Background: Laparoscopic cholecystectomy (LC) is the surgery of choice for patients suffering from gallstone diseases. Open cholecystectomy these days is performed after conversion from laparoscopic surgery due to various reasons. The aim of this study was to assess the factors responsible for conversion of LC to open surgery by identifying preoperative risk factors that could predict conversion and intraoperative technical/surgical difficulties and complications that cause conversion. Methods: A total of 310 patients were included in this prospective observational study conducted between November 2018 and March 2020. Results: Out of 310 cases, 38 were converted to open surgery with a conversion rate of 12.2%. Mean age was 10 years more in the converted group. Males had a higher chance of conversion than females (18.6 vs 7%). Conversion rate was significantly higher in patients with body mass index (BMI) >23 kg/m² (25%), with features of acute cholecystitis, who underwent interval cholecystectomy (25.8%), who underwent endoscopic retrograde cholangiopancreatography (ERCP) (>40%), with total white blood cell (WBC) counts ≥10,000/mm³ (25.6%), with serum albumin <3.5 g/dL (43.8%), with imaging findings of acute cholecystitis (25.6%), and with dilated common bile duct (CBD)/choledocholithiasis (33.3%). Conversion rate when LC was performed early after ERCP was 18% and when performed after 4–6 weeks was >50%. The most common causes for conversion were a frozen Calot's triangle due to dense inflammatory adhesions, leading to inadequate visualization of critical structures. Conclusion: Identifying patients with significant risk factors for conversion could minimize adverse effects of prolonged surgery by limiting duration of trial of laparoscopic dissection. Surgical residents need to identify low-risk patients preoperatively and require proper training before handling difficult cases. Clinical significance: Early LC should be considered in all patients who are able to withstand surgery, as delayed surgery increases the chances of conversion. Registration of the study: This prospective study has been registered in the Clinical Trials Registry of India (CTRI). CTRI Registration Number CTRI/2018/11/016338.

Aims and objective: To study postoperative pain, time taken for procedure, postoperative complications, return to normal activity, and recurrence between stapler and open hemorrhoidectomy. Materials and methods: For this study, 40 patients of second- and third-degree hemorrhoids were operated for stapler or open method of hemorrhoidectomy. Follow-up of all patients was taken at first week, third week, and 1 year postoperatively. Results: On the postoperative days one to four in stapler hemorrhoidectomy, there was decreased postoperative pain according to visual analog score, significantly reduced operating time and early gain of work (3 vs 20.5 days; p = 0.001). No difference in complications of both the method of surgeries was found. No recurrence was found in either of surgeries, while impaired wound healing was found more in open hemorrhoidectomy. After 1 year, there were no any complications such as recurrence, rectal stenosis, or perianal fistulas in stapler group. Conclusions: Stapler hemorrhoidectomy was found to have decreased postoperative pain, earlier return to work, earlier recovery time, and zero recurrence in comparison with the open technique up to 1 year. Clinical significance: Stapler hemorrhoidectomy can be a good option as compared to open hemorrhoidectomy in the form of less postoperative pain, hospital stay, and early return to work in second- and third-degree hemorrhoids without significant postoperative complications.

Aims: To study comparison of peroperative finding in difficult cholecystectomy with a scoring system, to evaluate the amount of complexity in the surgery and its outcome. Materials and methods: A study of 50 patients undergoing elective difficult laparoscopic cholecystectomy was done. In difficult cholecystectomy, peroperative scoring was carried out, and based on these findings evaluation of the amount of complexity and results of the surgery was assessed according to the scoring system. Results: Patients with chronic calculous cholecystitis were 16 and degree of difficulty had an average score of 5 while of acute calculous cholecystitis were 28 patients with an average score of 6 and mucocele of gall bladder were 3 cases with an average score of 7. Two cases of empyema gall bladder and one case of gangrenous gall bladder both with an average score of 8. All extreme difficulty cases with a score of 8 were converted to open. Increased severity of score is proportional to the increased complexity of the surgery. Conversion to open surgery is indicated in an extreme degree of difficulty with a score of 8. Conclusion: This intraoperative scoring system is important in the evaluation of the complexity of cholecystectomy surgery and evaluating the amount of complexity in carrying out laparoscopic cholecystectomy. Clinical significance: In mild, moderate, and severe degrees of difficult cholecystectomy according to the peroperative scoring system (5–7), can be completed laparoscopically without complication. In extreme level difficult cholecystectomy, peroperative scoring system (≥8) can guide us to make the decision to convert it into open surgery and also help in preventing life-threatening complications like bile duct injury.

