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Introduction: Management of patients with suspected bile leak or bile duct injury after laparoscopic cholecystectomy is challenging. Early laparoscopy in these groups of patients will benefit in terms of diagnostic as well therapeutic purpose. Objective: This study is done to assess utility of early re-laparoscopy in suspected bile duct injury in early postoperative period following laparoscopic cholecystectomy. Methodology: It is a descriptive study of all consecutive patients who underwent diagnostic as well therapeutic re-laparoscopy when required in suspected bile duct injury in early postoperative laparoscopic cholecystectomy that is within 72 hours of presentation. Study was conducted over a period from June 2019 to December 2020 at Kathmandu medical College, Sinamangal, Kathmandu, Nepal. Relaparoscopic operative findings and therapeutic intervention done were recorded. Result: The mean age at presentation was 34.6 years and male to female ratio was 1:1.8. During the study period, eleven patients underwent re-laparoscopy out of which one had no bile leak. Six out of ten were managed definitely in the same time of re-laparoscopy. However, four patients underwent definitive biliary reconstruction as they had already undergone arteriography in CT scan. Conclusions: Early re-laparoscopy may be beneficial prior to detail radiological investigations in suspected bile leak patients. Early re-laparoscopy can be an effective diagnostic as well therapeutic tool; and also it can help in planning for definitive repair in later date.

Hepatic hydatid cyst has different clinical presentations; its management is done by various modalities. This article reviews the etiology of the disease and its classification and diagnostic modalities. The medical, minimal invasive and surgical approach of its treatment, possible complications, and the management of such complications are discussed from a surgeon’s perspective.

Background: In pancreatic ductal adenocarcinoma, standardised concepts of radical surgical clearance have not been universally applied. Objectives: The main objective of this study is to reveal the status of circumferential resection margin of the apical tissue of the triangle namely the confluence of SMA and coeliac trunk in relation to circumferential resection margin of triangle tissue bounded by superior mesenteric artery, common hepatic artery and portal vein when performing the TRIANGLE operation. Methodology: This was a hospital-based cross-sectional study conducted at Kathmandu Medical College and Teaching Hospital, from September 2020 to December 2020. The study was done after ethical clearance from the Institutional Review Committee of Kathmandu Medical College. All consecutive patients who were subjected for Whipple’s operation for pancreatic head and uncinate process were included. Results: Fifteen patients underwent the “TRIANGLE” operation during a four months period. Median age of the patients was 65 ± 13.34 years (range 32–84 years). Medianpreoperative BMI 21.75± 2.5 (range: 18 to 26.7). Regarding histopathological results, an R0 resection was achieved in 9/15 patients. In nine patients,circumferential resection margin(CRM) of both the apical tissue and the rest of the triangle was negative. In the next three patients, the CRM of apical tissue was negative but the triangle tissue was positive whereas in the other three patients CRM of both the apical tissue and the triangle tissue were positive. Conclusion: This study emphasises the importance of inclusion of apical tissue dissection at the confluence of SMA and coeliac trunk in order to achieve R0 resection without significant short-term morbidity. However, a long-term follow is awaited.

Background: Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. Most of gall bladder cancers are detected incidentally only after pathological examination of the excised surgical specimens. In this study we investigated the characteristics of incidental gallbladder cancers in our center. Material & methods: We retrospectively reviewed all of the cholecystectomy specimens in sent for histopathology following laparoscopic cholecystectomy in the study period from January 2015 to October 2019. Clinicopathological characteristics were extracted from the patients' clinical charts, which included symptoms, radiological findings, laboratory data, and surgical procedures as well as outcome. Results: We identified 6 cases of incidental gall bladder cancer, consisting of 4 women and 2 men ranging in age from 28 to 77 years (mean age 60.5 after pathological study of 1530 resected gall bladders. Out of the 6 cases, 1 case was carcinoma in situ of gall bladder, 1 was T1b and other 4 cases were T2 carcinoma. Conclusions: The rate of incidental gallbladder carcinoma in our study was 0.39%. This lower incidence could in part be due to increasing use of routine laparoscopic cholecystectomy for symptomatic gallbladder. This strategy of increased early intervention further adds to the advantage of higher chances of gallbladder cancer detection in early stages, and thus better prognosis.

