Single-Port Colonic Surgery: The Bermuda Experience

Background Single Incision Laparoscopic Surgery (SILS) is attractive because it uses 1 umbilical incision for preparation and extraction of the specimen. However, the procedure is technically demanding compared to conventional laparoscopy, and it is unclear if it is possible to adopt this procedure in an isolated community like Bermuda with a small hospital. Methods from Results Clinical Laparoscopic Surgery Patients with Sigmoid Colon Cancer: Surgery With 1 Surgeon and 1 Camera Operator.


Introduction
Laparoscopic colonic surgery is advantageous because it results in better cosmesis, less incisional pain and faster recovery (1). Single Incision Laparoscopic Surgery (SILS) appears to be safe and effective when compared to multiport laparoscopy (2) but is technically challenging due to the resulting crowding of the laparoscopic instruments (3). Doctors learning this type of surgery reportedly have a steep learning curve, and longer operative times can lead to increased surgeon fatigue (4).
Experts from an international multicenter registry, the European Consensus of Single-port Expertise in Colorectal Treatment (ECSPECT) have stated that "The feasibility and safety, conversion and complication pro le demonstrated here provides guidance for patient selection" (5). The success of SILS in Europe has triggered debate about its application and transferability to other jurisdictions, including small island states, and from this has arisen recommendations for low-income countries, such as the training of local and regional healthcare providers and monitoring outcomes, which can be used for guidance in isolated communities seeking to offer SILS procedures (6).
The aim of this study is to evaluate the feasibility and safety of performing SILS colonic procedures within the single-hospital healthcare system of Bermuda, an island in the Atlantic Ocean with an area of just 54 km 2 (21 sq. miles) and a population of 70,000, located over 1000 km (640 mi.) from the nearest landmass.

Patient Selection
All patients receiving a SILS colon procedure in Bermuda were evaluated. Patients with benign and malignant indications were selected without preference for gender, age, body mass index or American Society of Anesthesiologists (ASA) classi cation. Previous abdominal surgery and tumor stage were not de nite exclusion criteria. As there is only 1 hospital in Bermuda, the database of the single hospital (King Edward VII Memorial Hospital) includes all patients who had SILS procedures and thus the complete cohort of colonic procedures could easily be analyzed. Every patient in the study was given detailed information regarding the procedure and written consent provided. The hospital ethics committee approved the study.

Surgical Technique
The technique has been presented in detail recently (7,8). In most cases, access was achieved through a single vertical umbilical incision of approximate length of 2.5 cm. This incision in some cases would be widened for specimen extraction. However, if a colostomy or ileostomy was planned or considered likely, the access incision was instead made at the intended stoma site, eliminating the need for a separate stoma incision. The procedures were performed or assisted by 2 experienced surgeons, one of whom had major experience in laparoscopic surgery and especially SILS at a German center prior to practicing in Bermuda.

Patient Characteristics
Baseline demographic characteristics of all 230 patients treated by single-port surgery are presented in Table 1. The diagnostic indications for surgery and anesthesia risk scores for each type of SILS procedure are shown in Table 2. The commonest diagnoses were diverticular disease (84 patients, 36.5%) and colon cancer (81 patients, 35.2%). The majority of operations were left colon procedures (sigmoid colectomy, high anterior resection, and left hemicolectomy). Table 3 presents the intraoperative outcomes of the study population. In this series, 4 (1.7%) procedures required conversion to an open procedure. No conversion to standard multiport laparoscopy was necessary. The reasons for conversion were post-in ammatory tissue changes and technical di culties, including bleeding and adhesions. The mean operating time was 127.8 ± 43.8 minutes with a range of 48-305 minutes, depending on the type of procedure.

Intraoperative Outcomes
Postoperative Outcomes Table 4 shows the length of hospital stay and complication rates. The mean length of stay was 6.0 ± 4.3 days with a range of 1-33 days. Complications were de ned using the Clavien-Dindo classi cation (9). The overall complication rate was 11.7% (27 patients), with left sided procedures accounting for 63% of all complications. There were 2 postoperative deaths (0.9 %).

Discussion
After the single port variation of laparoscopic surgery was introduced to colon surgery, surgeons all over the world started to use this technique. However, because of the steep learning curve of SILS surgery, even for experienced standard port laparoscopic surgeons, there has been some concern for increased complications resulting from surgeons who were less experienced in laparoscopic surgery trying to adapt this technique (10).
It has been deemed safe for colonic surgery and rules for further development have been established (11,7,5). Whether this type of surgical procedure is transferable to small isolated places like Bermuda is an important thought to consider.
One of our surgeons (B.V.) relocated from a German center for colonic surgery (Klinikum Leverkusen) to Bermuda in 2012. The data from 224 SILS-colon procedures from this center were published in 2012(8). In Bermuda, SILS procedures started that same year and a total of 230 operations have been done. Although there are some signi cant differences in patient demographics and disease distribution between the German and Bermudian experiences, some useful insight can still be gained from a comparison.
While the two groups were evenly matched in size and male/female distribution, they had some distinct differences (see Table 5). A larger portion of Bermudian patients underwent right-sided procedures (37% vs 13%). Compared to the German cohort, the Bermudian patients were nearly a decade older, a bit heavier, had much higher ASA risk scores, and were much more likely to have a malignant diagnosis (42.6% vs 16.1%). Despite these negative factors, the Bermudian cohort had on average a 23% shorter operating time, a 73% lower conversion to open rate, and a 40% shorter mean hospital stay, with an equivalent complication rate.
The peri-and postoperative complications were reported according to the Clavien-Dindo classi cation (9). There was a similar Clavien-Dindo severity distribution between the two groups with grade I-II representing 7% of Bermudian and 6.25% of German complications. There were two deaths in the Bermuda cohort; one was a patient who had an emergency SILS resection for segmental intestinal infarction and progressed to complete intestinal infarction, and the other had an emergency SILS resection for intestinal bleeding while on an anticoagulant and later developed an anastomotic leak. There were no deaths in the German cohort.
The morbidity and mortality rates for SILS colon procedures in Bermuda also compares favorably to other internationally published data.
An analysis of 256 patients undergoing right hemicolectomy for cancer showed an overall 30-day morbidity rate of 21.4% with no mortality. The authors concluded that compared to multiport procedures, single-port surgeries for right sided colon cancer may offer some advantages like lower operative morbidity, shorter hospital stay, and better cosmesis (15).

Conclusions
Single-port colon surgery is a technically demanding procedure. Published data show that in experienced hands it can produce results as good as conventional multiport colon surgery. The adoption of SILS-procedures should be guided by an experienced Single-Port surgeon.
The data from the Bermudian experience suggest that under the guidance of an experienced single-port surgeon, the SILS colon procedure can be safely implemented in a small single-hospital community like Bermuda.

Declarations
Funding: No funds, grants, or other support was received.
Con icts of interest/Competing interests: The authors have no relevant nancial or non-nancial interests to disclose.
Ethics approval: King Edward VII Memorial Hospital ethics committee approved the study. Consent to participate: Every patient in the study was given detailed information regarding the procedure and written consent provided.  Data are mean ± SD (range) unless otherwise stated. *103 Sigmoid resections, 6 high anterior resections, and 11 left hemicolectomies     Data are mean ± SD (range) unless otherwise stated.