Critical view of safety faster and safer technique during laparoscopic cholecystectomy?

Objective: Incidence of Bile Duct Injuries [BDI] during Laparoscopic Cholecystectomy [LC] is reported to be higher as compared to Open Cholecystectomy. Studies have shown varying degree of success in reducing BDI by using Critical View of Safety [CVS] technique before clipping and cutting any structure. In this study, we will see whether CVS technique is faster and safer compared to conventional infundibular technique

Methods: This comparative study was conducted on patients who presented to Surgical Out-Patient-Department [OPD] of Khyber Teaching Hospital from July 2015 to June 2016. Total of 438 patients were divided into two groups. Group-A in which LC was done using infundibular while in Group-B, CVS technique was utilized. Two groups were compared for operating time and BDI

Results: The operative time was significantly reduced for LC using CVS technique [50 mins vs. 73 mins]. Minor leaks were comparable [0.5% vs. 0.9%] but there was a significant difference in major LEAKS between the two techniques [0.5% vs. 1.4%]

Conclusion: Although the "critical view of safety" requires more dissection as compared to infundibular technique, but once learnt and mastered, it is faster and safer identification technique during laparoscopic cholecystectomy

Effect of bupivacaine on postoperative pain after laparoscopic cholecystectomy

Objective: To determine whether intraoperative local injection of 0.5% bupivacaine around port sites would decrease early postoperative pain after laparoscopic cholecystectomy, and the use of intravenous opioid analgesics postoperatively

Study Design: Randomised controlled trial.

Place and Duration of Study: Department of Surgery, Khyber Teaching Hospital, Peshawar, from July 2016 to June 2017

Methodology: Patients who underwent laparoscopic cholecystectomy were divided into two groups. Group A had instillation of 20 ml of 0.5% Inj. bupivacaine at the end of procedure into port sites and group B had no bupivacaine injection at trocar sites. Both groups had postoperative intravenous ketorolac 30 mg three times daily and intravenous opioid analgesics on demand. Pain was assessed 2 hours after recovery from general anesthesia, and at 6, 12 and 24 hours through visual analog scale 0-10

Results: One hundred and twenty patients completed this study with 60 patients in each group. A significant difference in mean postoperative pain scores was observed at 2 and 6 hours after surgery between the groups. Pain scores at 2 and 6 hours after surgery were 3.97 +/- 1.327 and 3.02 +/- 1.08 in group A, while it was 4.65 +/- 1.448 and 4.72 +/-1.277 in group B with p-values of 0.008 and 0.005, respectively. There was no significant difference in mean postoperative pain scores at 12 and 24 hours between the groups, with pain scores of 3.72 +/- 0.78 and 3.75 +/- 0.95 [p=0.488 and 0.744, respectively]. However, there was a significant difference in opioid analgesics use in first 24 hours with less analgesics use in bupivacaine injected group

Conclusion: Injecting 0.5% bupivacaine at trocar sites during laparoscopic cholecystectomy offers significant reduction in early postoperative pain

Retrieval of misplaced intrauterine device from sigmoid

Intrauterine contraceptive device [IUCD] is a form of contraception used for long durations and is most common method used worldwide. It is associated with rare but serious complications. Migration of IUCD into the abdominal cavity can cause injuries to adjacent organs leading to intestinal and bladder perforation, omental and mesenteric injuries, strictures and fistula formation. Here, we report a case of a patient with misplaced IUCD adherent to sigmoid colon after a period of 1 year in situ

Roux-en Y duodenojejunostomy for larger duodenal defects

Objective: To find the outcome of lateral duodenojejunostomy for larger duodenal defects due to different surgical conditions

Study design: Case series

Methodology: The clinical records were traced from the unit and hospital clinical record room. The data was collected and analyzed for the outcome of the procedure

Results: A total of six patients were managed with the surgical technique. All patients were allowed oral sips on 3[rd] postoperative day. One patient out of six needed ICU care of 42 days. Patient stay in ICU was of 42 days. Postoperative complications including anastomosis leak occurred in one patient. Nausea and vomiting was reported in two and wound infection in two patients. Mean hospital stay of the patients was 16.67 days

Conclusion: Roux-en Y duodenojejunostomy is a safe technique for the reconstruction of larger duodenal defects involving >50% [2/3[rd]] of the duodenal circumference

VAAFT: video assisted anal fistula treatment; bringing revolution in fistula treatment