Pancreatic injury following blunt trauma abdomen is presentation with significant morbidity and mortality. Our first case here is the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade V pancreaticoduodenal injuries following penetrating injury managed with pancreaticoduodenectomy and the second case is blunt trauma to the abdomen with pancreatic tail transection which is American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade III that was managed with Endoscopic Retrograde Cholangiopancreaticography (ERCP) and pancreatic duct stenting. The outcome depends on early diagnosis and needs a high index of suspicion due to subtle clinical and radiological findings initially. Hemodynamically unstable patients may have other associated visceral and vascular injuries, and damage control strategy will be a suitable option. Same sitting resection procedures like pancreaticoduodenectomy are rarely performed. Pancreatic injuries can often be managed non-operatively with percutaneous drainage and pancreatic duct stenting.

Background: Total pancreatectomy was abandoned for decades because of high peri and post-operative morbidity and mortality. However, with better peri-operative outcome and post-operative management of exocrine and endocrine insufficiency, the hesitancy to perform total pancreatectomy has been disappearing. Objectives: This study aims to study exocrinal and endocrinal effects of total pancreatectomy without Islet cell auto-transplantation and compare quality of life index among total pancreatectomy with Whipple patients. Methodology: This is a prospectively conducted matched-pairs study. Group A underwent total or completion pancreatectomy after non-salvageable complications of Whipple operation. A matched-pairs analysis of quality of life index of these patients by using SF-36 questionnaire were compared with Group B who underwent Whipple operation during the same period of time, according to age, gender and pre-operative diagnosis. Results: In four years (from February 2016 to February 2020), 160 patients underwent Whipple operation. The mean age of the patients was 59.9 +/-14.3 years. A total of nine patients underwent total pancreatectomy, among which two had per-operative decision of total pancreatectomy and seven had completion pancreatectomy. Median post-operative hospital stay was 11 days with two mortalities. Median follow-up of 12 months and quality of life index of total pancreatectomy patients were comparable to Whipple patients, although a few single quality of life items were reduced. Conclusion: Exocrinal pancreatic supplements and long acting insulin have augmented control of diabetes despite of not using Islet cell auto-transplantation. Quality of life index of total pancreatectomy patients were comparable to that of Whipple patients. Hence, this study signifies the importance of completion pancreatectomy following non-salvageable complications after Whipple operation in order to save life.

Background: Indocyanine green fluorescence image has been used in hepatobiliary surgery, which was mainly started by Japanese surgeons to visualize hepatobiliary structures probably because it is regarded as a reagent for estimation of hepatic function. Objectives: The objective of this study is to see the feasibility of use of indocyanine green in our setting during hepatobiliary surgery and its potential applications in the surgical treatment of benign and malignant liver pathology along with its selective use during difficult cholecystectomy to visualize extrahepatic biliary radical. Methodology: This is a prospective cross sectional observational study performed including all consecutive patients who were posted for liver resection, both benign or malignant and selectively used in biliary surgery when biliary anatomy was uncertain. Results: A total of thirty-nine patients had usage of indocyanine green, with a mean age of 51.6 ± 11.6 years (range, 31-75 years). In all our patients we were able to visualize the biliary system and liver parenchymal lesion.In the selective use of indocyanine green during difficult biliary anatomy during laparoscopic cholecystectomy 15/400 (3.75%), we were able to delineate biliary tree and hence five patients (1.2%) had to be converted to open cholecystectomy further preventing injury to the bile duct. Conclusion: Indocyanine green fluorescence imaging can be used safely and easily to identify liver tumors, hepatic segments, and extrahepatic bile ducts in real time during open and minimally invasive surgery. This allows surgeons to map the anatomical variations, status of resection margin and prevent surgical complications.

