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Introduction: The SingHealth Residency General Surgery Programme replaced the basic and advanced specialist training (AST) system in Singapore in 2010. The relative merits of both systems continue to be debated, especially the operational readiness of graduating residents. We set out to compare the operative and endoscopic volumes of graduates from the AST system with those from the first graduating batch of the residency programme during their registrar (or equivalent) years, as a reflection of procedural experience gained during traineeship., Methods: Operative and endoscopic records of four graduating residents and seven AST system trainees were extracted from the cluster-wide Operating Theatre Management system and compared. Surgeries were analysed as registrar-level operations and their corresponding subspecialties., Results: Registrars and senior residents performed a mean of 1,182 and 533 general surgical operations, respectively. Median percentage loss in operative volume was 50.6% (range 9.6%-75.5%). The mean number of total gastroscopies and colonoscopies performed by registrars (total gastroscopy, n = 819; total colonoscopy, n = 743) and senior residents (total gastroscopy, n = 376; total colonoscopy, n = 412) indicated a mean loss of 54.1% and 44.6%, respectively, in gastroscopic and colonoscopic experience., Conclusion: The residency programme aims to provide robust and complete surgical training. The operational readiness of its graduates is often scrutinised against that from the old system. Although a significant difference in surgical and endoscopic volumes was observed between the two trainee groups, this is only one marker of surgical experience and technical competence., (Copyright: © Singapore Medical Association.)

Introduction: Experience with robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited worldwide. In this study, we report our early experience with RAL HPB surgery in Singapore., Methods: A retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015 was conducted. The 20 cases were performed by three principal surgeons, of which 17 (85.0%) were performed by a single surgeon., Results: The median age of patients was 56 (range 22-75) years and median tumour size was 4.0 (range 1.2-7.5) cm. The surgeries performed included left-sided pancreatectomies (n = 10), hepatectomies (n = 7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n = 1), cholecystectomy for Mirizzi's syndrome (n = 1) and gastric resection for gastrointestinal stromal tumour (n = 1). The median operation time was 445 (range 80-825) minutes and median blood loss was 350 (range 0-1,200) mL. There was only 1 (5%) open conversion. There were 2 (10.0%) major morbidities (> Grade II on the Clavien-Dindo classification) and no 30-day/in-hospital mortalities. There was no reoperation for postoperative complications. The median postoperative stay was 5.5 (range 3-22) days., Conclusion: Our initial experience confirms the feasibility and safety of RAL HPB surgery., (Copyright: © Singapore Medical Association.)

Introduction: We aimed to analyse the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single centre., Methods: A retrospective review of patients who underwent LLR from 2006 to 2014 at our institution was performed. To explore the evolution of LLR, the study was divided into three equal consecutive time periods (Period 1: 2006-2008, Period 2: 2009-2011, and Period 3: 2012-2014)., Results: Among 195 patients who underwent LLR, 24 (12.3%) required open conversions, 68 (34.9%) had resection of tumours in the difficult posterosuperior segments and 12 (6.2%) underwent major (≥ 3 segments) hepatectomies. Median operation time was 210 (range 40-620) minutes and median postoperative stay was 4 (range 1-26) days. Major postoperative morbidity (> Grade II) occurred in 11 (5.6%) patients and 90-day/in-hospital mortality was 1 (0.5%). During the study, the number of LLRs performed showed an increasing trend (Period 1: n = 22; Period 2: n = 19; Period 3: n = 154). Other statistically significant trends were: (a) increase in malignant neoplasms resected; (b) increase in resections of difficult posterosuperior segments; (c) longer median operation time; and (d) decrease in open conversion rates., Conclusion: Over the study period, the number of LLRs increased rapidly. LLR was increasingly performed for malignant neoplasms and lesions located in the difficult posterosuperior segments, resulting in longer operation times. However, open conversion rates decreased, and there was no change in postoperative morbidity and other perioperative outcomes., (Copyright: © Singapore Medical Association)

Introduction: The use of laparoscopic distal pancreatectomy (LDP) has increased worldwide due to the reported advantages associated with this minimally invasive procedure. However, widespread adoption is hindered by its technical complexity. Robotic distal pancreatectomy (RDP) was introduced to overcome this limitation, but worldwide experience with RDP is still lacking. There is presently evidence that RDP is associated with decreased conversion rate and increased splenic preservation as compared to LDP., Methods: We conducted a prospective study on our initial experience with robotic spleen-saving, vessel-preserving distal pancreatectomy (SSVP-DP) between July 2013 and April 2014., Results: Three consecutive patients underwent attempted robotic SSVP-DP. The indications were a 2.1-cm indeterminate cystic neoplasm, 4.5-cm solid pseudopapillary neoplasm and 1.2-cm pancreatic neuroendocrine tumour. For all three patients, the procedure was completed without conversion, and the spleen, with its main vessels, was successfully conserved. The median total operation time, blood loss and postoperative stay were 350 (range 300-540) minutes, 200 (range 50-300) mL and 7 (range 6-14) days, respectively. Two patients had minor Clavien-Dindo Grade I complications (one Grade A pancreatic fistula and one postoperative ileus). One patient had a Clavien-Dindo Grade IIIa complication (Grade B pancreatic fistula requiring percutaneous drainage). All patients were well at the time of reporting after at least six months of follow-up., Conclusion: Our preliminary experience with robotic SSVP-DP confirmed the feasibility of the procedure.