To share our findings that the new treatment modality Video Assisted Anal Fistula Treatment [VAAFT] is a better alternate to the conventional treatments of Fistula in Ano in our setup with minor changes in the initial method described by Meinero. Karl Storz Video equipment including Meinero Fistuloscope was used. Key steps are visualization of the fistula tract, correct localization of the internal fistula opening under direct vision and endoscopic treatment of the fistula. This is followed by an operative phase of fulguration of the fistula tract using glycine solution mixed with manitol, curetting the tract with curette and fistula brush. Internal opening is closed with a Vicryl 1 suture. Total of 40 patients were operated using VAAFT from October 2013 to March 2014. Three were re-operated. The other 37 cases were followed up at 6 weeks, 3 months and 6 months. Primary healing took place in 20 [50%] cases at 6 weeks. In the remaining 17 [42.5%] cases, minor discharge occurred with itching which resolved till the next visit at 8 weeks and 12 weeks. As the main aim in treating fistula is proper identification of the internal opening, excision of the tract and sparing the sphincter function, VAAFT achieves all aims with additional benefits of patients' satisfaction and negligible scaring

Rate and risk factors for surgical site infection at a tertiary care facility in Peshawar, Pakistan

Surgical site infections [SSI] are among the most common complications in surgical patients and have serious consequences for outcomes and costs. This study aimed to determine the rates and risk factors affecting surgical site infections and their incidence at Surgical 'C' Unit, Khyber Teaching Hospital, Peshawar, Pakistan. The study was conducted to compare with rates obtained by large international multi-centre studies. A review of all general surgical interventions involving an incision, excluding anal procedures, performed between December 2008 and March 2009 [n=269] was undertaken. Various clinical parameters were recorded. Infection rates were calculated. Data were analysed using the Fisher's exact test. The overall SSI rate was 9.294%, 4.88% in clean cases [C], 8.39% in clean contaminated cases [CC], and 20.45% in contaminated or dirty cases [D]. There were significantly higher surgical site infection rates among patients with combined American Society of Anaesthesiologists scores II and III than those with ASA score I in clean contaminated [p=0.0007], and dirty cases [p=0.0212]. There were also significantly higher surgical site infection rates among patients with combined Co-morbidity Scale score 1-6 than those with no comorbid factors in clean contaminated [p=0.0002]. Surgical site infection rate was highest in gastrointestinal system surgeries. The Surgical site infections can be minimised by adopting international protocols for surveillance

Transabdominal repair of vesicovaginal fistula: an experience of 27 cases

To review the causes of vesicovaginal fistula and outcome of its repair through transabdominal approach. This is a descriptive cross sectional study which was conducted in Surgical "D" unit, Khyber Teaching Hospital Peshawar from January 2004 to December 2009. The record of all cases of vesicovaginal fistula that had undergone transabdominal repair was reviewed. Complex vesicovaginal fistula cases were excluded. Operative findings and procedure's details were obtained from operation notes. Post-operative follow up findings after one week, three weeks, forty days and three months were noted for every case. A total of 27 cases had undergone transabdominal repair for vesicovaginal fistula with age ranging from 26 to 63 years. Twenty two cases developed vesicovaginal fistula as a result of obstructed labour and five as a result of Gynaecological surgery [post-hysterectomy]. Mean post-operative hospital stay was seven days. Failure of repair was seen in one case only. Five cases were lost during follow up. Eight [29.63%] cases developed urinary tract infection, and two [7.40%] cases developed transient urinary stress incontinence. This study suggests that obstetrical trauma is the commonest cause for developing vesicovaginal fistula and the transabdominal approach gives satisfactory results in its repair