The aims of present study were as following: To compare extracorporeal knotting vs clips for ligating cystic duct in laparoscopic cholecystectomy in terms of feasibility operative time (incision to closer) based on types of cholecystitis postoperative pain, operative cost, and associated morbidities like gallbladder perforation, bile leak, liver bed injury, port site infection, migration of clips, and slipping of knot. Methodology: All the patients were assigned by randomization into either of two groups: study group—patients in whom extracorporeal knotting was done for ligation of cystic duct, and control group—patients in whom clips were used for clipping of cystic duct. Period of study was from November 2018 to June 2020. Results: This was a case series analysis conducted from November 2018 to June 2020; i.e., for a period of 20 months, 60 cases were subjected to laparoscopic cholecystectomy. In the control group, 11 patients had intraoperative complications, and no complications in the study group. In the study group, mean time taken for the operation was 67.37 minutes when compared to control group of 61.83 minutes. The cost of the suture material used in study group was 302 rupees, and the average cost of the titanium clips used in control group was 500 rupees. Conclusion: In laparoscopic cholecystectomy, extracorporeal knotting has the advantages over clipping of cystic duct in operative cost and lesser intraoperative complications with the only limitation being operative time.

Introduction: First laparoscopic cholecystectomy in situs inversus totalis (SIT) patients was described by Campos and Sipes. We present a retrospective study of five cases in whom laparoscopic cholecystectomy was done for symptomatic cholelithiasis. Methodology: This is a retrospective study from 2005 to 2021. All the patients in the study were done by a single surgeon at various hospitals in the state. All recorded data from patients and from hospitals was taken and analyzed. Results: Our study included five patients with the mean age of 31.6 years. All the patients were females. Our patients presented with complaints of epigastric pain (2), dyspepsia (1), and pain in the left upper abdomen (2). There was no associated cardiac anomaly in our patients. The first three patients were operated on using conventional mirror image technique, the fourth one by modified mirror image, and the last one using French technique. In initial cases operating time was 45–50 minutes which decreased up to 35–40 minutes in the last cases. All patients were discharged on the first postoperative day after tolerating orals and with the satisfactory condition on discharge. There was no intra- or postoperative complication in our study. There was no 30-day mortality in our patients. Conclusion: SIT is a rare congenital anomaly. A laparoscopic cholecystectomy is a safe approach with meticulous dissection in these patients with cholelithiasis. Technical difficulties could be overcome due to learning and better understatement of ergonomics of these patients.

Background: In patients undergoing bariatric surgery, different techniques have been used to avoid venous thromboembolism (VTE), including pharmacological prophylaxis and mechanical prophylaxis. Our aim was to determine the effectiveness of the prophylaxis procedure (pharmacological and mechanical prophylaxis) to prevent VTE following bariatric surgery. Patients and methods: We performed the present cross-sectional study on patients with morbid obesity who were scheduled to undergo bariatric surgery. The primary outcome of the present stud was the incidence of VTE. The diagnosis of VTE was based on a duplex ultrasound. Patients were followed up for 1 month after the procedure. Results: Two patients develop pulmonary embolism (6.1%). The first patient was female aged 40-years-old who underwent a sleeve gastrectomy (SG). Her body mass index (BMI) was 43 kg/m² and she had a history of diabetes, hypertension (HTN), and VTE 5 years ago. On the 5th postoperative day, she complained of shortness of breath and chest pain, which was followed by the diagnosis of pulmonary embolism and ICU admission. The second patient was a female aged 49-years-old who underwent one anastomosis gastric bypass (OAGB) operation. Her BMI was 55 kg/m² and she had a history of diabetes, HTN, and chronic obstructive pulmonary disease (COPD). Twelve days after operation, she complained of chest pain, palpitations, and shortness of breath, which was followed by the diagnosis of pulmonary embolism and ICU admission. Conclusion: In conclusion, VTE is associated with an increased risk of morbidity and mortality after bariatric surgery; however, it can be prevented using an extensive course of thromboprophylaxis. For the best regime in VTE prevention after the bariatric operation, more prospective experiments are needed.

