As obesity is becoming a global epidemic, many solutions have been proposed to patients – from medical to psychological to surgical. Recently, with the advances of laparoscopic surgery and the safety of the anesthesia, bariatric surgeries are expanding, particularly in the countries affected by obesity the most. Saudi Arabia is one of the highest countries with an obesity rate. This study aims to explore the complications of various bariatric surgeries (gastric banding, gastric bypass, and vertical sleeve gastrectomy) by reviewing the literature that has been published in Saudi Arabia. Findings from this study would enlighten clinicians and patients about the prevalence of these complications in this geographical area and allow a thoughtful comparison between the complication rate among different countries and practice types.

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Introduction: Median arcuate ligament syndrome (MALS) is a rare but debilitating gastrointestinal disorder. Division of the ligament (obstructing flow to the celiac artery) cures the symptoms, and a celiac ganglionectomy is also performed. Retroesophageal dissection causes dilatation of the hiatus. Severe gastroesophageal reflux disease (GERD) in the first six patients (Group A) led us to add an antireflux procedure in (Group B) 18 patients. Manometric and 24 h pH data support this. This article has been reported in line with SQUIRE guidelines. Materials and Methods: Over 7 years, we encountered 24 patients with MALS. The diagnosis was clinched by CT angiography, by the characteristic “Hook sign”. We have devised a standard operating strategy, involving retroesophageal mobilization, diaphragmatic crural exposure dividing the MAL, clearing out the perivascular neural tissue around the celiac axis, and exposing the celiac artery origin and its branches. The procedure was completed by crural approximation; Toupet fundoplication was performed in Group B patients. Relief from MALS symptomatology was obtained in all patients. Group A patients had severe reflux. Results: All patients were pain free within the 1^st month of follow-up and regained normal weight by 6 months. Postoperative reflux symptoms initially were seen in four patients in Group B and all six patients in Group A. By the 6^th month postprocedure, all Group B patients were symptom free and all Group A patients had persistent GERD. Conclusion: To our knowledge, there is no reported series in English literature with a formal protocol for MALS. Our approach provides an efficacious solution to a debilitating disorder. The addition of fundoplication has shown significant improvement in reflux symptoms.

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Background: Despite the safety of bariatric surgery (BS), only 0.4% of patients that qualify for it proceed to undergo the procedure. One hypothesized reason is the selectiveness of patients for medical providers. Methods: An online survey was distributed to bariatric surgeons around the world to identify what criteria they observed prospective bariatric patients found most important when selecting a medical provider. Questions were evaluated on a 10-point scale. Results: Our survey was distributed to 76 surgeons practicing in 16 countries. The most influential factors that affect patients' decisions on choosing their bariatric provider were seen to be a recommendation received from others and surgeon reputation. The proximity of the hospital to the patients' home was seen to be of least importance. It was seen that the quality/accreditation of the surgeon was significantly more important in surgeons working in the public setting when the data were analyzed according to the setting of practice. Conclusion: With the emergence of BS, choosing a provider has become of utmost importance. The most influential factors that were seen to affect patient's decisions were recommendations for the surgeons and reputation. This data could lay the groundwork for how medical providers market themselves when working in the BS field.

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Introduction: Abdominal pain and shoulder pain after laparoscopic cholecystectomy (LC) is most likely a combination of direct stretching of the diaphragm caused by insufflation and the release of hydrogen ions. Reducing postoperative discomfort after LC is an area of active research. Many methods such as low pressure pneumoperitoneum and intraperitoneal instillation of drugs (local anesthetic, saline) to reduce pain have been carried out. Drainage of gas after elective LC reduces early postoperative abdominal pain including shoulder pain. Materials and Methods: Seventy-five adult female patients with symptomatic gall stones were worked up on the outpatient department basis. After detailed history and physical examination, patient underwent elective surgery. After elective laparoscopic cholecystectomy, active suction was performed by inserting the laparoscopic suction irrigation device through a 5-mm trocar. Continuous suction will be applied for 60 s. In all the patients, port sites were closed in the standard manner. Postoperative pain, residual gas volume, and analgesic requirement were assessed and analyzed. Results: The median patient age was 32 years, median duration of surgery being 40 min. Residual gas volume (gas under diaphragm) was present in 22 patients out of 75 patients which accounts for 29.3% of the study population. The median amount of residual gas calculated using the formula was 7.3 ml (4.9–16.10 ml). Out of 75 patients studied, about eight patients developed shoulder pain and the rest of the patients complained of abdominal pain. Out of 75 patients studied, one patient developed gall bladder fossa collection. Conclusion: Active gas suction is a very simple procedure that is safe and feasible. Performing this procedure significantly decreases the residual intraperitoneal gas volume and postoperative pain after laparoscopic surgery and our surgeons should pay more attention in active aspiration of carbon dioxide at the end of laparoscopic operation.