Experience of laparoscopic appendecectomies versus open appendecectomies

To compare the outcome of laparoscopic and open appendecectomies in terms of operative time and post-operative morbidity. This prospective study was done from March, 2008 to March, 2009, at Surgical "C" Unit of Khyber Teaching Hospital, Peshawar. All consecutive appendectomies [open and laparoscopic] performed over this time were included. Demographic details, operative time, conversion, infective post-operative complications and delay in discharge were recorded. The patients were divided into two groups, laparoscopic appendectomies [LA] and open appendectomies [OA]. A total of 165 appendectomies were performed, 72 in the LA group and 93 in OA group. Eighteen appendectomies were perforated at the time of operation. The patients' ages ranged from 12-65 years [median 24 years]. Eighty were males and eighty five were females. Operative time in LA group was longer with mean duration of 45 minutes [range 35-75 minutes] compared with 35 minutes [range 30-55 minutes] in OA group. A glove finger was used as extraction bag in 59 [83%] in LA group. LA patients' wound infection was recorded in12 patients, two out of 72 in LA and 10 out of 93 in OA group. The site of infection was the port of specimen extraction in LA group. Intra-abdominal abscesses complication was observed in one case in the OA group. LA group had shorter hospital stay [mean 1.5 days] than [OA] [mean 3.5 days], and early return to normal activity, 8-15 [mean 10.5] days in LA and15-25 [mean18.5] days in OA. Laparoscopic Appendectomy [LA] is safe and has major benefits like less post-operative pain, decreased wound infection, early hospital discharge and earlier return to work than Open Appendectomy [OA]. LA is recommended in all patients with acute appendicitis if laparoscopy is not contraindicated

Laparoscopic cholecystectomy: an audit of cases done at a tertiary care hospital

The study aims to describe the complications and hospital stay associated with laparoscopic cholecystectomy. During the period from 01 August 2007 to 31 July 2009, all patients who were operated with laparoscopic cholecystectomy were included. The age, gender and other related data including the outcome and complications in 245 laparoscopic cholecystectomy cases were recorded. The findings documented in numbers and percentages were compared and discussed with those of other studies. 194[78.79%] were females and 51[21.21%] were males. Ages of female patients ranged from 25-51 years and of males from 28-54 years. Most of the patients were discharged on the 1[st] post-operative day. There were 13 cases converted to open surgery [5.3%]. Laparoscopic cholecystectomy was successfully completed in the remaining 232 patients with an average operating time of 93.74 +/- 21.7. Twenty four patients experienced morbidity. These included infections [n=10], bleeding [n=4], biliary peritonitis [n=5], visceral injury [n=1], pneumonia [n=2] and partial small bowel tear [n=2]. No bile duct injury or mortality was seen. Laparoscopic cholecystectomy is being performed in this setting with acceptable morbidity, mortality and conversion rates. A concerted effort to increase the performance of laparoscopic cholecystectomy may increase cost effectiveness in this setting

Influence of ASA score and charlson comorbidity index on the surgical site infection rates

To compare the frequencies of surgical site infections [SSI] in ASA class-I [American Society of Anaesthesiologists-I] with ASA class II-III and CCI-0 [Charlson Co-morbidity Index-0] with CCI 1-6 in clean [C] and clean contaminated [CC] surgeries. Analytical study. This study was conducted in a General Surgical Unit of Khyber Teaching Hospital, Peshawar, from December 2008 to April 2009. A total of 310 clean and clean contaminated general surgical interventions with pre-operative ASA score of I-III, were included in the study, excluding anal and cystoscopic procedures. On the basis of past medical record, patients were grouped into ASA-I [patients without any co-morbidity] and ASA II-III [patients with co-morbidities] on the basis of their ASA score pre-operatively. In the same way patients were divided into CCI-0 [patients without co-morbidities] and CC 1-6 [patients with co-morbidities] according to CCI score. All the patients were operated in the same environment by the same set of surgeons. Postoperatively the surgical wounds were observed for SSI by using ASEPSIS daily scoring system for one month prospectively. SSI rates in ASA-I was compared with SSI rates in ASA II-III. Similar comparison of SSI rates was performed in CCI-0 and CCI 1-6. Data was tested by using the Fisher's exact test with confidence interval of 95%. The overall SSI rate was 6.1% [n=19] with 4.23% [n=5] in clean cases [C] and 7.29% [n=14] in clean contaminated cases [CC]. There were significantly higher surgical site infection rates among patients in ASA II-III than those with ASA-I in clean contaminated surgeries [p=0.003]. There were also significantly higher surgical site infection rates among patients with CCI score 1-6 than those with CCI-0 in clean [p=0.024] and clean contaminated [p=0.002]. American Society of Anaesthesiologists [ASA] score and Charlson comorbidity index [CCI] has strong influence on SSI rates in clean and clean contaminated cases. Patients' with co-morbidities undergoing clean and clean contaminated general surgical procedures have greater SSI rates than those without any co-morbidity