Background: Elective surgery, especially bariatric surgery, was stopped during the coronavirus disease-2019 (COVID-19) pandemic in the United Kingdom. Obesity is a major risk factor for COVID-19-related mortality. As the COVID-19 infection and mortality rates in Devon had been relatively low, bariatric procedures resumed with the necessary precautions in Plymouth with the easing of lockdown restrictions in mid-May. The aim of this study was to examine the outcome of bariatric surgery during the COVID-19 pandemic. Methods: Details of 38 patients, who underwent bariatric surgery between June 2020 and November 2020, were analyzed prospectively. All patients underwent a COVID-19 swab test 24–48 hours prior to the surgery. The primary outcome measure was COVID-19-related morbidity. Secondary outcomes were non-COVID-19-related morbidity, mortality, and weight loss at 6-week follow-up. Results: Thirty-eight patients [24 females; median age 51 (24–63) years, median body mass indices (BMI) at surgery 42.9 (32.4–62.5) kg/m²] underwent bariatric surgery. Thirty-seven patients were of White British ethnicity. No patient tested positive for COVID-19 pre- and postoperatively. No patient had any COVID-19-related morbidity or mortality. One patient developed a staple line bleed and returned to theater for relook laparoscopy and hemostasis. One patient developed an anastomotic leak and had a relook laparotomy for lavage and drain placement. The median length of hospital stay was 1 day. One patient was preplanned for intensive care admission and he stayed in a high dependency unit (HDU) for 1 day. All patients were followed up for 6 weeks and the median (range) excess weight loss (%EWL), at 6 weeks, was 24.4% (−0.9–53.6). Conclusion: Bariatric surgery can be performed safely in an area of low COVID-19 prevalence with the necessary precautions.

Aim and background: Helicobacter pylori (H. pylori) infection can cause chronic gastritis and gastric malignancy. Upper gastrointestinal endoscopy is performed to assess the symptoms of abdominal pain but endoscopy alone is not confirmatory. Therefore, either pathological evaluation of biopsies of mucosa or detection of urease in the mucosa by rapid urease test (RUT) produces accurate diagnosis. The study aimed to assess the role of H. pylori infection among patients with chronic abdominal pain and endoscopy-suggested chronic gastritis and also to evaluate the association of endoscopic findings and RUT. Materials and methods: The prospective randomized study was performed on 50 patients with clinical findings suggestive of chronic gastritis or abdominal pain of unknown etiology. Data regarding patient history and routine physical and clinical examination were recorded. Upper gastrointestinal endoscopy was performed in all patients. Organs including the esophagus, stomach, and duodenum were examined for abnormality and biopsy was performed at various sites of the affected organ. The obtained specimen from biopsy was subjected to RUT. Results: Endoscopic finding suggested gastritis in 6% (n = 38) of the patients among which 31 patients were RUT positive. A significant association was found between endoscopic findings and RUT (p = 0.013). Patients of 31–40 years of age (n = 11) and males were found to be more commonly affected as indicated by a positive reaction to RUT (n = 27). Conclusion: RUT facilitates rapid and accurate diagnosis of H. pylori infection, and along with endoscopy, can be used in the diagnosis of H. pylori infection in chronic gastritis. Clinical significance: Early diagnosis of H. pylori is essential to formulate early and appropriate clinical strategies for better management of the patient. RUT is a well-known diagnostic test that is rapid, cheap, and simple. It detects urease in or on gastric mucosa produced by the bacteria.