Introduction The advent of neoadjuvant therapy in the management of pancreatic adenocarcinoma has significantly improved the prognosis of the disease. Nevertheless, the only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. We aim to evaluate the feasibility of a novel technique, namely, the periarterial divestment, which has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction. Materials and methods In this single-center, retrospective, descriptive, cross-sectional study done between August 2019 and July 2021, seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant therapy were included. Arterial divestment was performed in six of seven patients and arterial reconstruction was performed in one of the patients. The data on perioperative and the early oncological outcome were recorded. Results Five patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent superior mesenteric artery reconstruction due to deeper tumor infiltration into the arterial wall. The intraoperative frozen section of periarterial tissue was positive in three cases and the final histopathological specimen after the divestment showed a positive margin in two of the cases. The clinically significant postoperative pancreatic fistula was noted in two patients, and one patient experienced grade C post-pancreaticoduodenectomy hemorrhage due to a hepatic artery pseudoaneurysm. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea. There were no mortality and the median postoperative hospital stay was seven days. Conclusion The need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient's oncological outcome. However, further validation of this technique must be done by well-designed studies with a greater sample size.

Not available.

Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used for pancreatic head and peri-ampullary tumors. The aim of our study was to determine the frequency of various approaches of superior mesenteric artery pancreaticoduodenectomy along with its postoperative complications in a tertiary care center. Methods: This is a descriptive cross-sectional study of patients undergoing superior mesenteric artery first pancreaticoduodenectomy with different approaches conducted at Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal, from May 2018 to April 2020. Ethical approval was taken from the Institutional Review Committee (reference no: 310520193). The whole sampling method was adopted. Thirty-four patients undergoing a superior mesenteric artery first pancreaticoduodenectomy at our center with different approaches were included in the study. The data analysis was done in the Statistical Package for the Social Sciences version 20. Results: For 34 patients chosen for the study, the male: female ratio was 1.6:1, with a mean age of 53.7 years. The medial uncinate approach was done in the majority of the cases, 26 (76.4%), whereas the inferior infracolic (mesenteric) approach was done in 1 (2.9%) case. Regarding postoperative complications, Clavien Dindo grade 3 and grade 4 were present in 11 (32.3%) patients, pancreatic fistula (Grade B and C) was observed in 6 (17.6%) patients, and mortality occurred in 2 (5.8%). The mean hospital stay was 16±9 days. Conclusions: Superior mesenteric artery first pancreaticoduodenectomy with a different approach can be performed with acceptable morbidity and mortality. Early determination of resectibility is achieved in selected cases.

Background: Laparoscopic approach for early gall bladder cancer (T1b and T2) has been seen to have equal or better early outcomes and late outcomes in terms of overall survival rate and recurrence rate.Methods: This is a prospective cross sectional observational study performed including all consecutive patients who were diagnosed with gall bladder cancer by a single surgical team from August 2018 to February 2020 at Kathmandu Medical College Teaching Hospital or referred from outside for completion extended cholecystectomy where laparoscopic cholecystectomy was done in some other centre.Results: The mean age of the patients was 51.01±9.42 years in the laparoscopic extended cholecystectomy (N=10) group and 49.6±8.35 years in the open extended cholecystectomy (N=10) group (p value=0.711). Conversion rate was 20% in laparoscopic group. The operative time was longer in the laparoscopic group (287 +/-66.50 minutes, 120.0 to 446 minutes vs. 200+/-66.50 minutes, 100 to 405.0 minutes; p< 0.004.However, the laparoscopic extended cholecystectomy group showed faster time to oral intake and time to first passage of flatus and had shorter hospital stay by 2.2 days (4.8+/-0.78 days) than open approach 7+/-0.81 days.(p value=0.00).There were no significant differences between the groups in the tumour size (p=0.079) and number of harvested lymph nodes 9.3 (5 to 13) in laparoscopic group vs. 11.2 (8 to 15) in open extended cholecystectomy group (p=0.250).Conclusions: Laparoscopic extended cholecystectomy is feasible in early gall bladder cancer along with achievement of oncological safety.Keywords: Gall bladder cancer; laparoscopic extended cholecystectomy; open extended cholecystectomy