Total versus sub-total thyroidectomy for multinodular goiter

The aim of the study was to compare total and subtotal thyroidectomy [STT] for benign bilateral multinodular goiter [BBMNG] in terms of the proportion of hypoparathy-roidism and recurrent laryngeal nerve paralysis [RLNP]. Quasi experimental Place and duration of study: Department of Surgery, Khyber Teaching Hospital Peshawar, from 1st October 2007 to 30th September 2008. A total of 60 patients with bilateral multinodular goiter, were divided in to two groups A and B [30 patients in each group]. Group A patients were subjected to IT while group patients to STT. Sample technique used was non-probability purposive. Demographic details, biochemical findings, indications for operation, operating time and complications under study were noted for either group. There was no significant difference in the age, gender, hormonal status or duration of goiter between the two groups [P=0.123, P=0.74, P=0.509 and P=0.6, respectively]. The mean operating time was longer [138 +/- 30 min versus 112 +/- 33 min, P=0.046] for TT vs STT. Either temporary RLNP or HPT occurred in 3 [9.9%] or 6 [20%] of the patients undergoing total compared with 2 [6.6%] or 3 [9.9%] of the patients undergoing SIT [P=0.64 and P=0.278, respectively]. Permanent RLNP was observed in none and HPT in one patient only in TT group compared with none of either complication in STT group [P=0.313 for permanent HPT]. The present study shows that TT can be performed without increasing risk of complications, and it is an acceptable alternative for benign MNG, especially in endemic regions, where patients present with a huge multinodular goiter

Outcome of mesh repair for incisional hernia

To determine the results of incisional hernia repair with prosthetic mesh. It is a retrospective descriptive study, conducted at Surgical "D" ward Khyber Teaching Hospital, Peshawar from January, 2002 to October, 2006. A total of 121 patients were included in this study. Those patients with incisional hernia, who were repaired with mesh and completed the minimum of 9 months of follow up, were included. Patients who were clinically diagnosed to have incisional hernia were admitted and after necessary preparation, were operated and defect in the abdominal wall was closed by a synthetic mesh. During the early post operative and follow up period, patients were looked for complications like seroma, infection, chronic discharging sinus formation and recurrence. Out of 121 patients, 73 were female and 48 were male. In most of the patients the incisional hernia resulted from emergency procedures. In 35 [28.9%] patients, there was post operative seroma formation, 17 [14%] patients had wound infection. one [0.8%] patient developed subcutaneous heamatoma due to unidentified bleeding which later on required evacuation under general anesthesia. Eight [6.6%] developed recurrence of hernia out of which some patients were treated by repeat Mesh repair. In 12 [9.9%] patients there was mild to moderate skin margin necrosis and in these cases debridement was a proof of successful treatment. Partial wound dehiscence was found in 3.3% of patients. Incisional hernia is more common in midline laparotomy wounds specially performed in emergency conditions and onlay mesh repair procedure has high acceptable outcomes

Pseudomyxoma peritonei: a review of 17 cases

To evaluate the various presentations, causes and management of Pseudomyxoma Peritonei [PMP], and to create awareness among young surgeons regarding its importance. Retrospective study from Jan. 1999 to Dec. 2005. Surgical Unit of Khyber Teaching Hospital, Peshawar and Gynaecology and Obstetrics Unit, Hayatabad Medical Complex, Peshawar. All patients who had Pseudomyxoma Peritonei during the study period. The clinical records of all patients undergoing laparotomy for various causes were reviewed and cases of PMP separated. Their biodata, clinical presentation, clinical diagnosis, investigation results, operative findings, histopathology report and outcome were recorded. Out of 23,573 cases that underwent laparotomy 17 cases of PMP were on record. All were diagnosed incidentally per-operatively. Most [47.05%] cases were seen in the age group of 30-40 years and 58.82% patients were females. Abdominal pain, mass, abdominal distension and intestinal obstruction were the common presenting features. Ultrasound and CT scan reported three cases as ovarian cysts, three as multiple encysted fluid collections with thin cyst walls, two as ascites, two as ascites with peritoneal thickening, but none as PMP. Surgery was the mainstay of treatment. Appendicectomy with clearing of mucin in 11[64.70%], oophorechtomy and appendicectomy in 3[17.64%], bilateral oophorechtomy and hysterectomy in 2[11.76%], right hemi-colectomy in 1[5.88%] and second look surgery for complications were done in 2[11.76%] cases. Mortality was 11.76% and due to complication including one due to intestinal obstruction and another due to septicemia following second look surgery. Histopathological tissue diagnosis was available in only 13 cases and included mucinous adenoma appendix in five, mucinous cystadenoma ovary in three, mucinous epithelial cells of unknown origin in four and mucinous cystadenoma of borderline malignancy in one case. PMP is under reported in our setup. Pre-operative diagnosis is difficult and incidental findings usually go unnoticed due to lack of awareness and standard management protocol. There is a need to create awareness among surgeons, radiologists, pathologist and oncologist regarding this condition for the better outcome

