Objective: To determine the frequency of post-operative morbidity in terms of wound infection, wound dehiscence, gall bladder fossa collection and post- operative pancreatitis in patients with Mirizzi syndrome undergoing cholecystectomy. Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of General Surgery, Combined Military Hospital, Peshawar Pakistan, from Apr 2019 to Feb 2022. Methodology: A total of 150 patients of age 20-70 years of either gender, diabetics and undergoing cholecystectomy for Mirizzi syndrome were included. Cholecystectomy was done in every patient. After surgery patients were shifted to post-surgical wards and were evaluated for wound infection, dehiscence within 24 to 48 hours while their stay in the ward. Ultrasound was performed after 24 hours to check for Gall bladder fossa collection. After 48 hours of procedure, patients were discharged and were followed in OPD for up to 2 months and Post-op morbidity was noted. Results: Out of 150 patients of Mirizzi syndrome studied, 32(21.3%) showed any one of more complications while 128(78.7%) did not show any complication. Mean age of the study participants was 41.45±8.75 years. Wound infection was found in 16(10.6%) patients, wound dehiscence in 07(4.6%) patients, gall bladder fossa collection in 03(2%) patients and post-operative pancreatitis in 06(4%) patients. Method of surgery had statistically significant relationship with presence of complications among study participants (p-value<0.05). Conclusion: This study concluded that these complications were found in considerable no of patients managed for Mirizzi syndrome. Male patients and patients managed with open surgical method ....

Objective: To compare the frequency of post-op “surgical site infection” in uncomplicated laparoscopic cholecystectomies in patients who received post-op antibiotics versus those who did not. Study Design: Quasi-experimental study Place and Duration of Study: Department of General Surgery, Combined Military Hospital, Rawalpindi, Pakistan from Jun 2022 to May 2023. Methodology: A total of 342 patients [171 in the Antibiotics-Group and 171 in the No-Antibiotics-Group] fulfilling the inclusion criteria who underwent uneventful laparoscopic cholecystectomy were included in the study. In all these patients, baseline characteristics were documented. Patients in Group-A were given antibiotic therapy post-operatively, while patients in Group­-B were not given antibiotics after the operation. Patients in both groups were followed up on day 10 after the surgery to assess for “surgical site infection. Results: In our study, the mean age of the study population was 38.41±10.12 years. There were 127(37.13%) male participants, while 215(62.87%) participants were female. The mean body mass index (BMI) was 31.14±4.49 kg/m2. Composite frequency of “surgical site infection” was 38(11.10%). In patients who were given post-op antibiotics, the frequency of “surgical site infection” was 16(9.35%), while in patients who did not receive any antibiotics after the surgery, the frequency of “surgical site infection” was 22(12.86%), (p=0.302). Conclusion: Antibiotic therapy should be reserved for patients who develop “surgical site infection” instead of being used in all patients.

Objective: To compare the incidence of port site infection with and without use of retrieval bag for extraction of gall bladder in elective laparoscopic cholecystectomy. Study Design: Quasi experimental study. Place and Duration of Study: Combined Military Hospital, Bahawalpur Pakistan, from Oct 2019 to Dec 2020. Methodology: Sixty patients were enrolled in this study after screening through inclusion and exclusion criteria. There were all planned to undergo laparoscopic cholecystectomy and were randomly allocated into two equal groups. Group A included patients in whom retrieval bags were used and Group B comprised patients in whom extraction bags were not used. All patients were followed up by clinical examination for development of infection at the port site till 10th post-operative day. Frequency of clinical development of infection at gall bladder extraction port site was noted for every group. Result: Mean age of the patients was 41.00±13.70 years with an age range of 22-85 years. Among all patients, 9(18%) were male and 51(82%) patients were females. In Group A, 2 patients developed port site infection clinically, whereas in Group B, 3 patients developed infection. The p-value was calculated and was found to be 0.64. These results are not statistically significant showing that use of retrieval bag in elective laparoscopic cholecystectomy does not statistically decrease the occurrence of port site infection. Conclusion: Use of retrieval bag does not significantly affect the development of port site infection from where gall bladder is extracted.

