Pure single-incision laparoscopic cholecystectomy using an articulating instrument: the Ewha Method in a...

Conventional multiport laparoscopic cholecystectomy (CMLC) is the gold standard for benign gallbladder disease. Single-incision laparoscopic cholecystectomy (SILC) offers superior cosmesis but has limited adoption due to technical challenges. We introduce the Ewha Method, a modified SILC technique using an articulating instrument to improve visualization, ergonomics, and safety.

We retrospectively analyzed 530 patients who underwent SILC between November 2023 and August 2024. Surgical outcomes were compared between senior (n = 338) and junior (n = 192) surgeons. Difficult surgery (DS) was defined as conversion to CMLC or operative time >60 minutes. Multivariable analysis identified risk factors for DS, and the learning curve was evaluated.

The junior surgeon group included more high-risk patients, with higher proportions of elderly (≥65 years, 42.2% vs. 12.7%), male (53.6% vs. 29.9%), comorbidities, preoperative percutaneous transhepatic gallbladder drainage (PTGBD; 30.7% vs. 0.0%), and gangrenous cholecystitis (7.3% vs. 0.3%). The conversion rate was higher for junior surgeons (10.4% vs. 0.3%), but the severe complication rate was similar (0.5% vs. 0.0%). No bile duct injuries or incisional hernias occurred. Independent predictors of DS included diabetes mellitus (hazard ratio [HR], 4.045), preoperative PTGBD (HR, 5.780), leukocytosis (HR, 7.457), impacted stones (HR, 7.913), and gangrenous cholecystitis (HR, 38.736). The learning curve plateaued after 38 cases in low-risk patients.

The Ewha Method standardizes SILC, ensuring safety and efficiency with a short learning curve and minimal complications. It may serve as a viable alternative to CMLC, warranting further validation in diverse clinical settings.