Background: When a viscus or part of a viscus protrudes through the umbilicus, it is known as umbilical hernia. These hernias constitute as one of the common hernias of adults. Umbilical hernias are common in individuals with increased intra-abdominal pressure such as obesity, ascites, or chronic abdominal distension including malignancy. Mesh repair in umbilical hernia can be open mesh repair or laparoscopic mesh repair with each having their own advantages and disadvantages. This study attempts to evaluate various operative procedures and postoperative results of umbilical hernia in public sector hospital. Methods: Study was an interventional study with a total sample size of 80. Study population were all the patients admitted with umbilical hernia to the surgical wards of hospitals associated with Bangalore Medical College and Research Institute. The study was conducted from November 2018 to May 2020. After admission, patients fulfilling the inclusion criteria were enrolled into the study and informed written consent was obtained. All the details and investigations of each patient were recorded in the case record form at the baseline visit. In 40 patients, open mesh repair of umbilical hernia was done, and in another 40 patients, laparoscopic mesh repair of umbilical hernia was done. The duration of surgery and various other postoperative complications were recorded. Results: Eighty cases of umbilical hernia were operated, out of which, in 40 patients, open mesh repair was done and, in another 40 patients, laparoscopic mesh repair was done. Thirty-six of 40 patients were females, and 4 of 40 patients were males in the laparoscopic mesh group. Thirty-two of 40 patients were females, and 8 of 40 patients were males who underwent open mesh repair. Mean age was 45.0 years, and mean operating time was 64.75 minutes for open mesh repair group, whereas mean age was 42.37 years and mean operating time was 50.38 minutes for laparoscopic mesh repair group. Operating time showed statistical significance. Conclusion: Laparoscopic mesh repair of umbilical hernia is becoming the procedure of choice in public sector hospitals in terms of decrease operating time, early recovery, less pain and less complications in postoperative period, and reduced duration of hospital stay as compared to open mesh repair of umbilical hernia.

Introduction: The incidence of perforated peptic ulcers (PPU) has decreased with effective medical treatment such that surgical repair has become a relatively infrequent procedure. We hypothesized that the surgeon's experience and the patient's clinical presentation are the most influential factors that determined the surgical approach. Methods: A retrospective chart review of PPU repairs in the last 10 years was performed to collect surgeon demographics, patient clinical condition, comorbidities, and whether surgeries were done at a regional or tertiary site. Outcome variables included length of stay, complications, and readmissions. A multivariate analysis was used to establish statistically significant correlations. Results: Of 219 operations for PPU, 49 were started laparoscopic (23.2%), 12 were converted to open (5.7%), and 162 were performed open (76.5%). The open and laparoscopic cohorts were similar without statistical difference between the groups in terms of age, sex, comorbidities, previous steroid use, NSAID, and anticoagulation use. Surgeons who attempted laparoscopy were more likely to have completed MIS fellowship (60.2%, p <0.001). The patients who had laparoscopic repair had a significantly shorter length of stay (8.5 vs 12.6 days; p <0.01). The patients who had an open repair had slightly more complications (18.4 vs 5.4%), readmissions (5.2 vs 2.7%), and hospital mortality (12.1 vs 5.4%) than their laparoscopically treated counterparts, although none was statistically significant. Conclusion: Surgeons who completed a minimally invasive fellowship were more likely to perform a laparoscopic repair of perforated peptic ulcer, regardless of the patient's clinical presentation, comorbid conditions, and demographics. Patients who underwent laparoscopic repair had a significantly shorter LOS. Educational efforts directed toward community surgeons who do not have prior MIS training are likely to benefit patients with PUD by increasing access to laparoscopic surgery for PPU.

Aim: In this study, a technical modification has been performed by using falciform ligament between the mesh and esophagus thereby preventing mesh to come in direct contact with the hollow viscera so reducing mesh-related complications. Materials and methods: From January 2016 to December 2017, patients requiring the use of prosthetic mesh at the hiatus during laparoscopic antireflux surgery (LARS) surgery were included in the study. Principles of an ideal LARS have adhered. After mesh repair at hiatus and appropriate fundoplication, the falciform ligament was released from its attachment to the ventral abdominal wall and was placed between the mesh and the posterior esophagus avoiding direct contact between the mesh and hollow viscera. Postoperatively patients were followed up for a minimum of 2 years. A retrospective analysis was done of the prospectively collected data. Results: Sixteen patients were included in the study (12 patients had redo surgery and four had large hiatus hernia requiring prosthesis). Average age of the patients was 48.5 years and the average BMI was 24.8. The mean operative time was 128.2 minutes. None of the patients had a recurrence of hiatus hernia, long-term dysphagia, any mesh-related complication, or any unexpected event related to surgery on 2-year follow-up. Conclusion: This innovative technique of using falciform ligament as a bridge between the mesh and the esophagus prevents the mesh-related complication without compromising the strength of hiatal repair. Clinical significance: To prevent the recurrence of hiatus hernia, the use of prosthetic meshes is advocated in patients with large hiatal surface areas. Concern about the safety of mesh at the hiatus has been there. This technique helps in reducing the mesh-related complication at the hiatus.

