Clinical outcomes of single-port, modified two-port, and three-port laparoscopic cholecystectomy: A comparative retrospective cohort study

Abstract

BACKGROUND

While laparoscopic cholecystectomy (LC) is the gold standard procedure for symptomatic gallbladder pathologies, the pursuit of minimizing invasiveness and improving cosmetic outcomes has led to techniques like single-port (SP) and modified two-port (MTP) LC. However, their comparative efficacy against the conventional three-port (TP) approach, particularly the novel MTP technique, requires further validation.

AIM

To compare the cosmetic, operative, and clinical outcomes of MTP, SP, and TP LC.

METHODS

This retrospective cohort study included 142 patients with symptomatic gallbladder disease who underwent MTP, SP, or TP LC from January 2024 to January 2025. All procedures were performed by a single experienced surgeon. The primary outcome was cosmetic satisfaction at one month. Secondary outcomes included operative time, intraoperative blood loss, hospital stay, and postoperative complications. Multivariable analyses were performed following adjustment for age, sex, and body mass index, with a Bonferroni correction applied.

RESULTS

All procedures were completed laparoscopically. MTP LC demonstrated the shortest operative time (52.5 ± 19.5 minutes), which was significantly shorter than that of SP LC (103.1 ± 34.9 minutes, P = 0.009) and comparable to that of TP LC (55.2 ± 23.0 minutes, P = 0.566). MTP LC also yielded the shortest hospital stay (1.2 ± 0.5 days). Cosmetic outcomes were superior for MTP and SP LC vs TP LC(P < 0.05). Blood loss was minimal (< 10 mL) in all groups. One case of postoperative infection occurred in the SP LC group. After adjustment for confounding factors, MTP LC maintained a shorter operative time vs SP LC (β = -48.2, P < 0.001) and exhibited comparable safety to TP LC (odds ratio: 1.02, P = 0.31).

CONCLUSION

MTP LC balances the cosmetic benefit of SP LC with the efficiency and safety of TP technique, though its generalizability requires prospective validation.

Key Words: Single-port laparoscopic cholecystectomy; Modified two-port laparoscopic cholecystectomy; Three-port laparoscopic cholecystectomy; Clinical outcomes; Retrospective cohort study

Core Tip: This retrospective cohort study compares modified two-port (MTP), single-port (SP), and three-port (TP) laparoscopic cholecystectomy (LC) to determine the optimal balance between invasiveness, efficiency, safety, and cosmetic outcomes. MTP LC demonstrated the shortest operative and recovery times, no complications, and excellent scar concealment, outperforming SP and TP LC. While SP LC achieved similar cosmetic results, it was limited by prolonged operative time and higher infection risk. These findings highlight MTP LC as a preferred, patient-centered approach for symptomatic gallbladder disease.

INTRODUCTION

Laparoscopic cholecystectomy (LC) is universally considered the best-practice approach for managing gallbladder pathologies such as cholecystitis and cholelithiasis, owing to its minimally invasive nature, reduced postoperative pain, and rapid recovery[1-3]. In recent years, the focus of surgical innovation has shifted toward further reduction in invasiveness to address patient demands for improved cosmetic outcomes and faster return to daily activities[2,3]. Although three-port (TP) LC is well established as a safe and effective technique, reduced-port approaches—including single-port (SP) and modified two-port (MTP) LC—have gained increasing attention for their potential to minimize incision numbers and sizes[2-4].

These reduced-port techniques aim to reduce tissue trauma, alleviate postoperative pain, and enhance scar aesthetics[5]. However, SP LC is associated with technical challenges, including compromised instrument triangulation, ergonomic difficulties, and the need for specialized instruments, which may prolong operative time and increase complication risks[6-9]. While previous studies have compared two of these approaches (e.g., SP vs TP), few have systematically evaluated MTP, SP, and TP LC in a single cohort to clarify their relative advantages[10,11]. A critical knowledge gap exists: Whether MTP LC can integrate the superior cosmesis of SP LC with the proven efficiency and safety of TP LC, as existing evidence on MTP LC is limited and lacks rigorous comparative analysis.