Objective: To compare the frequency of perioperative complications in patients with acute cholecystitis who undergo “early laparoscopic cholecystectomy” versus those who have “interval laparoscopic cholecystectomy”. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Aug 2022 to May 2023. Methodology: This study included all the patients who had acute cholecystitis and were admitted to the surgery ward for its management. Half of the patients were selected who underwent early laparoscopic cholecystectomy, while the remaining half had interval laparoscopic cholecystectomy. The frequency of perioperative complications was noted in both groups. Results: In our study, we included 50 patients (25 in group-A, who had “early laparoscopic cholecystectomy” while 25 in group-B, who had “interval laparoscopic cholecystectomy”). The mean age of the study population was 43.70±5.91 years. 18(36.00%) were male while the remaining 32(64.00%) were female. In our study, frequency of perioperative complications in group-A was injury to common bile duct 2(8.00%), biliary leak 3(12.00%), haemorrhage 4(16.00%) and conversion to open cholecystectomy 1(4.00%) while in group-B these were 0(0.00%), 1(4.00%), 2(8.00%) and 0(0.00%), respectively [with corresponding p-values of 0.149, 0.297, 0.384 and 0.312, respectively. Conclusion: Interval laparoscopic cholecystectomy is a better surgical treatment option for patients with “acute cholecystitis”.

Objective: To compare the analgesic efficacy of Local Anaesthetic infiltration with Bupivacaine at Trocar site in Laporoscopic Cholecystectomy when injected preoperatively vs postoperatively. Study Design: Quasi-experimental study. Place and Duration of Study: Department of General surgery, Combined Military Hospital, Rawalpindi Pakistan, from May to Nov, 2016. Patients and Methodology: Patients meeting the inclusion criteria were randomly divided into two groups using coin method. Group A received pre-operative injection of Bupivacaine infiltrated at the trocar sites. Patients in Group B received the similar dosage post-operatively. The pain of the patients was assessed post-operatively using Visual Analog Score (VAS) at 6, 12 and 24 hours and compared. Results: A total of 190 patients were equally divided into Group A and B (95 each). The mean age was 46±13.77 years in Group A and 43±14.80 years in Group B.23.68% (n=45) of patients were aged between 12-24 years, 13.15% (n=25) were of 25-36 years, 22.63% (n=43) were aged 37-48 years and 40.52% (n=77) of the patients were between the age of 49-60 years. 75.78% (n=144) of patients were males, while 24.21% (n=46) were females. The Mean±SD VAS post-operative pain scoring Group A and Group B was 4.5±0.04 vs 5.0± 0.40, respectively. The p-value was <0.001and the difference is statically significant. Conclusion: We concluded that the use of pre-operative local anesthesia helps reduce post-operative pain in patients undergoing laparoscopic cholecystectomy.

Objective: To evaluate the role of physiological and operative severity score for the enumeration of mortality and morbidity in predicting mortality in patients undergoing emergency laparotomy. Study Design: Prospective Comparative study. Place and Duration of Study: General Surgical Ward 1 and 2, Combined Military Hospital, Rawalpindi, from Jan to Aug, 2018. Methodology: Adult patients between 12 and 60 years of age admitted from Emergency Department in Surgical ward who underwent emergency laparotomy within 48 hours of admission were enrolled in the study. Physiological and operative scores were measured for Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity and predicted mortality calculated. Patients were stratified into three groups according to the predicted mortality. Patients were then followed up 30 days post-operatively and mortality noted. Observed to predicted (O:P) mortality was calculated. Results: A total of 94 patients were enrolled out of which 85 were followed up. All patients were male with a mean age of 56.5±16 years. Most common indication for surgery was intestinal obstruction and gut perforation. Mean duration of admission was 7.97±3.5 days. Out of 85 patients 13 patients died within 30 days of surgery which equals a crude mortality rate of 15.2%. Observed to predicted mortality ratio (O:P) was 0.65. Conclusion: Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity slightly overpredicted the mortality in or study. Still it is a useful tool in risk stratification of patients according to expected outcome and...