Penetrating colonic injuries: management by primary repair

To assess the out come of primary repair in Penetrating Colonic Injuries. Prospective, interventional study from August 2001 to February 2004. Setting: This study was conducted at DHQ Hospital, Bannu. All patients who sustained colonic injury either by gunshot or stab injury were included in the study. Only those patients were included who were hemodynamically stable, did not have life threatening co-existing injuries and on operation were found to have mild to moderate peritoneal fecal contamination. All patients were operated after initial resuscitation and colonic injuries found were repaired primarily without fecal diversion. During the immediate and early postoperative period, these patients were observed for any complications like peritonitis, wound infection, peri-anastomotic abscess, pelvic, sub-diaphragmatic or interloop abscesses and colocutaneous fistulae. Patients were discharged home after they passed stools and their postoperative period remained uneventful for few days. Out of the 35 patients, majority were young males [80%]. The commonest mode of injury was fire arm, seen in 80% of the cases. The time interval between injury and repair was 4-12 hours [mean 6 hours]. Simple repair with interrupted suture was the commonest procedure performed, followed by right hemicolectomy. Twelve [34%] patients developed complications in the form of wound infection, intra abdominal abscesses and fecal fistulae. The total hospital stay was 7-21 days with the mean [9 +/- 2 days]. Primary anastomosis is safe and has excellent results in Penetrating Colonic Injuries

Doppler detected opening size and flow chart as predictors of early failure of arteriovenous fistula in hemodialysis patients

To determine whether Flow rate and the Size of the opening can predict early failure of arteriovenous fistulae in haemodialysis patients on Doppler ultrasonography. Prospective, quasi experimental study from March 2004 to January 2006. This study was conducted in Surgical "c" ward of the Khyber Teaching Hospital, Preshawar. A total of 92 patients with ESRD [End Stage Renal Disease] who were selected for haemodialysis. All the patients were subjected to Doppler study during the first week of AVF [arteriovenous fistula] construction, and the stomal size and blood flow rate detected. Both these parameters were used as predictors of AVF failure on follow-up visits during the next six months. Out of 92 patients, 13 [14.1%] had an initial stomal opening ranging from 2.3-3.5 mm and 44 [47.8%] from 3.5-5mm, while in 35 [385] patients the opening was > 5 mm. Twenty two [23.9%] patients had an initial flow rate of <400ml/min, 52 [56.5%] 400-700 ml/min and in 18 [19.5%] patients the flow rate was >700 ml/min. During the six months follow-up visits there were 14 [15.3%] AVF failures; all these patients had an initial flow rate of less than 400 ml/min, with a stomal opening of <3 mm in size. Initial stomal opening size and flow rate can be used as good predictors of early Arterio-venous failure in haemodialysis patients on Doppler ultrasonography

Surgical treatment of fractured penis

To evaluate the outcome of surgical repair of fractured penis. Case Series. This study was conducted in surgical department of Khyber Teaching Hospital, Peshawar from March 1999 to October 2003. A total of 23 cases were studied during this period. Patients with fractured penis were admitted and early surgical intervention was done in all cases under general anesthesia repairing the corpus cavernosusm. Patients were followed for a minimum period of 6 months. The outcome of the procedure in terms of early and late complications like sub optimal painful erection, late penile deformity, difficulty in coitus and pulsatile diverticulum were looked for. The average hospital stay of patients after surgery was 24-48 hours. Three[13%] patients had wound infection and collectively 5 [21.7%] patients out of 23 developed late complications. i.e. 2 patients had penile deformity, one each developed difficulty in coitus, pulastile diverticulum and painful erection. Early surgical intervention has good results with less complication rate in cases of fractured penis

Combined open prostatectomy and pre peritoneal repair of concurrent inguinal hernia