Background: With more sphincters preserving surgery being performed for distal rectal cancer, these have been associated with clusters of symptoms experienced by the patient after reversal of diverting ileostomy collectively known as low anterior resection syndrome.Objective: Our objective is to know incidence of Lower Anterior Resection (LAR) syndrome in different phase of time in our context using low anterior resection symptom score translate in Nepali language.Methodology: This is an observational descriptive study conducted at Department of Surgery, Kathmandu Medical College and Department of Clinical Oncology, Bir Hospital, Kathmandu from Jan 2015 till Jan 2017. All patients who had undergone low and ultra low anterior resection for middle and low rectal cancer respectively after a long course of neo adjuvant concurrent chemo radiotherapy, having undergone a reversal of diverting ileostomy after 6 weeks of primary surgery were included. A Nepalese version of low anterior resection score was developed after translation from English and scoring was done on 30th day, at the end of 6 months and 1 year postoperative following reversal of ileostomy.Results: Out of 43 consecutive patient 100 % of patients had features of major low anterior resection syndrome during 30 days of ileostomy reversal. However, 46.5% patient showed major low anterior resection syndrome during 6 months of follow up and that decreased to 34.9% showed major LAR syndrome upon one year of follow up.Conclusions: The Low anterior resection syndrome score converted in Nepali language is feasible to use and helps in comparing the functional results of reconstruction after low or ultralow anterior resection and our study have shown improvement in score with time. Journal of Kathmandu Medical College,Vol. 7, No. 2, Issue 24, Apr.-Jun., 2018, page: 59-63

Background: Total mesorectal excision has been gold standard since 1978. But standardization of surgery with quality assurance of total mesorectal excision specimen has been a challenging issue in developing countries. However, quality of macroscopic total mesorectal excision can be graded immediately by operating surgeon before specimen has been fixed in formalin and photographic documentation of gross specimen by surgeons is possible and practical.Objective: To grade macroscopic total mesorectal excision specimen by surgeon and document it photographically and compare it with reporting received from pathologist. Methods: A prospective observational study conducted from Jan 2014 to Jan 2016 at Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal. All consecutive patients with rectal cancer (upper/middle and lower) without distant metastasis were included. Immediate after surgery, macroscopic specimen of TME were graded by operating surgeon and photo-documentation with one anterior, one posterior and two right and left lateral views of total mesorectal excision photos were taken and documented with printed form along with operative notes.Results: There were 40 patients with rectal cancer who underwent surgery during this period. Among those patients, the median age was 25 years of which 30% were females. Twenty-four patients underwent low anterior resection whereas thirteen had ultralow anterior resection and three had abdominal perineal resection. All patients had photo documentation. Complete mesorectal excision was seen in 36 patients and four patients had near complete total mesorectal excision when graded by surgeons. However, pathologist reported six (16.6%) patients having near complete mesorectum among those which had been graded as complete by surgeons.Conclusion: Grading of macroscopic total mesorectal excision specimen by surgeon is feasible and with use of photographic documentation, it can help to assess the quality of surgeons work and can be a good tool for feedback for surgeons to improve.

Background: Acute pancreatitis is a common and challenging disease that can develop both local and systemic complications. According to the Atlanta classification, local complications include peri-pancreatic collection, acute necrotic collection, pseudocyst and walled-off necrosis.Methods: A hospital-based retrospective study was conducted in the department of surgery at Kathmandu medical college teaching hospital. Patients were recruited using purposive sampling method and those who underwent laparoscopic, retroperitoneal or open surgical procedures for the management of local complications of acute pancreatitis from June 2017 to July 2021. The indication, perioperative outcome and associated complications were evaluated in all the cases.Results: Between June 2017 to July 2021, 432patients were admitted to the surgery department with acute pancreatitis or with complications of acute pancreatitis. Twenty-one patients required surgical intervention in the form of external drainage, cysto-enterostomy, VARD or open necrosectomy due to failure of endoscopic or radiological intervention or due to positions of lesions being inaccessible to these techniques. All patients had clinical improvement following surgery with an acceptable complication rate given the severity of the disease.Conclusions: Although various endoscopic techniques are now available to manage the pancreatic fluid collection and pancreatic necrosis, surgery remains essential in managing the disease.

Background: Bleeding oesophageal varices are a major complication of portal hypertension following liver cirrhosis. Child Pugh’s score has been used as a prognostic tool while managing a patient with liver cirrhosis.Objective: To clinically correlate Child Pugh’s score and oesophageal varices in upper gastrointestinal endoscopy in cirrhotic patient.Methods: This is a prospective descriptive study done from January 2014 to January 2015. Cirrhotic patients who were referred for upper gastrointestinal endoscopy with or without history of upper GI bleeding were included. Patients were categorized according to Child Pugh’s score into A, B, C and correlated with their endoscopic finding of grading of varices.Results: A total of 50 cirrhotic patients underwent upper gastrointestinal endoscopy during one year. Out of which 60% were in Child Pugh’s category A, 30 % in category B and 10 % in category C. Among them 62% had grade I varices, 20% had grade II varices and 18 % had grade III varices. Those who presented with history of hematemesis had higher grades of oesophageal varices in comparison to those without hematemesis.Conclusion: Cirrhotic patients with higher Child Pugh’s score had higher grades of oesophageal varices leading presentation with hematemesis. Hence, routine screening of cirrhotic patient is necessary before the development of varices.

