INTRODUCTIONAbdominal cocoon syndrome is characterized by small bowel encapsulation by a fibro-collagenous membrane or “cocoon”. It is a rare cause of intestinal obstruction.PRESENTATION OF CASEA 42-year old man presented with sub-acute intestinal obstruction. Intra-operatively, the entire small bowel was found to be encapsulated in a dense fibrous sac. The peritoneal sac was excised, followed by lysis of the inter-loop adhesions. Postoperative recovery was unremarkable.DISCUSSIONMost patients with abdominal cocoon syndrome present with features of recurrent acute or chronic small bowel obstruction secondary to kinking and/or compression of the intestines within the constricting cocoon. An abdominal mass may also be present due to an encapsulated cluster of dilated small bowel loops.CONCLUSIONAbdominal cocoon is a rare condition causing intestinal obstruction and diagnosis requires a high index of suspicion because of the nonspecific clinical picture. CECT of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Peritoneal sac excision and adhesiolysis is the treatment and the outcome is usually satisfactory.

Introduction: Congenital diaphragmatic hernia usually occurs in childhood. Presentation in adulthood is extremely rare. Surgical repair has been associated with low morbidity and mortality and excellent long term outcomes with low rate of recurrence. Here we present our experience of surgical management of diaphragmatic hernia over the last 10 years. Material and Methods: Records of 40 patients who underwent surgery for adult diaphragmatic hernia between January 2007 to December 2017, were reviewed retrospectively. Results: Median age of presentation was 38 (18-71) years with a male female ratio of 1.6:1. The most common symptom was breathlessness, followed by chest discomfort. Laparotomy and mesh repair was the most commonly performed procedure followed by anatomical repair. No recurrence was reported during the follow-up period ranging from 3 months to 7 years. Conclusion: Congenital diaphragmatic hernia is a rare surgical condition primarily diagnosed in infants and seen rarely in adults. Surgical repair has been associated with low morbidity and mortality and excellent long term outcomes with low rate of recurrence.

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SUMMARYColonic volvulus is a relatively uncommon cause of large bowel obstruction, accounting for 10% of colonic obstructions. Volvulus of the transverse colon is quite rare, accounting for only 4-11% of all reported cases. We report an unusual case of documented volvulus of the transverse colon in a pregnant woman with intestinal malrotation and concomitant acute intestinal obstruction by congenital bands and adhesions. BACKGROUND

Background: Laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstones. However, a conversion to open surgery may be required to complete the procedure safely. The aim of this study is to identify the predictive factors of conversion from laparoscopic to open cholecystectomy in elective setting.Methods: A retrospective review of all patients underwent laparoscopic cholecystectomy electively for symptomatic gallstones from January 2016 to December 2017 was performed. Data considered for analysis were: demographic data, preoperative laboratory values of liver function tests, gall bladder wall thickness on ultrasound, preoperative ERCP, indication for surgery, history of acute cholecystitis, presence of intraoperative adhesions and frozen Calot's triangle. Conversion to open cholecystectomy was chosen as the dependent variable for both, univariate and multivariate analysis.Results: 546 patients underwent laparoscopic cholecystectomy. 333 were females (60.9%) and 213 (39.1%) males, with a mean age of 44.6 years. The most common indication for surgery was symptomatic cholelithiasis. Conversion to open cholecystectomy occurred in 48 cases (8.8%) and the most common reason for conversion was inability to define the Calot’s triangle anatomy due to inflammation/adhesions. Univariate and multivariate analyses of various variables demonstrated that male gender, gall bladder wall thickness >5 mm and presence of previous documented acute cholecystitis had statistically significant co-relation with higher rates of conversion (p<0.001).Conclusions: Presence of acute cholecystitis, gall bladder wall thickness >5mm on preoperative ultrasound and male gender were independent predictor factors for conversion from laparoscopic to open cholecystectomy. Such patients should be properly counselled about the increased risk for conversion and should be operated by surgeons experienced in laparoscopic procedures to reduce the rate of conversion and operative complications.

Gastric schwannoma (GS) is a rare neoplasm of the stomach. It accounts for 0.2% of all gastric tumors and is mostly benign, slow-growing, and asymptomatic. Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors and up to 60-70% of GIST occur in the stomach. Schwannoma and GIST have similar radiological and endoscopic features making it extremely difficult to differentiate them preoperatively. Differential diagnosis of these two submucosal tumors is important because of the malignant potential of GIST and the relatively benign course of gastric schwannomas. This case stresses on the importance of including gastric schwannomas in the differential diagnosis of a submucosal gastric mass as it has the ability to mimic a gastrointestinal stromal tumor, which is a leading differential diagnosis because of its common occurrence at this site.

Bile duct injury constitutes a major proportion of morbidity associated with cholecystectomy (laparoscopic>open). It has a lot of impact on patient health and subsequent medico-legal repercussions. Anatomical aberrations in the Calot's triangle anatomy is more common than meets the eye. A thorough understanding of anatomy, identification of the variant structures, Use of intraoperative cholangiogram and low threshold for conversion to open procedure could prove life-saving in many cases. Optimal timing of intervention has to be planned once the type of injury is identified. Minor leaks are usually managed with endoscopic interventions. More proximal leaks and complete transaction of bile duct usually require Roux En Y hepaticojejunostomy. The principal is to ensure complete drainage of all segments and prevention of sepsis. More grave scenarios like concomitant vascular injury, segmental atrophy and secondary biliary cirrhosis require referral to a tertiary centre and subsequent multidisciplinary approach. The aim of the study was to establish the true incidence, classification and management of bile duct injuries that could be life - saving in a few cases and career- saving in many others.

Biliary cystadenoma is a very rare cystic neoplasm of the liver that usually occurs almost exclusively in middle-aged women. These are slowly progressive tumours and cannot be safely differentiated from cystadenocarcinomas on preoperative imaging and hence should always be considered for resection. Historically these cystic tumors have been treated by a variety of techniques including aspiration, fenestration, internal drainage, partial resection resulting in high rates of recurrence. In addition biliary cystadenoma is a premalignant lesion and only surgical excision can differentiate it from its malignant counterpart, biliary cystadenocarcinoma.