Objective: To compare the effects of preemptive intraperitoneal instillation of local anesthetic (lignocaine) with conventional instillation after the removal of gall bladder in elective laparoscopic cholecystectomy. Study Design: Quasi-experimental study. Place and Duration of study: General Surgical ward, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Apr 2018. Methodology: Patients fulfilling the inclusion criteria were randomly assorted into two groups. Group A received intraperitoneal lignocaine at the conventional timing where was in Group B local anesthetic was instilled preemptively at the time of insertion of trocar. Post operatively pain was measure on visual analogue scale at 3,6 and 12 hours. Results: Total of 184 patients were followed up post-operatively. Mean age of patients in Group A was 44.5±13.57 years and in Group B was 46.2±13.9 years. Mean post-operative pain on visual analogue scale score for Group A was 2.53±0.73 and that for Group B was 2.0±0.66 with p -value<0.01. Conclusion: The use of preemptive instillation of local anesthetic intraperitoneal was found better as compared to conventional timing of instillation in reducing the post-operative pain in elective and uncomplicated cases of laparoscopic cholecystectomy.

Objective: To compare the effects of preemptive intraperitoneal instillation of local anesthetic (lignocaine) with conventional instillation after the removal of gall bladder in elective laparoscopic cholecystectomy. Study Design: Quasi-experimental study. Place and Duration of study: General Surgical ward, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Apr 2018. Methodology: Patients fulfilling the inclusion criteria were randomly assorted into two groups. Group A received intraperitoneal lignocaine at the conventional timing where was in Group B local anesthetic was instilled preemptively at the time of insertion of trocar. Post operatively pain was measure on visual analogue scale at 3,6 and 12 hours. Results: Total of 184 patients were followed up post-operatively. Mean age of patients in Group A was 44.5±13.57 years and in Group B was 46.2±13.9 years. Mean post-operative pain on visual analogue scale score for Group A was 2.53±0.73 and that for Group B was 2.0±0.66 with p-value<0.01.Conclusion: The use of preemptive instillation of local anesthetic intraperitoneal was found better as compared to conventional timing of instillation in reducing the post-operative pain in elective and uncomplicated cases of laparoscopic cholecystectomy.

Objective: To compare endoscopic pilonidal sinus treatment (EPSIT) vs total excision with primary closure (EPC) for pilonidal sinus disease in Combined Military Hospital Rawalpindi regarding intra and post-operative outcomes. Study Design: Comparative cross-sectional. Place and Duration of Study: Department of Surgery, Combined Military Hospital Rawalpindi, from Sep 2017 to Aug 2018. Methodology: A total of 94 patients, all male patients were included. All 94 have primary pilonidal sinus; Patient were randomized in a double-blind study to undergo EPSiT or EPC by non-probability, consecutive sampling into two equal groups. Results: The mean ± age SD of patients was 28 years ± 2.6 years. All patients completed the follow-up. All 94 patients divided equally for EPSiT and EPC. The patients completed the follow-up. All 94 patients divided equally for EPSiT and EPC. Surgery duration of EPSiT with a median duration of 34.5 minutes (IQR 30-39) and EPC 40.5 minutes (IQR 35-46); The median hospital stay was 8.5 hours (IQR 4-14) in EPSIT and 21.5 hours (IQR 15-28) in EPC. Complete wound healing in EPSiT was 93.6% and EPC was 81%. Wound complication rate was lower for EPSiT 3 (6.3%) and 8 (17%) or EPC (p-value 0.108). One case of wound dehiscence reported in EPC. Recurrence occurred in EPSiT was 3(6.3%) and EPC 9(19.1%). Conclusions: In our experience, EPSiT was viable as EPC in the treatment of pilonidal sinus.