Background: Surgical complications represent a signifi cant cause of morbidity and mortality with the rate of major complications after inpatient surgery in industrialized countries. The purpose of this study was to summarize experience with surgical checklist use and efficacy for improving patient safety.Objective: To evaluate the compliance of implementation and outcome of World Health Organization Surgical checklist use in surgical practice at Kathmandu Medical College.Methods: This is a prospectively designed descriptive study including adult patients undergoing surgical procedure in Kathmandu Medical College Hospital from June 2013 till June 2014. Obtained data on compliance of World Health Organization safety checklist use by practitioner and its outcome in patient’s safety were assessed using SPSS version 15.The surgeries that underwent under local anesthesia were excluded from the study.Results: World Health Organization checklist was implemented in all 288 patients undergoing various surgical procedures with acceptable compliance by all 41 practitioners. Although it had no impact on correctable mortality and morbidity, frequent instrument malfunctions were offi cially recorded. Attitudes towards use of checklist was good as 100% of participants wanted use of checklist if they were having operation on themselves. However 22% of the participants complained of extra time needed to fi ll the checklist. Time taken to fi ll up sign in column of checklist was on average from 120 to 150 seconds (mean 135±5secs) and sign out was 80-100 seconds (mean 95±6secs). Only 69% of the participants were available for sign out. Scissor malfunction was detected in 4(1.38%) cases and operation theatre table related problem was found in one case (0.34%).Conclusion: Implementation of World Health Organization Surgical Safety Checklist can be done with acceptable compliance and instrumental malfunction was well documented.

Background: Pilonidal sinus disease is a common condition usually seen in young adults. Although several methods of treatment have been described, but all have been associated with high recurrence rates. This study was carried out to evaluate the advantages and results of rhomboid excision and Limberg flap reconstruction in the management of pilonidal sinus disease.Objective: To evaluate the advantages and results of rhomboid excision and Limberg flap reconstruction in the management of pilonidal sinus diseaseMaterial and Methods: This was prospective descriptive study conducted in Unit III, Department of Surgery, Kathmandu Medical College Teaching Hospital from August 2013 to August 2015. First 50 patients with diagnosis of pilonidal sinus were included .Exclusion criteria was patients with pilonidal abscess.Results: Total 50 patient were included in 2 years time. Mean age was 23.48 ± 3.9 years with all male patients only. Median duration of surgery was 32 ± 4.4 minutes .Median time for normal activities was 21± 3.9 days and median follow up time was 18±8.5 months. No recurrence was noted till then. Post surgery, patient applied hair removal cream: 44%, hair shaving: 34% and laser therapy for hair follicles: 22%.Conclusion: Modified Limberg flap is better option for pilonidal sinus with least recurrence. However, post surgical counseling for hair removal is very important in order to prevent recurrence and should be multidisciplinary approach along with dermatologist colleagues.

Background: Laparoscopy surgery trials are small and unconvincing at present and are limited to higher centers. The objective of the study is to determine the clinical features, prevalence of site of hydatid cyst and complications of this modality of this treatment.Methods: A cross sectional study was carried out in all patients with one or two hepatic hydatid cyst who underwent laparoscopic management in KMCTH from January 2013 to March 2015 were included in the study. Aspiration, deroofing and evacuation of the hydatid cyst were done.Results: Twenty six patients underwent laparoscopic management for liver hydatid cysts. Males were seven (65.38%) and females were 9(34.61%).The mean age was 35.5±13.1 years (range 21-55years.) The commonest complaint was pain and discomfort in 13(50%) patients and lump in 6(13.06%) patients. Twenty four (92.3%) patients were successfully treated with laparoscopic approach. Two (7.69%) patients had to be converted to laparotomy because of dense adhesions and bleeding. Mean operation time was 43.6±10.6 minutes. Two (7.69%) patients had port site infection. One (3.84%) patient had bile leak and no recurrence and mortality in our series.Conclusions: Laparoscopic management of liver hydatid cyst was safe and effective in selective group of patients in equipped hospital.