Revision bariatric surgery has become a standard technique in bariatric surgery processes. Patients who have experienced insufficient weight reduction or subsequent weight gain following an initial surgery have a variety of options for revision. The objective of this report was to explore the role of a sleeve gastrectomy (SG) revision to a banded gastric bypass (BGBP) for inadequate weight loss or weight gain. Patients who had BGBP revision surgery after SG were identified in a prospectively kept database and information on comorbidity resolution and weight was obtained. The effects of the revision activities were evaluated and analyzed. Sixty-two patients underwent reconsideration of SG to BGBP. The average time for the revision was 27 months in the range 7–60 and the follow-up after BGBP was 6–36 months. In this study the average initialism weight before the SG was 113.5 ± 20.5 kg and the body mass index (BMI) was 41.71 ± 8.1 kg/m². The mean percentage of weight loss %TWL at revision and at the nadir weight was 18.5 and 13.5%, respectively. The average %TWL was 25.9 ± 10.1, 29.7 ± 9.2, and 26.9 ± 9.6 at first-, second-, and third-year follow-up, respectively, after revision to BGBP. Type II diabetes (T2D) and hyperaeration (HTN) were resolved in 70 and 78.6% of the patients, respectively. With no complications or mortality AI revisions were done laparoscopically. It is practically feasible and safe to switch from SG to BGBP. The weight reduction from the BGBP sleeve is not only more desired than the weight loss from the primary sleeve, but it also results in successful comorbidity resolution. BGBP is a better bet to changing for altering SG for insufficient weight regain or weight loss.

Aim: In the past years, studies have reported the superiority of laparoscopic appendectomy (LA) over open appendectomy (OA) in randomized studies. Hence, this prospective study was designed to evaluate the clinical outcome of LA compared to the OA. Methods: All the patients who were diagnosed with appendicitis and visited Tikrit Teaching Hospital in the study period were included in this study. They were divided into two groups: LA and OA groups. The two groups were compared on operating time, hospital stay, the incidence of surgical site infection, and other postsurgical complications. Results: In the present study, a total of 128 patients (who visited Tikrit Teaching Hospital in Iraq) were included. Among them, 63 were included in the LA group and 65 people were in the OA group. The only significant difference that was observed in LA and OA group was in CRP count. In the OA group, the CRP count was significantly higher compared to the LA group (p = 0.024). The mean operating time was almost comparable between the LA and OA group. Blood loss was higher in the OA group and the difference was statistically significant (p = 0.038). Even hospital stay was also shown to be statistically higher in the OA group. A significant difference was reported in the wound infection among the LA and OA groups. In the OA group, wound infection was significantly higher (10.75%) than in the LA group (3.17%). No other adverse events were reported to be statistically different. Conclusion: Our findings revealed that LA has many advantages over OA, including a shorter hospital stay, earlier return to work, and a lower risk of wound infection. Clinical significance: LA significantly reduces postoperative complications and improves the surgical outcome.

Large ovarian cysts are ovary tumors with diameters more than 10 cm. Nowadays days these cases are rarely seen because they are diagnosed and managed early due to the ease of access to good imaging modalities. Benign serous cystadenoma is the most common type of epithelial neoplasm with benign serous cystadenoma ¾ and mucinous cystadenoma ¼. During the surgical management of large ovarian cysts in young girls, the main goal to keep in mind is the preservation of the reproductive and hormonal function of the ovaries. In this paper, the author represents a case report of a young female diagnosed with a very large ovarian cyst with a diameter of approximately 30 cm managed using laparoscopic surgery.

