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

Abstract

Purpose: 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. Methods: 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. Results: 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. Conclusion: 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.