Elderly population is growing because of increasing life expectancy. Decision-making for major surgery like pancreaticoduodenectomy in this group is challenging. Therefore, we evaluated the feasibility of this procedure by comparing perioperative outcomes in Septuagenarians and Octogenarians patients. From August 2017 to December 2019, 18 consecutive patients who underwent pancreaticoduodenectomy were enrolled. These patients were divided into two groups (group1 – septuagenarians and group 2 – octogenarians). A comparative study between two groups was done regarding perioperative outcome and early complications. 18 patients were enrolled, 10 patients (55.6%) were septuagenarians (70-80 years) and 8 (44.4%) patients were Octogenarians (>80 years). There was no significant difference in the rate of surgical and medical complications between the two groups. Furthermore, there were no significant differences in risk factors, blood loss and operating time between the groups. Overall mortality in the study is 5.5%. Pancreaticoduodenectomy is feasible treatment option in septuagenarians and octogenarians with the help of multidisciplinary approach. Age alone should not be considered as decision maker for pancreaticoduodenectomy.

Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the biliary pathway. It is a time honoured, durable, less resource intensive and a definitive procedure. Objectives: The aim of this study was to evaluate the indications of Hepaticojejunostomy and to assess the outcome of surgery following change in surgical technique of Hepaticojejunostomy. Methods: All patients who underwent RYHJ from Magh 2067 (January 2011) till Ashad 2071 (July 2014) in a single surgical unit at the Department of Surgery, Kathmandu Medical College Teaching Hospital were included. Demographics of the patient, indications for surgery, type of surgery, hospital stay and duration of drain placement were evaluated. Since, this is a prospective descriptive study, only mean value was calculated for age, hospital stay and duration of drain placement using SPSS Statistics 17.0 for statistical analysis. Results: Twenty patients underwent RYHJ during the study period. Fifteen percent (n=3) were done for malignant diseases. The most common indication was choledocholithiasis (n=8, 40%) followed by choledochal cyst (n=3, 15%) and bile duct injury (n=3, 15%). The morbidity was minimal. The mean duration of drain in situ was four days (range one to 14 days) and the mean hospital stay was six days (range two to 15 days). Prolonged drain placement and hospital stay was noted in two patients with malignant diseases. However, they were non bilious in nature. We encountered no mortality. Conclusion: Roux-en-Y Hepaticojejunostomy (RYHJ) is a common and safe method of biliary reconstruction. The indication of the procedure is varied and wide.DOI: http://dx.doi.org/10.3126/jkmc.v3i3.12247Journal of Kathmandu Medical CollegeVol. 3, No. 3, Issue 9, Jul.-Sep., 2014, page

Introduction: Safe dissection of Calot’s Triangle is important during the performance of laparascopic cholucystectomy. The purpose of the study is to determine the frequency of demonstrable Rouviere’s sulcus in patients with symptomatic gall stones and its role in safe dissection in Calot’s triangle. Methods: This is a prospective descriptive study design done in Department of surgery, Kathmandu Medical College Teaching Hospital from Jan 2013 to Jan 2015. Patients who were posted for laparoscopic cholecystectomy were included. During laparoscopy, Rouviere’s sulcus was noted in the operative note and classified according to following: Type I: Open type was defined as a cleft in which the right hepatic pedicle was visualized and the sulcus was opened throughout its length. Type II: if the sulcus was open only at its lateral end. Type III If the sulcus was open only at its medial end. Type IV: Fused type was defined as one in which the pedicle was not visualized. Results: A total of 200 patients underwent laparoscopic cholecystectomy during period of 2 years. Out of which Rouviere’s sulcus was visualized in 150 patients (75 %).Type I (open type) was commoner in 54%, type II in 12%, Type III in 9% and type IV (fused type) in 25%. Conclusions: Rouviere’s Sulcus is an important extra biliary land mark for safe dissection of Calot’s triangle during laparoscopic cholecystectomy. Keywords: Rouviere’s Sulcus, laparoscopic cholecystectomy, bile duct injury.