The views expressed in this publication/presentation are those of the author(s) and do not reflect the official policy or position of William Beaumont Army Medical Center, Department of the Army, Defense Health Agency, or the US Government. Background: There have been numerous studies comparing various aspects of bariatric surgery, such as hand sewn vs stapled anastomoses, electronic vs manual staplers, and reinforced vs nonreinforced staple lines. There has never been a randomized controlled trial comparing different staplers in sleeve gastrectomies. Methods: Our study was a randomized control trial comparing the staple reload time, complications, and stapler cost for the Medtronic I-Drive and the Ethicon Echelon. Our primary endpoints were time, hemostasis, bleeding, necessity for transfusion, and leak rate in a military system. Results: Sixty-three patients were consented for the study with a final number of 26 in the Echelon arm and 25 in the I-Drive arm after fallout. There were a total of 140 stapler reloads in the Echelon arm and 123 in the I-Drive arm. The median staple reload times were 39.78 seconds for the I-Drive and 41.77 seconds for the Echelon (p = 0.42). The total time for sleeve creation was 12.14 minutes in the Echelon arm and 14.26 minutes in the I-Drive arm (p = 0.04). There were two misfires in each group (four total) and no positive leak tests, transfusions, or postoperative complications. The average cost for staplers, reloads, and reinforcement for the I-Drive was $2,037.26 for the civilian rate and $2,097.66 for the government rate. The average cost for the Echelon was $1,835.65 for the civilian rate and $2,268.97 for the government rate. Conclusion: The Medtronic I-Drive and the Ethicon Echelon are comparable in reload time, stapler misfires, leak test rates, and cost. WBAMC IRB Study Trial Number: NCT02731079.

Background: The incidence of primary ventral hernias has been relatively static, while the incidence of incisional hernias has increased over time with the increase in the number of abdominal surgeries performed. The repair of ventral wall hernias continues to be a surgical challenge. Laparoscopic ventral hernia repair is nowadays being performed in every laparoscopic center and has become a preferred treatment methodology of ventral hernias. This approach is a feasible option for almost all ventral hernias. Materials and methods: This was a prospective observational study, conducted in the Department of Surgery, Hamdard Institute of Medical Sciences and Research, New Delhi over a period of 2 years from December 2016 to December 2018. A total of 40 patients who met the inclusion criteria were included in the study. The procedure was done by a single surgical team. The average follow-up ranged from 6 to 12 months. Results: Out of 40 patients in the age-group of 30–79 years, 24 were females and 16 were males. Fifty-five percent of the patients had incisional hernias with the average defect size ranging from 2 to 4 cm. The average operative time was 71–90 minutes. The hospital stay ranged from 2 to 4 days.There was no major intraoperative complication in our study. There was no conversion to open. Early postoperative pain was noted in 10 patients. Port site infection was noted in one patient and two patients developed postoperative seroma. Chronic pain was noted in one patient at 6 months follow-up. Port site herniation was noted in none. The recurrence of hernia was noted on one patient at the end of the follow-up. Conclusion: Laparoscopic ventral hernia repair, although sometimes technically challenging is an extremely safe and effective option in the management of ventral hernias. This approach offers a good cosmetic outcome to the patient without compromising on the results of hernia repair.

Introduction: Since 1987, laparoscopic cholecystectomy has been regarded as the gold standard treatment for cholelithiasis. Surgical clips, harmonic scalpel and ligature, or bipolar cautery can be used to control the cystic artery during this treatment. In this paper, we examine the use of bipolar electrocautery vs clip ligation to control the cystic artery during laparoscopic cholecystectomy. Method: This is a clinical comparative study that was carried out in total of 60 patients who underwent laparoscopic cholecystectomy conducted for 3 year duration (2016–2019). The patients were monitored for postoperative hemorrhage and bile leak, as well as differences in hospital stay length and postoperative sequelae. Results: In our study, the cystic artery was controlled using bipolar electrocautery in 30 patients (group B) and by surgical clips in 30 patients (group A). In both groups, the length of stay in the hospital and the duration of surgery were similar. In Group A, no incidences of intraoperative hemorrhage or bile leak were documented, but Group B had two cases of bile leak and four cases of intraoperative cystic artery bleed. Conclusion: We conclude that, especially in developing countries, bipolar diathermy and clip application are equally effective strategies for hemostatic control of the cystic artery during laparoscopic cholecystectomy.