This study addresses this gap by conducting a comprehensive retrospective cohort analysis of 142 patients who underwent MTP, SP, or TP LC. We hypothesized that MTP LC would achieve SP-LC-like cosmetic outcomes while maintaining TP-LC-like operative efficiency and safety[12]. The primary objective was to compare scar visibility among the three approaches, with secondary endpoints including operative duration, intraoperative blood loss, hospital stay, and postoperative complications. The findings will provide evidence-based guidance for surgical decision-making in symptomatic gallbladder disease.

MATERIALS AND METHODS

Study population

A total of 142 patients (age 17-84 years) diagnosed with symptomatic gallbladder pathologies (e.g., gallstones, polyps, chronic cholecystitis, gallbladder atrophy, adenomyosis, or gallstone entrapment) were enrolled from the Second Department of Hepatobiliary Surgery, First Affiliated Hospital of Wannan Medical College, from January 2024 to January 2025.

Inclusion and exclusion criteria

Inclusion criteria: (1) Age 17-84 years; (2) Body mass index (BMI) < 40 kg/m²; (3) Preoperative diagnosis of symptomatic gallstones, gallbladder polyps, gallstones with chronic cholecystitis, gallbladder atrophy, gallbladder adenomyosis, or gallstone entrapment; and (4) Provision of written informed consent and agreement to adhere with the study protocol.

Exclusion criteria: (1) Contraindications to laparoscopy; (2) Long-term anticoagulant therapy; (3) Diagnosis of acute cholecystitis, choledocholithiasis, or gallbladder cancer; and (4) Concurrent liver cysts, liver tumors, or abdominal hernias requiring repair. The patient selection process is summarized in Figure 1.

Figure 1  The patient selection process.

Preoperative assessments

All patients underwent routine preoperative evaluations, including blood tests (complete blood count, liver function, and albumin measurement), electrocardiography, abdominal ultrasound, and chest X-ray.

Surgical techniques

Patients were placed in the supine position to allow intravenous access, induction of general anesthesia, and subsequent endotracheal intubation. The surgical instruments are shown in Figure 2. All procedures were performed by a single consultant surgeon experienced in all the three techniques (> 600 LCs performed).

Figure 2  Surgical instruments used.

SP LC: The operating surgeon stood between the patient’s legs, and the assistant (laparoscope handler) stood on the patient’s left side. A single bracket-shaped incision (25-30 mm) was made along the inner margin of the umbilicus. A SP access device was placed, through which a laparoscope, grasper, and electrocautery hook were introduced (Figure 3A).

Figure 3 Placement of surgical instruments. A: Placement of surgical instruments in single-port technique; B: Placement of surgical instruments in three-port technique; C: Placement of surgical instruments in modified two-port technique.

TP LC: The operating surgeon and assistant both stood on the patient’s left side. Incisions included a subumbilical incision (10 mm trocar for laparoscope), sub-xiphoid incision (10 mm trocar for electrocautery hook), and right subcostal incision (5 mm trocar for grasper) (Figure 3B).

MTP LC: This technique utilizes three incisions but functions as a clustered approach to minimize visible scarring and fascial trauma. The surgeon and assistant both stood on the patient’s left side. Incisions included a right inner marginal umbilical incision (10 mm trocar for laparoscope), left inner marginal umbilical incision (5 mm trocar for grasper), and a sub-xiphoid incision (5 mm or 10 mm trocar for electrocautery hook) (Figure 3C). All incisions are concealed within natural body folds, reducing cosmetic impact.

Wound closure

For all groups, fascial defects ≥ 10 mm were closed with 0-vicryl figure-of-eight sutures. Skin closure was performed with 4-0 monocryl subcuticular sutures.

