Letter to the Editor Dear Editor, The COVID-19 pandemic has brought about profound challenges in Singapore 1 with surgery drawing scrutiny due to the need to conserve personal protection equipment (PPE), ventilators, intensive care unit (ICU) beds as well as concerns of concurrent COVID-19 infection in surgical patients with reported mortality rate of up to 20%. 2 Given the scarcity of resources and risks associated with concurrent COVID-19 infection in the surgical patient, international guidelines have recommended medical treatment for acute issues related to cholelithiasis that are normally treated surgically. 3 This stance has implications on the management of acute cholecystitis (AC) with meta-analyses demonstrating conclusive benefits of index admission early laparoscopic cholecystectomy (ELC) over interval delayed laparoscopic cholecystectomy (DLC) that include decreased total length of stay, decreased readmission for persistent pain and gallstone-related morbidity, earlier return to work, improved quality of life and increased cost-effectiveness. 4,5 The need to balance the surgical risk and resource considerations of acute cholecystitis with the obligations of delivering optimal outcomes and avoiding morbidity thus poses an ethical dilemma during this pandemic. With the rapidly evolving pandemic coupled with different subspecialty surgeons managing AC in Singapore, opinions and practices may inevitably vary among institutions and surgeons. Resource and manpower constraints would also translate to changing practices on the ground. Thus, the aim of this study is to evaluate the impact of COVID-19 on the management of AC in Singapore. An anonymous online survey was developed and disseminated across all seven public restructured hospitals in Singapore in April 2020 via electronic mail. Inclusion criteria was consultant specialist surgeons who perform laparoscopic cholecystectomy in Singapore. The survey was administered through an online platform, Google Forms (Google LLC, Menlo Park, California, USA). The survey includes questions on demographics of survey respondents, impact of the
Currently, laparoscopic liver resections are routinely performed at an increasing number of centres and has extended to include major liver resections as well as more challenging segments of the liver. We believe that patient positioning and port placement is a critical yet under described component of successful laparoscopic liver resection to achieve optimal visualisation and allow for an ergonomic and safe dissection. In this article, we describe the advantages of various types of patient positioning as well as provide illustrations for an array of trocar configurations previously described in literature. Whilst there is no universally accepted standardization of port placement for various resection types, this descriptive article can serve as a guide for the various possibilities of port configurations that can be individually adapted by surgeons based on their preference as well as the patient's physique and anatomy.
Background: Radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma has been shown to be safe and oncologically superior to distal pancreatosplenectomy. Modified robotic RAMPS has become increasingly adopted. We present a robotic case whereby optimal port placement facilitated smooth transition to full laparoscopy in a semi-urgent setting. Methods: A 58-year-old female presented with a 2 cm pancreatic body tumour in October 2022. Modified anterior RAMPS was performed to ensure margin clearance. She was positioned supine with split-legs. Ports were placed in the right anterior axillary line (R1, 8 mm: prograsp), right mid-clavicular line (R2, 8 mm: fenestrated bipolar), supraumbilical (R3, 8 mm: camera) in an imaginary diagonal fashion, with an additional left anterior axillary line port (R4, 8 mm: vessel sealer) and a 12 mm assistant port in the left mid-clavicular line. During the dissection of the root of splenic artery, unrecoverable robotic vision-cart error resulted in a timer countdown requiring quick withdrawal of the robotic instruments and conversion to laparoscopy. R3 was upsized to 12 mm and the laparoscope switched to the left 12 mm assistant port -allowing the first surgeon to use R1/R2 and the upsized R3 to complete the resection. Results: The operative time was 288 minutes, and estimated blood loss was 100 mL. The postoperative course was uneventful and she was discharged on post-operative day 7. Histology revealed moderately differentiated invasive adenocarcinoma (pT2N1M0) with uninvolved margins. Conclusions: Robotic platform error is rare but may be untimely, requiring an expedient switch to laparoscopic approach. Wherever possible, initial port placements should facilitate easy conversion to laparoscopy with suitable ergonomics.
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