INTRODUCTION: Use of laparoscopic surgery has demanded principles of less trauma of access hence less scar and so probably less complications. Hence conventional laparoscopic surgeries were tried with natural orifice transluminal surgery (NOTES) and then single incision laparoscopic surgery (SILS). With refinement in instruments and surgeons skills SILS have bridged up between conventional and NOTES in order to quench the desire of less or no scar at all. METHODS: Comparative case control study between conventional laparoscopic cholecystectomy and SILS in public teaching hospital. RESULTS: Total 20 patients underwent SILS cholecystectomy and 20 underwent conventional cholecystectomy and found that no difference between both in terms of post operative pain score, hospital stay and post operative wound infection except significant difference in mean operative time and patient's level of satisfaction was less in patient with SILC if were subjected to pay for instruments in order to maintain cosmesis. CONCLUSIONS: Though SILS have gained rapid acceptance in surgical fraternity, large number of randomized controlled trials are necessary to show its benefit over conventional laparoscopic cholecystectomy. Keywords: cholecystectomy, conventional, laparoscopy, single incision, surgery

INTRODUCTION: This study evaluates if addition of information leaflet after the usual verbal counseling improves the level of understanding of patients undergoing surgery about their disease, the need for surgery and its complications. METHODS: It is a prospective observational case control study in which the control group receives verbal counseling only and the study group is given an information leaflet in addition to the verbal counseling after random allocation. An interviewer (surgical resident) interviews both the group using a set questionnaire. The answers are scored and added to give total marks. RESULTS: There were total 114 patients undergoing gall bladder surgery with 59 in the study group and 55 in the control group. The level of understanding was good or satisfactory in 18.2 % in the control group compared to 76.3% in the study group (P < 0.000). This statistically significant improvement was seen even among illiterate group when analyzed separately. CONCLUSIONS: Addition of information leaflet significantly improves the patients understanding of their disease irrespective of their education status. KEYWORDS: education level, informatino leaflet, informed consent, understanding.

Inguinal vasal obstruction following hernia repair is related to either direct injury to vas or ischemic injury leading to delay stricture. Not much has been described regarding the long term impact of synthetic mesh as far as integrity of the cord structure is concerned. Here, we report a case that underwent mesh explantation for posthernioplasty inguinodynia as well as recurrence and found to have total occlusion of the lumen of vas segment adherent to the explanted mesh on microscopic examination.Key Words: inguinal hernia, polypropylene mesh, vas obstruction

Background : Peptic ulcer disease is one of the most common diseases prevalent in developing country like Nepal and with availability of endoscopy there have been increase in diagnosis and therapeutic use of endoscopy. Objective: The aim of this study is to investigate the prevalence of peptic ulcer disease in patient who came for upper gastrointestinal endoscopy in Kathmandu Medical College Teaching Hospital. Materials and methods : All patients who were referred to department of endoscopy from outpatient department (OPD) and inpatient department with symptoms like dyspepsia, upper GI bleeding were included from August 2004 to August 2008. Results : A total of 2761 patient were evaluated, with mean age group of 40.57 years (range 8- 95 years) and with sex distribution of male 1353 (49%) and female 1408 (51%) and racial difference into Aryan 2050 (74.2%) and Mongoloid 771 (25.8%). There were 983 patients (35.60%) with peptic disease which includes erosive gastritis, non erosive gastritis, duodenitis and gastroduodenitis without obvious ulcer. The prevalence of peptic disease with or without ulcer was more common in age group of 20- 49 years (n= 764, 27.67 %) with 70 patient with gastric ulcer (2.5%) and 50 patient with duodenal ulcer (1.8%). There was no significant racial difference among incidence of peptic ulcer (P value= 0.527). Conclusions : Peptic ulcer disease is a significant cause of morbidity in urban population of Nepal with more prevalent of erosive diseases in productive age group (20-49 years). However both male and female have equal incidence of peptic ulcer disease and there was no significant racial difference in its incidence. Key words: Peptic ulcer diseases; Oesophago-gastroduodenoscopy; H. pylori DOI: 10.3126/kumj.v7i2.2706 Kathmandu University Medical Journal (2009) Vol.7, No.2 Issue 26, 135-138