To determine whether concurrent inguinal hernia in patients undergoing open prostatectomy can be safely and effectively repaired by the preperitoneal approach. A retrospective descriptive study from 1994 to 2004. Surgical Department of Khyber Teaching Hospital, Peshawar. Four hundred and ninety eight patients with Benign Prostatic Hypertrophy. All the patients had their history taken, and thorough examination and appropriate investigations done. They underwent open prostatectomy and pre peritoneal repair of the inguinal hernias. Postoperative complications including wound infection, pelvic collection, secondary hydrocoeles, nerve injuries, persistent groin pain, testicular atrophy, hernia recurrence, etc. were assessed during each follow-up visit. Out of the 498 patients that underwent open prostatectomy during the study period, 47 [9.4%] underwent additional 53 preperitoneal hernioplasties; in six patients the hernias were bilateral. In 39 [73.5%] cases the hernias were indirect and in 14 [26.5%] direct. Apart from two [3.7%] recurrences no other postoperative complications were noted that were attributable to the hernia repair. Hernia repair can be performed safely and expeditiously during open prostatectomy using the pre peritoneal approach. This approach avoids a potential future operation as well as the potential complications of unrepaired hernias

surgical intervention an ideal treatment of De-Quervain's disease?

To evaluate the outcome of surgical treatment of DeQuervain s disease. Prospective study conducted from January 2004 to February 2005. Khyber Teaching Hospital, Peshawar. Clinically diagnosed cases of DeQuervain s disease who failed to respond to conservative treatment i.e. analgesics, splinatge and local steroid injections. The above mentioned patients were operated under local anesthesia and the tendons of extensor pollieis brevis and abductor pollicis longus were released. The patients were followed up for a minimum of four months to assess the clinical outcome of the procedure. There were 23 females and two male patients. Their ages ranged from 35 to 55 years with a mean age of 40 years. The two male patients were exposed to repetitive friction in terms of profession while all female patients were manual workers. Five out of 23 female patients had rheumatoid arthritis. The results of surgery showed that 22 patients had complete resolution of symptoms; in two patients the procedure ended up with failure as symptoms did not resolve and in one patient there was temporary skin paresthesia over the anatomical snuff box. Surgical intervention has promising results in DeQuervain s disease, when medical treatment fails

Experience of day care surgery at Peshawar

To evaluate the results of Day Care Surgery in our set-up. Retrospective study from Jan. 2003 to May 2005. Surgical 'C' Unit of Khyber Teaching Hospital, Peshawar. A total of 190 patients who underwent Day Care Surgery were included in this study. All patients were evaluated and counselled before hand, and asked to come on a given date. On the day of surgery they were shifted to the Operation Theatre, operated, kept under observation and sent home the same day with the advice to contact the concerned surgeon in case of any problem or complication. The patients were followed-up on the 3rd and 7th days, and examined for evidence of any local or distant complication. The patients were once again followed within a months time. Out of 190 patients, there were 131 male and 59 female patients, with an age range of two months to 65 years. All patients went home following surgery the same day except two, who were apprehensive and had to he kept for night. Twelve made telephone calls and were given advice. Five patients were readmitted with vomiting. two with severe pain and two with reactionary hemorrhage, and were discharged home the next day. One patient with hernia repair was readmitted after two days with scrotal oedema and treated. Day Care Surgery in uncomplicated cases is safe and cost effective. Majority of the patients were satisfied with this approach of early discharge

Incidence of gall stones in Carcinoma gall bladder patients

To determine the incidence of Gall stones in cases of Carcinoma Gall bladder.Retrospective descriptive study conducted from June 1999 to August 2002.Surgical B Ward of Khyber Teaching Hospital, Peshawar.All patients who were diagnosed as having Carcinoma Gall BladderThe presence or absence of stones was noted in cases of Carcinoma Gall Bladder, detected on preoperative ultrasonography or per-operatively on macroscopic examination, and later confirmed on histopathology. Out of the 40 patients with Carcinoma Gall Bladder in this series, 37 [924%] had Gall stones. There were 34 [85%] females and 6 [15%] males with an age range from 27 to 65 years. Six [15%] patients were in Stage /, 15 [37.5%] in Stage II, 14 [35%] in Stage III, while 5 [12.5%] cases were in Stage IV In 36 patients simple cholecys-tectomy was performed, whereas in 4 patients only biopsy was taken from liver metastasis.There is a strong association of Carcinoma Gall bladder- with gall stones