Objective: To assess the frequency of anatomical variations of the extra-hepatic biliary tract in patients undergoing laparoscopic cholecystectomy in Combined Military Hospital & Pak Emirates Military Hospital Rawalpindi. Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of General Surgery, Combined Military Hospital & Pak Emirates Military Hospital, Rawalpindi, from Mar to Aug 2017. Methodology: A total of 136 patients of either gender with cholelithiasis of more than one month were included. Participants were distributed into equal number of groups for both hospitals by lottery method. All the participants had under gone laparoscopic cholecystectomy by consultant general surgeon or senior registrar under direct supervision. Structures mainly assessed for variations were gall bladder, cystic duct, common hepatic duct, supraduodenal part of common bile duct, cystic artery, and hepatic artery which were characteristically encountered during laparoscopy. Results: Overall Extra hepatic biliary variations were 136 (23%), at Combined Military Hospital 68 (16%) and Pak Emirates Military Hospital 68 (29.4%). Gall bladder anomaly was seen in 3% patients, cystic duct anomaly 4.4%, supraduodenal part of common bile duct anomaly 0.7%, cystic artery anomaly 11% and hepatic artery anomaly was seen in 3.6% patients (p>0.05). Conclusion: Anatomic variations were found to be not uncommon in our set up. Thus, there is a need for doctors to continuously refresh knowledge of normal anatomy and the variants of biliary tract.

Objective: To find the outcomes of laparoscopic cholecystectomy in gall bladders with all grades peri-operative inflammation. Study Design: Prospective observational study. Place and Duration of Study: Combined Military Hospital, Rawalpindi, from Nov 2018 to Aug 2019. Methodology: All patients with symptomatic gall bladder disease who underwent laparoscopic cholecystectomy (emergency/elective procedure) and American Anesthesiology Society (ASA) Score 1 or 2 were included in the study. Results: A total of 330 patients with a mean ± SD age of 48.01 ± 14.13 years underwent laparoscopic cholecystectomy. Out of 330 patients, 129 (39.1%) had acute inflammation of gall bladder while 201 (69.9%) cases were operated electively. The rate of conversion and complications were somehow lesser in both categories as the overall conversion rate was 15 (4.5%). Conclusion: Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gall stones. Moreover, it is safe option in acute and chronic inflammation of Gall bladder if performed by a experienced laparoscopic surgeon.

Objective: To compare Harmonic scalpel with conventional Monopolar Electrocautery hook in terms of gallbladder perforation rate in Laparoscopic Cholecystectomy. Study design: Randomized controlled trial. Place and Duration of Study: Department of Surgery Combined Military Hospital (CMH) Rawalpindi, Pakistan, from Feb 2013 to Oct 2013. Methodology: Consecutive 280 patients of cholelithiasis, fulfilling inclusion criteria, were included in this study after taking written informed consent and approval from hospital ethical committee. They were divided into two equal groups of 140 patients i.e. “Group A” who underwent LC by Harmonic scalpel and “Group B” in which conventional Monopolar electrocautery was used for dissection of gallbladder. Results: An increased incidence of 21.42% gallbladder perforation (GBP) in laparoscopic cholecystectomy (LC), was observed in “Group B” using Monopolar electrocautery for dissection as compared to 8.57% in “Group A” using Harmonic scalpel (p=0.002). Male gender was significantly associated with increased GBP i.e. 33.33% as compared to females 12.29% irrespective of the instrument used. Conclusion: Harmonic scalpel is better alternative to traditional Monopolar Electrocautery in LC due to decrease incidence of GBP.