Outcome measures

Primary outcome: Cosmetic satisfaction was assessed via a standardized telephone interview at one month postoperatively by a trained research nurse blinded to the surgical technique. Patients rated their scar appearance on a 10-point scale (1 = highly visible, raised, or discolored; 10 = nearly invisible). Scores 8-10 were categorized as “excellent/minimally visible”, and 1-7 as “visible/acceptable”. While a validated scale (e.g., Patient and Observer Scar Assessment Scale) was not used due to retrospective constraints, the standardized 10-point scale was piloted in 10 preliminary patients to ensure consistency.

Secondary outcomes: Operative time (recorded from skin incision to closure), intraoperative blood loss (estimated by the surgeon and anaesthetist), length of hospital stay (from surgery to discharge eligibility), postoperative complications (e.g., infection, bleeding, and bile leak), and postoperative pain (assessed via a Verbal Numerical Rating Scale, 0-10 at 24 hours and 48 hours postoperatively; data were extracted from electronic medical records where available).

Statistical analysis

Data were analyzed using IBM SPSS Statistics for Windows, version 27.0. Continuous variables, presented as the mean ± SD with 95% confidence intervals (CIs), were compared using the one-way analysis of variance. Categorical variables, presented as frequencies and percentages with 95%CIs, were compared using the χ² test or Fisher’s exact test (for small cell sizes). P < 0.05 was considered statistically significant. The study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines[13].

RESULTS

Patient demographics and preoperative parameters

Patient demographics and preoperative parameters are summarized in Table 1. All 142 procedures were completed laparoscopically without conversion to open surgery. The cohort comprised 93 females (65.5%) and 49 males (34.5%). Gender distribution differed significantly: The SP group had no male patients, whereas the MTP and TP groups included 9 (29.1%) and 40 (40%) males, respectively (P < 0.05)[14]. The mean age was 45.8 ± 16.2 years (MTP), 53.3 ± 11.3 years (TP), and 40.5 ± 12.4 years (SP), with significant differences between MTP and TP (P = 0.005) and between TP and SP (P = 0.001). The SP group had a significantly lower mean BMI (22.3 ± 2.1 kg/m²) compared to the MTP group (24.8 ± 2.9 kg/m², P = 0.012). These baseline imbalances (younger age, lower BMI, and exclusive female enrollment in the SP group) are acknowledged as potential selection bias. No significant differences were observed in white blood cell count, liver function (aspartate transaminase and alanine transaminase), albumin levels, comorbidities (diabetes and hypertension), or prior abdominal surgery among the three groups.

Table 1 Patient demographics and preoperative parameters, n (%)/mean ± SD (95% confidence interval).

Index	MTP (n = 31)	TP (n = 100)	SP (n = 11)	P value (MTP vs TP)	P value (MTP vs SP)	P value (TP vs SP)
Age (years)	48.5 ± 16.2 (42.7-54.3)	53.3 ± 11.3 (51.0-55.6)	40.5 ± 12.4 (33.4-47.6)	0.005	0.322	0.001
Gender
Male	9 (29.1)	40 (40.0)	0 (0.0)	0.270	0.044	0.009
Female	22 (70.9)	60 (60.0)	11 (100.0)
BMI (kg/m2)	24.8 ± 2.9 (23.8-25.8)	24.6 ± 3.3 (24.0-25.2)	22.3 ± 2.1 (20.9-23.7)	0.749	0.012	0.280
WBC (× 109/L)	5.9 ± 1.6 (5.4-6.4)	5.8 ± 1.7 (5.5-6.1)	5.2 ± 1.5 (4.3-6.1)	0.813	0.199	0.232
AST (U/L)	36.5 ± 48.4 (20.1-52.9)	44.9 ± 100 (25.1-64.7)	20.3 ± 10.0 (14.0-26.6)	0.653	0.281	0.420
ALT (U/L)	26.6 ± 15.4 (21.5-31.7)	34.9 ± 54.9 (24.1-45.7)	25.5 ± 8.2 (20.3-30.5)	0.408	0.825	0.573
ALB (U/L)	45.6 ± 3.7 (44.4-46.8)	44.6 ± 3.5 (44.0-45.2)	43.9 ± 4.3 (41.0-46.8)	0.150	0.203	0.537
Comorbidities
Diabetes	0 (0.0)	3 (3.0)	0 (0.0)	0.632	0.772	1.000
Hypertension	3 (9.7)	11 (11.0)	0 (0.0)
None	28 (90.3)	86 (86.0)	11 (100.0)
Prior abdominal surgery
Yes	12 (38.7)	40 (40.0)	5 (45.5)	0.795	0.473	0.974
No	19 (61.3)	60 (60.0)	6 (54.5)