Introduction: In this study, we report our initial experience with robotic hepatectomy., Methods: Consecutive patients who underwent robotic hepatectomy at Singapore General Hospital, Singapore, from February 2013 to February 2015 were enrolled in this study. The difficulty level of operations was graded using a novel scoring system for laparoscopic hepatectomies., Results: During the two-year period, five consecutive robotic hepatectomies were performed (one left lateral sectionectomy, one non-anatomical segment II/III resection, one anatomical segment V resection with cholecystectomy, one extended right posterior sectionectomy and one non-anatomical segment V/VI resection). Two hepatectomies were performed for suspected hepatocellular carcinoma, two for solitary liver metastases and one for a large symptomatic haemangioma. The median age of the patients was 53 (range 38-66) years and the median tumour size was 2.5 (range 2.1-7.3) cm. The median total operation time was 340 (range 155-825) minutes and the median volume of blood loss was 300 (range 50-1,200) mL. There were no open conversions and no mortalities or major morbidities (> Clavien-Dindo Grade II). The difficulty level of the operations was graded as low in one case (Score 2), intermediate in three cases (Score 5, 6 and 6) and high in one case (Score 10). There was one minor morbidity, where the patient experienced Grade A bile leakage, which resolved spontaneously. The median length of postoperative hospital stay was 5 (range 4-7) days., Conclusion: Our initial experience confirmed the feasibility and safety of robotic hepatectomy., (Copyright © Singapore Medical Association.)

We report a case of combined heart and liver transplantation for familial amyloid polyneuropathy. This is the first such combined transplant performed in Asia, and differs from previously described cases, in that cardiopulmonary bypass was continued at partial flow during liver transplantation in our case. This was done in order to provide haemodynamic support to the cardiac graft and to protect it from the impending reperfusion insult that frequently accompanies liver transplantation. The utility of this management course is discussed, along with its actual and potential complications. We also describe the impact of a lung-protective ventilation strategy employed during cardiac transplantation.

Introduction: Splenectomy is routinely performed in conventional distal pancreatectomies. Spleen removal with its possible sequelae of infections and haematological complications has prompted the development of spleen-preserving techniques. This study aimed to evaluate the safety and clinical outcomes of distal pancreatectomy with preservation of the spleen., Methods: A retrospective review of 24 consecutive patients who underwent spleen-preserving distal pancreatectomy in a tertiary care hospital was conducted., Results: There were 17 female and seven male patients, and the mean age was 47 (range 14-77) years. Median American Society of Anesthesiologists score was II (range I-III) . The indications were as follows : mucinous cystadenoma (n = 7), serous cystadenoma (n = 6), insulinoma (n = 3), intraductal papillary mucinous tumour (n = 2), pseudocyst (n = 3), papillary cystic adenoma (n = 1), neuroendocrine neoplasm (n = 1), and metastatic carcinoma of the thyroid (n = 1). Two patients developed postoperative pancreatic fistula and another two patients developed postoperative ileus with spontaneous resolution. Mean operative time was 172 (range 105-250) minutes. Mean length of postoperative hospital stay was 6.7 (range 5-11) days. There was no perioperative mortality in this series., Conclusion: Spleen-preserving distal pancreatectomy can be safely performed with low morbidity, and should be considered in the surgical management of distal pancreatic disease.

Hepatocellular carcinoma (HCC) is the commonest primary liver tumour. Recurrences are common in the liver although extrahepatic metastases can occur and frequently involve the adrenals. When this occurs in the right adrenal gland, it can be confused with an exophytic HCC arising from the posterior surface of the liver. The distinction between a primary HCC and a metastasis is important but can be difficult in this clinical setting. We report a 52-year-old man with recurrent HCC presenting as an "exophytic" posterior liver surface lesion that was actually a right adrenal metastasis. Although right-sided adrenal metastases of HCC can be difficult to distinguish from intrahepatic recurrences, even with modern diagnostic imaging, management either way involves surgical exploration and resection whenever possible.

This pictorial essay aims to show the clinical mimicry of hepatocellular carcinoma (HCC) and its diagnostic difficulty, and to create awareness among clinicians and radiologists of potential diagnostic pitfalls. A selected consecutive series of hepatectomies with proven HCC over a three-year period, identifying clinical presentation, blood results and imaging of patients with difficult preoperative diagnosis, was reviewed. The imaging of the focal liver lesions is presented pictorially with pathological correlation. Six patients out of 34 cases of resected HCC were diagnosed to have benign (three liver abscesses) and neoplastic (one Klatskin tumour, one colorectal liver metastasis, one gallbladder cancer) conditions. Compared to the rest in the series, all six patients had normal serum alpha fetoprotein levels. On computed tomography, the mosaic appearance of HCC mimicked locules of liver abscess while HCC with pseudocapsule (rim enhancement) was misdiagnosed as unilocular abscess or metastatic lesion. Arterial enhancement on contrast-enhanced triphasic computed tomography was useful in diagnosis of HCC. In summary, HCC can mimic benign and neoplastic clinical syndromes. The diagnosis of liver abscess can delay subsequent diagnosis of HCC and potentially complicate the treatment plan. Contrast-enhanced triphasic computed tomography or magnetic resonance imaging is useful to resolve difficult diagnosis, especially when the serum alpha fetoprotein level is not raised.