This study aims to share the results of haemorrhoidal artery ligation under direct vision in the management of symptomatic haemorrhoids. We conducted a case series of 70 patients at Combined Military Hospital Rawalpindi & Quetta, from January 2015 to October 2017. All patients underwent Haemorrhoidal Artery Ligation (HAL) and Recto Anal Repair (RAR). Ligation of superior haemorrhoidal artery was done under direct vision following manual palpation. Patients were followed up postoperatively at 1, 3 and 6 months. At 1 month follow up, all 70 (100%) patients were pain free. Post operative bleeding was observed in 7 (10%) patients but did not require surgical intervention. Sixty two (89%) patients were able to return to their daily activities 1 week after surgery and 57 (81%) resumed military duties or joined their work place at 2 weeks. 70 (100%) patients were asymptomatic and 45 (64%) highly satisfied with their surgery at 3 months. This increased to 53 (75%) at 6 months. 48 (69%) said that they would recommend this procedure to someone else. Prolapse recurrence was observed in 1(1.42%) patient 6 months post operatively which was dealt by band ligation. All patients completed follow-up at 1, 3 and 6 months. HAL is a simple yet safe technique with few complications, acceptable patient satisfaction and early return to work.

Objective: To identify the frequency, associated risk factors and intraoperative reasons for conversion of Laparoscopic Cholecystectomy to open Cholecystectomy. Study Design: Case series study. Place and Duration of Study: This study was conducted in department of Surgery, Combined Military Hosptial Rawalpindi, from May to Oct, 2018. Methodology: Patients admitted for laparoscopic cholecystectomy were included in the study. Demographic information, ASA Score of physical health, Ultrasonogram Abdomen findings and presence of pericholecystic fluid were documented. The reasons for conversion from laparoscopic cholecystectomy (LC) to open Cholecystectomy (OC) for example excessive haemorrhage, visceral injury, equipment failure, injury to Common bile duct were also noted. Results: In this study 15 (8.77%) patients were converted from laparoscopic cholecystectomy to open cholecystectomy. The most common reason 6 (40%) of conversion was Fibrosis at Calots Triangle and Adhesions due to inflammation. In patients who converted most 10 (66.7%) were 41-60 years old and in patients who had successful laparoscopic cholecystectomy majority 70 (44.9%) patients belonged to age group 21-40 years. The male gender had significantly (p-value <0.05) higher rate of conversion (53.3% vs. 46.7%). There was significant (p-value <0.05) association of ASA score and presence of pericholecystic fluid with rate of conversion. Conclusion: Male gender, higher ASA score, and presence of pericholecystic fluid are significant contributors for conversion of laparoscopic cholecystectomy to open cholecystectomy. The most common reason for conversion was Fibrosis at Calots Triangle and Adhesions due to inflammation.

Objectives: To compare Open versus Closed method of creating pneumoperitoneum in terms of first access complications. Study Design: Randomized clinical trial. Place and Duration of Study: Surgical Department, CMH Rawalpindi, from October 2014 to April 2015. Material and Methods: Total 550 Patients presenting in surgical OPD and undergoing elective laparoscopic procedures were included and randomly divided into two equal groups by lottery method. In group A, open technique (Hasson cannula) and in group B, closed technique (Veress needle) was used. All patients were monitored during surgery for any first access related complications and this was carried out at regular intervals. Data for each patient was recorded on patient’s proforma. Results: We found better safety profile of open (Hassan) method over close (Veress Needle). Except for more gas leakage in open group (6.2%) as compared to closed (5.1%), all other complications occurred more frequent in closed group. The mean access time in the Open Group (3.2 ± 1.1 minutes) was less than for the Closed Arm (5.4 ± 0.7 minutes). Conclusions: There was difference in frequency of complications in both groups with Open method being safer and rate of complication was less as compared to the close method.