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Since the birth of laparoscopic surgery, the morbidity in context to conventional surgery has hugely reduced; nevertheless, the laparoscopic surgery has its own specific complications, one of them being port-site hernia, which can be devastating. As the minimal access surgery is advancing to the single-port or single-incision laparoscopic surgery and bariatric and robotic surgery, the rise in port site hernia will be noticeable. However, the dilemma still exists regarding the pathogenesis, prophylactic closure of larger port sites, and the optimum technique of management of port-site hernia due to a lack of high level of evidence. Herein, we present a female patient with port-site hernia, leading to small bowel obstruction from one of the working ports.

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Ovarian pregnancy is a rare form of ectopic pregnancy. Clinical and imaging diagnosis is challenging and so can be the management, as was in our case, where the pregnancy being located in the ovary was not clear in the beginning. Various case series have concluded that an ovarian pregnancy, in a few cases, can present as an adnexal mass. We present a case of left ovarian pregnancy in a 31-year-old woman. Transvaginal ultrasound showed an empty uterus and a left adnexal mass. A suboptimal rise in beta-human chorionic gonadotropin (β-hCG) levels suggested an ectopic pregnancy. The patient declined a surgical intervention, even after explaining the risks and a likely need of surgery, in view of high β-hCG level. A single dose of methotrexate was given in the presence of hemodynamic stability and absence of pain. Subsequently, a laparoscopy was performed when the patient presented with pain abdomen and a rising β-hCG level, 7 days after methotrexate was administered. Ovarian wedge resection was done. Histopathological assessment confirmed the diagnosis. Increasingly, operative laparoscopy is the method employed for the surgical management of ovarian ectopic pregnancy. In view of concerns about future fertility, the current practice is to resect ovarian pregnancy and preserve healthy ovarian tissue.

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Background: Magnesium plays a role in the active transport of calcium (Ca⁺²) and potassium ions across cell membranes. Most of Mg⁺² is intracellular or in the bone <1% is in the blood serum. Post thyroidectomy, hypoparathyroidism leads to acute hypocalcemia that leads to hypomagnesemia. The relation of Ca⁺² and magnesium (Mg⁺²) metabolism is complex and mainly related to the interaction of these cations with parathyroid hormone (PTH) post thyroidectomy. Magnesium is an essential regulator of Ca⁺² flux and intracellular action of Ca⁺². Hypomagnesemia impairs hypocalcaemia-induced PTH release, which is corrected rapidly after magnesium replacement. Attempting to correct only hypocalcemia may prolong symptoms. It is important to monitor both Ca⁺² and Mg⁺² levels following thyroidectomy to facilitate prompt resolution of symptoms. The aim: is to highlight the prevalence of hypomagnesemia following thyroidectomy and its association with hypocalcemia which mandate early recognition and treatment to prevent prolongation of hypocalcemia and permanent hypoparathyroidism. Methods: Institutional review board was obtained (E20-4615) and posted in ClinicalTrials.gov NCT04351451. Informed consent taken from all patients. This is a prospective open Label observational pilot study in patients who underwent thyroidectomy. The study period was from January 2019 to January 2020. A total of 74 patients with normal renal function. Serum Ca⁺², magnesium, phosphate level, and Vitamin D level are all checked preoperatively and in the first postoperative day. Results: Post thyroidectomy 56.8% of patients had hypomagnesemia. 59.5.1% had hypocalcemia and 41.9% of had combined low level of Ca⁺² and Mg⁺² (P = 0.004). Conclusions: Causes of hypocalcemia and hypomagnesemia following thyroidectomy is of multi factorial related mainly to Ca⁺², Mg⁺² interaction in relation to PTH level.

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