Continuous variables were compared via one-way analysis of variance, while categorical variables were compared via χ² or Fisher’s exact test (for small cell sizes). MTP: Modified two-port laparoscopic cholecystectomy; TP: Three-port laparoscopic cholecystectomy; SP: Single-port laparoscopic cholecystectomy; BMI: Body mass index; WBC: White blood cells; AST: Aspartate transaminase; ALT: Alanine transaminase; ALB: Albumin.

Intraoperative outcomes

Intraoperative outcomes are detailed in Table 2. SP LC had a significantly longer operative time (103.1 ± 34.9 minutes; 95%CI: 82.3-123.9) compared to both MTP (52.5 ± 19.5 minutes; 95%CI: 45.8-59.2, P < 0.01) and TP LC (55.2 ± 23.0 minutes; 95%CI: 50.7-59.7, P < 0.01), though there was no significant difference between MTP and TP LC (P = 0.566). After adjusting for age, BMI, and sex, the difference in operative time between the SP and MTP/TP groups remained significant (P < 0.001). All patients had minimal intraoperative blood loss (< 10 mL), with no significant differences among groups.

Table 2 Intraoperative and postoperative outcomes, n (%)/mean ± SD (95% confidence interval).

Outcome measure	MTP (n = 31)	TP (n = 100)	SP (n = 11)	P value (MTP vs TP)	P value (MTP vs SP)	P value (TP vs SP)
Operative time (minutes)	52.5 ± 19.5 (45.8-59.2)	55.2 ± 23.0 (50.7-59.7)	103.1 ± 34.9 (82.3-123.9)	0.566	0.009	0.000
Intraoperative blood loss < 10 mL	31 (100) (89.1-100.0)	100 (100) (96.3-100.0)	11 (100) (71.5-100.0)	1.000	1.000	1.000
Hospital stay (days)	1.2 ± 0.5 (1.0-1.4)	1.3 ± 0.6 (1.2-1.4)	1.5 ± 0.5 (1.2-1.8)	0.341	0.136	0.384
Postoperative complications	0 (0) (0.0-10.9)	0 (0) (0.0-3.6)	1 (9.1) (1.1-31.0)	< 0.001	0.089	0.0087
Postoperative pain (VNRS)
24 hours	2.1 ± 1.0 (1.8-2.4)	2.3 ± 1.1 (2.1-2.5)	2.5 ± 1.2 (1.8-3.2)	0.320	0.210	0.450
48 hours	1.2 ± 0.8 (0.9-1.5)	1.4 ± 0.9 (1.2-1.6)	1.6 ± 1.0 (1.0-2.2)	0.280	0.170	0.390

MTP: Modified two-port laparoscopic cholecystectomy; TP: Three-port laparoscopic cholecystectomy; SP: Single-port laparoscopic cholecystectomy; VNRS: Verbal Numerical Rating Scale (0-10, higher = worse pain).