Cervicothoracic cystic lymphangiomas are found commonly in children less than 2 years of age, but the same are rare in adults. These form as a result of abberant development of embryonic lymph sac which is gradually filled with lymph fluid.1 They are commonly found in the head and neck region but can be present anywhere in the body. Preoperative diagnosis is based on careful history of a soft, painless, fluctuant, gradually enlarging mass and imaging. Surgery constitutes the basis of treatment and provides postoperative confirmation of diagnosis via histology. We, here report a case of cervicothoracic cystic lymphangioma in a 24-year male. The rationale of reporting this case is to discuss its presentation, diagnosis and surgical management. Moreover, we also want to highlight its scarcity in adults, the swelling being a diagnostic challenge and role of histology in affirmative diagnosis.

Objective: To review the mass casualty management at Combined Military Hospital Quetta (CMH QTA), from 2012 to 2015 and to recommend measures for enhancement of capabilities in order to handle major mass casualty events.Study Design: Descriptive, cross sectional.Place and Duration of Study: Combined military hospital Quetta, from Jan 2012 to Dec 2015.Material and Methods: This study is a review of the patients brought to CMH QTA, in different types of mass casualty events from 2012 to 2015. The type of trauma, the procedure carried out and the patient outcome in each case was recorded. The data were analyzed and based upon the mortality and morbidity of casualties, the evaluation of facilities available and required was carried out as per Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.Results: Over a period of four years, out of 3507, the highest number of casualties (42%) were received in year 2013. Civilians represented the commonest victims (79%) followed by army personnel (13%) and frontier corps (8%). The gunshot wounds and Improved Explosive Device (IED) blasts were on the top (53.5%) as a cause of mass casualty followed by road traffic accidents (37.5%). The highest number of patients (89%) underwent minor procedures like debridement, stitching and aseptic dressing. Twenty five percent of patients required a team work of various surgical specialists.Conclusion: The existing resources are sufficient for managing minor and moderate mass casualty scenarios but proper planning and enhancement of resources (equipment, infrastructure and personnel) is essential to cope with any probable major mass casualty event. We recommend training of paramedical staff for receiving, triage, resuscitation and definitive management of casualties.

Objective: To compare the efficacy of ondansetron with a combination of ondansetron and dexamethasone after elective laparoscopic cholecystectomy in terms of postoperative nausea and vomiting. Study Design: Randomized controlled trial. Place and Duration of Study: Department of Surgery, Combined Military Hospital Rawalpindi Pakistan, from Apr 2014 to Mar 2015. Materials and Methods: Two hundred and twenty two patients fulfilling the inclusion criteria were selected for study and divided into two groups of 111 each. Group A was given ondansetron while group B was given combination of ondansetron and dexamethasone at induction of general anesthesia. Patients of both groups were observed at 24 hours postoperatively for nausea and vomiting. Results: Sixty six patients in group A had nausea as compared to 50 patients in group B (p-value 0.03), 46 patients in group A had vomiting as compared to 19 patients in group B (p-value <0.001), showing statistically significant difference between the two groups. Conclusion: Postoperative nausea and vomiting is significantly lower in ondansetron and dexamethasone combination group as compared to ondansetron alone group after elective laparoscopic cholecystectomy.