Aim: The study was aimed to describe the outcome of single-incision laparoscopic surgery (SILS) and conventional totally extraperitoneal (CTEP) repair for inguinal hernias in terms of the following: (i) operative time; (ii) rate of conversion to open; (iii) postoperative complications; (iv) hospital stay; (v) cost; (vi) time until return to normal daily work; (vii) postoperative pain score; and (viii) cosmesis. Materials and methods: The present study was a prospective observational study done at the Government Medical College Srinagar, Department of surgery and allied super specialities. Results: The mean operating time in the CTEP group was 41.2 and 42.8 minutes for SILS TEP. Overall complications were slightly more in CTEP. The mean postoperative hospital stay was 19.2 and 21.8 hours in CTEP and SILS TEP, respectively. The average time to resume normal work was 3.7 ± 0.8 days in CTEP repair and 3.3 ± 1.2 days in SILS TEP repair. The mean visual analogue scale score at 6 hours in the CTEP group was 3.1 ± 2.8 and in the SILS TEP group 2.8 ± 0.8. The mean cosmetic result was 4.1 ± 0.9 in the SILS TEP group. Conclusion: Laparoscopic repair of inguinal hernias is associated with good results in both techniques. SILS TEP inguinal hernia repair using conventional laparoscopic instruments is a safe and feasible alternative to CTEP in experienced hands. The outcomes of SILS TEP for operation time, postoperative complication, hospital stay, time until return to normal activity, and rate of conversion to open are comparable to CTEP. However, the approach provided an advantage in terms of cosmesis and postoperative pain. Clinical significance: SILS TEP although having a learning curve and difficult to use in large/complete groin hernias is a good technique for use in small hernias using routine laparoscopic instruments in a resource-limited setting with significant outcome in terms of cosmesis.

Aim: In April 2020 routine elective surgery in England was suspended in response to coronavirus disease-2019 (COVID-19). Low COVID-19 infection and mortality rates in the South West of England allowed urgent elective surgery in Plymouth to continue with the necessary precautions. The aim of this study was to assess outcomes following elective laparoscopic cholecystectomy during the initial phase of the COVID-19 pandemic. Materials and methods: Records of 54 consecutive patients undergoing urgent elective laparoscopic cholecystectomy between March 25, 2020, and June 25, 2020, were analyzed retrospectively. Patients were telephoned after 30 days. All patients underwent COVID-19 swab testing 24 to 72 hours prior to surgery and during admission if clinically indicated. The primary outcome measure was COVID-19 related morbidity. Secondary outcome measures were non-COVID-19 related morbidity, mortality, and length of hospital stay. Results: Fifty-four patients [19 male, 35 female; median age 59 years (20–79); median body mass index (BMI) 31 kg/m² (22.9–46.8); median ASA 2]underwent laparoscopic cholecystectomy during the study period. Fifty-one patients (94%) were of White-British ethnicity. One patient tested positive for COVID-19 preoperatively. There were no COVID-19 diagnoses postoperatively and no COVID-19 related morbidity. There were no deaths at 30 days. Forty-four patients (81%) had a day-case procedure. Forty-two (78%) procedures were performed by a supervised trainee. Conclusion: Elective laparoscopic cholecystectomy can be performed safely and training maintained in areas of low COVID-19 prevalence with the necessary precautions. Clinical significance: This small study provides some evidence to aid decision-making around the provision of elective surgical services during this ongoing pandemic.

The incidence of ectopic pregnancy, which constitutes about 2% of all pregnancies, is increasing due to increasing risk factors and availability of better diagnostic modalities. It is one of the important causes for maternal mortality in the first trimester. Some ectopic pregnancies, usually the ones in the uterus, may be missed in the initial ultrasound evaluation and require high index of suspicion. If ultrasound is inconclusive, MRI may help in the diagnosis. Management modalities include expectant, medical, combined medical/surgical, and surgical treatment. In patients opting for surgery, laparoscopy provides excellent visualization of the pathology, decreases maternal morbidity, and improves the fertility outcome in future pregnancies. Here we are discussing four rare ectopic pregnancies: two cases of cesarean scar pregnancy, one case of interstitial pregnancy, and one case of rudimentary horn pregnancy and their successful management by laparoscopy.