Postoperative outcomes

Postoperative outcomes are detailed in Table 2. The MTP group had the shortest mean hospital stay (1.2 ± 0.5 days; 95%CI: 1.0-1.4), followed by the TP (1.3 ± 0.6 days; 95%CI: 1.2-1.4) and SP groups (1.5 ± 0.5 days; 95%CI: 1.2-1.8), but differences were not statistically significant (P > 0.05). One case of postoperative abdominal infection occurred in the SP group (9.1%; 95%CI: 1.1-31.0), but its incidence was not statistically different from that of the TP (0%; 95%CI: 0.0-3.6, P = 0.087 after Bonferroni correction) or MTP group (0%, 95%CI: 0.0-10.9, P = 0.241). No complications were reported in the MTP group. The abdominal infection was managed successfully with antibiotics. No other major complications, such as bile duct injury or postoperative hemorrhage, were recorded in any group. Postoperative pain data were available for 89% of patients (n = 126). At 24 hours, mean Verbal Numerical Rating Scale scores were 2.1 ± 1.0 (MTP), 2.3 ± 1.1 (TP), and 2.5 ± 1.2 (SP), with no significant differences (P = 0.32). At 48 hours, scores were 1.2 ± 0.8 (MTP), 1.4 ± 0.9 (TP), and 1.6 ± 1.0 (SP), again not statistically different (P = 0.28).

At the 1-month follow-up, the MTP and SP groups achieved excellent scar visibility (scores 8-10) in all patients, while the TP group had significantly lower rates of excellent cosmesis (P < 0.05). Representative postoperative scar appearances are shown in Figure 4.

Figure 4 Postoperative scar appearance. A: Postoperative scar appearance 1 month after modified two-port laparoscopic cholecystectomy: Umbilical and sub-xiphoid incisions with minimal visibility; B: Postoperative scar appearance 1 month after single-port laparoscopic cholecystectomy: Umbilical incisions with minimal visibility; C: Postoperative scar appearance 10 days after three-port laparoscopic cholecystectomy: Umbilical and sub-xiphoid incisions with mild bruise and early signs of healing.

Figure 4A demonstrates the remarkable cosmetic result achieved through the MTP LC technique. The incision sites, located within the umbilicus and sub-xiphoid, are nearly imperceptible, reflecting minimal scarring and excellent healing, highlighting the aesthetic advantage of the MTP method. Figure 4B demonstrates the remarkable cosmetic result achieved through the SP LC technique. The incision site, located within the umbilicus, is nearly imperceptible, indicating minimal scarring and excellent healing, highlighting the aesthetic advantage of the SP method. Figure 4C displays three well-placed incision sites with mild bruising and early signs of healing. While the presence of multiple ports affects cosmetic appearance compared to lesser port methods, the outcome remains clinically acceptable and within expected postoperative norms. Continued improvement in scar appearance is anticipated with proper wound care.

DISCUSSION

This retrospective cohort study systematically compared MTP, SP, and TP LC, focusing on cosmetic outcomes, operative efficiency, safety, and recovery. The key novelty lies in the comprehensive evaluation of three techniques in a single cohort, addressing the lack of rigorous comparative data on MTP LC.

Operative efficiency

SP LC was associated with significantly longer operative times (103.1 ± 34.9 minutes) compared to MTP and TP LC. This aligns with previous studies highlighting technical challenges of SP surgery, including limited instrument triangulation, restricted maneuverability, and ergonomic constraints that prolong dissection and retraction[15-17]. In contrast, MTP LC balanced minimal invasiveness with surgical feasibility: Its operative time (52.5 ± 19.5 minutes) was comparable to that of TP LC (55.2 ± 23.0 minutes), indicating that the clustered port design (dual umbilical + sub-xiphoid incisions) resolves the technical limitations of SP LC without compromising efficiency.

Safety and recovery

All groups had minimal blood loss (< 10 mL), reflecting the inherent advantage of laparoscopic surgery in reducing tissue and vascular trauma[18]. The SP group had a 9.1% rate of abdominal infection, but this was not statistically significant from that of the other two groups after Bonferroni correction and adjusting for baseline covariates. This finding is consistent with reports of potential higher complication risks in SP procedures due to concentrated instrument insertion through a single incision, but the small sample size in the SP group (n = 11) makes it vulnerable to single-event outliers, limiting definitive safety conclusions[19,20]. MTP had no postoperative complications, likely due to its balanced port placement (distributing instruments across two umbilical incisions and a sub-xiphoid incision) that reduces local tissue stress and infection risk.