Aims: To determine frequency of incidental gallbladder cancer (IGBC) in Pakistani population, its demographic/histopathological features and type of surgical resections performed. Methods: This observational study was conducted at Combined Military Hospital (CMH)/Armed Forces Institute of Pathology (AFIP) Rawalpindi, Pakistan from July 2009 to July 2015. Clinical as well as pathological records of all patients who underwent laparoscopic cholecystectomy (LC) / open cholecystectomy (OC) were reviewed and data was obtained regarding IGBC and benign gallbladder pathology. Patients diagnosed Sajid Muhammad Tanveer1, Hussain Syed Mukarram2, Hashmi Shoaib Nayyar3, Mustafa Qurat Ul Ain4, Shaheen Neelofar5 Affiliations: 1MBBS, FCPS, Assistant Professor & Classified Surgical Specialist, Department of General and Laparoscopic surgery, Combined Military Hospital Rawalpindi, Punjab, Pakistan; 2MBBS, FCPS, Associate Professor & Head of Department, Department of General and Laparoscopic Surgery, Combined Military Hospital Rawalpindi, Punjab, Pakistan; 3MBBS, FCPS, FRCP, Professor & Head of Department, Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan; 4MBBS, Senior Registrar, Department of Chemical Pathology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan; 5MBBS, Senior Medical Officer, Department of General and Laparoscopic Surgery, Combined Military Hospital Rawalpindi, Punjab, Pakistan. Corresponding Author: Muhammad Tanveer Sajid, C/o Hafiz Ghulam Mustafa Ezzy traders Hakeem jee building Jinnah road Abbottabad, KPK, Pakistan, 22010; Email: doc_tanveersajid@hotmail.com Received: 02 April 2016 Accepted: 22 June 2016 Published: 23 February 2017 with cancer underwent staging investigations and were offered definitive surgery. Overall frequency and clinicopathological features of IGBC were studied. Results: One hundred sixtyfour patients out of 10,549 had IGBC (1.55%). Mean age of presentation in IGBC and benign gallbladder pathology patients was 59.23±12.17 and 45.73±13.11 years respectively (p-value <0.001). Cancer patients had significantly more comorbid (73.17% versus 39.43%, p-value <0.001) and larger stones (p-value <0.001). Histopathology revealed adenocarcinoma in 148 (90.24%), adenosquamous carcinoma in 08 (4.88%), undifferentiated in 04 (2.44%), squamous cell carcinoma in 02 (1.22%), sarcoma and melanoma in one patient each (0.61%). Most of the tumors were well differentiated (36.59%) and liver was most commonly infiltrated organ (52.44%). Thirty-four patients had stage I, 38 patients had stage II, 49 patients had stage III and 43 patients had stage IV cancer (20.73%, 23.17%, 29.88%, 26.22% respectively). Surgical resection included no further treatment in 31 patients as cholecystectomy proved adequate vis-à-vis stage, extended cholecystectomy in three patients (1.83%), radical cholecystectomy in 17 (10.37%), pancreaticoduodenectomy (Whipple) in 6 (3.66%), palliation/symptomatic management in 42 (25.61%) patients while 65 (39.63%) patients refused surgery. Adequate lymphadenectomy was performed only in 50 (30.49%) patients while 44 (26.83%) showed positive resection margins. Conclusion: IGBC must be kept in mind while performing cholecystectomy and every specimen should undergo routine histopathological examination. Radical surgery should be offered and may improve outcome in carefully selected cases.

Objective: To provide a comparative analysis of mean post-operative pain score after preservation and elective excision of ilioinguinal nerve (IIN) using standard Lichtenstein hernia repair (LHR) technique. Study Design: Randomized controlled trial. Place and Duration of Study: Department of Surgery Combined Military Hospital (CMH) Rawalpindi/ Peshawar, from 15 May 2013 to 15 May 2014. Materials and Methods: One hundred and fifty patients with diagnosis of inguinal hernia satisfying inclusion/exclusion criteria were included. Patients were divided into two groups randomly. In group A, IIN was carefully protected while excision were done in group B. Demographic as well as data concerning groin pain at 03 months post operatively were collected and analyzed using SPSS. Results: A total of 150 patients were included. Mean age in group A was 37.32 ± 10.45 years while in group B was 36.56 ± 10.26 years (p=0.653). Majority of the patients in both groups were male {group A 89.33% (67), 92% (69) in group-B}, while female constituted only minority {8 (10.67%) in group A and 6 (8%) group-B}, the difference being statistically insignificant (p=0.571). Majority of the patients had indirect hernia and mean operation time was similar in both groups. Mean postoperative pain score was 3.76 ± 1.11 and 2.82 ± 0.677 in group A and B respectively, the difference being statistically significant (p<0.001). Conclusion: Mean post-operative pain score is higher in preservation techniques compared to elective excision of IIN for the treatment of inguinal hernia.