually appears several years after the procedure. This type of pathology is presented without specific clinical manifestations and with few analytical alterations. Complementary radiological studies, such as computed tomography (CT) scan, should be performed. However, pneumoperitoneum and extravasation of oral contrast are usually absent. Depending on the size of the defect, primary suture or gastric remnant resection may be performed. Nevertheless, surgical treatment should not be delayed. Clinical significance: Long-term complications after bariatric surgery are in many circumstances managed by general practitioner surgeons. The low incidence and scarce manifestations make the diagnosis of this pathology challenging. Furthermore, bariatric surgery is progressively increasing its presence all over the world. Complications after this procedure must be known and kept in mind because an early diagnosis is crucial to give a proper treatment and reduce morbidity and mortality.