MTP also had the shortest hospital stay (1.2 ± 0.5 days), attributed to minimal tissue trauma, short operative time, and absence of complications, factors that collectively accelerate recovery. While length of stay differences were not statistically significant among groups, the clinical relevance of shorter hospital stays (e.g., reduced healthcare costs and faster return to normal activities) supports MTP LC as a patient-centered option. Postoperative pain scores were similar across all groups, suggesting that reduced-port techniques do not offer significant analgesic benefits compared to TP LC in this cohort. This may be due to the overall minimally invasive nature of LC, with pain primarily driven by peritoneal irritation rather than incision number.

Cosmetic outcomes

Cosmesis is a key patient-reported outcome in reduced-port surgery[20-23]. Both MTP and SP achieved excellent scar visibility, as their incisions were concealed within umbilical folds or sub-xiphoid regions. In contrast, TP’s three separate incisions (subumbilical, sub-xiphoid, and right subcostal) resulted in more visible scarring. This finding confirms that reduced-port techniques prioritize patient aesthetic preferences, with MTP offering the added benefit of avoiding SP’s technical drawbacks.

Patient selection

Gender distribution varied significantly: The SP and MTP groups had a higher proportion of female patients, reflecting greater emphasis on cosmetic outcomes among women[22,23]. The TP group had a higher mean age, likely due to its established safety profile, making it preferred for elderly patients who may be less tolerant of prolonged operative times or increased complication risks associated with SP LC[22,23]. The SP group’s lower BMI (22.3 ± 2.1 kg/m²) suggests that surgeons may select this procedure for patients with lower body fat to ensure adequate surgical exposure, as higher BMI can exacerbate SP’s technical challenges[22,23]. These patient selection patterns highlight the presence of selection bias, which was addressed via multivariable adjustment but remains a limitation of the retrospective design.

Limitations

Our study has limitations. First, its retrospective and non-randomized design introduced potential selection bias, as evidenced by the younger age, lower BMI, and exclusively female enrollment in the SP group, reflecting surgeon selection for technically favorable cases. Second, scar assessment was based on a subjective 10-point telephone scale rather than a validated tool (e.g., Patient and Observer Scar Assessment Scale, Vancouver Scar Scale), lacking inter-rater reliability. Third, postoperative pain data were incomplete (available for 89% of patients) and not systematically recorded preoperatively, limiting robust evaluation of analgesic outcomes. This is a major limitation in reduced-port surgery research. Fourth, the sample size for the SP group was small (n = 11), and long-term follow-up (> 6 months) is lacking, so incisional hernia rates (a potential risk in SP surgery[23]) cannot be confirmed. Fifth, all procedures were performed by a single surgeon, which improves consistency but limits external validity and generalizability to other centers or less experienced surgeons. We have initiated a 3-year follow-up study to address these gaps.

Clinical implications

The choice of surgical technique should be individualized based on patient priorities and characteristics: For patients prioritizing cosmesis and minimal invasiveness without compromising efficiency or safety, MTP LC is a promising option (hypothesis-generating, not definitive guidance). SP LC may be considered for patients with low BMI (≤ 22 kg/m²) who strongly prioritize a single scar, but patients should be counseled on longer operative times and potential for higher infection risks (limited by small sample size). TP LC remains a safe choice for elderly patients, those with high BMI, or those for whom operative time is a critical factor (e.g., comorbidities requiring shorter anesthesia exposure).

CONCLUSION

This study demonstrates that MTP LC is a balanced approach among the three techniques evaluated. It successfully bridges the gap between the superior cosmesis of SP surgery and the proven efficiency and safety of the conventional TP technique. While SP offers excellent cosmesis, its longer operative time and potential for higher complication risk restrict broad applicability. TP LC remains a safe alternative but is less favorable for patients prioritizing aesthetics. For surgeons and patients seeking an optimal balance between minimal scarring and operative practicality, MTP LC may be considered a preferred approach in selected cases, but conclusions are tempered by the retrospective design, selection bias, and small SP cohort. Future prospective studies with long-term follow-up and larger sample sizes are needed to confirm these findings and definitively establish the role of MTP LC in the surgical management of gallbladder disease.