Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

Contents lists available at ScienceDirect

Laparoscopic, Endoscopic and Robotic Surgery

journal homepage: www.keaipublishing.com/en/journals/
laparoscopic-endoscopic-and-robotic-surgery

Short-term outcomes of single-incision compared to multi-port

laparoscopic gastrectomy for gastric cancer: A meta-analysis of
randomized controlled trials
Sameh Hany Emile a, *, Samer Hani Barsom b
a
General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
b
Internal Medicine Department, University of South Dakota, Sanford School of Medicine, South Dakota, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Single-incision laparoscopic surgery has emerged as a safe and less invasive approach to
Received 21 September 2023 conventional multi-port laparoscopy. The present meta-analysis aimed to assess the collective outcomes
Received in revised form of single-incision laparoscopic gastrectomy (SILG) compared to multi-port laparoscopic gastrectomy
6 October 2023
(MLG) for gastric cancer.
Accepted 10 October 2023
Available online 14 October 2023
Methods: A PRISMA-compliant systematic review of randomized controlled trials (RCTs) that compared
SILG and MLG for gastric cancer in PubMed and Scopus through January 2023 was conducted. The main
Edited by Qingjie Zeng outcomes of the review were complications, postoperative pain, conversion to open surgery, hospital
stay, and recovery.
Keywords: Results: Three RCTs including 301 patients (61.8% male) were included. A total of 151 patients underwent
Single-incision SILG, and 150 underwent MLG. SILG was associated with a shorter operative time (WMD ¼ 16.39,
Laparoscopic 95% CI: 27.38 to 5.40, p ¼ 0.003; I2 ¼ 0%) and lower pain scores at postoperative day 3 (WMD ¼ 1.18,
Gastrectomy 95% CI: 2.27 to 0.091, p ¼ 0.033; I2 ¼ 99%) than MLG. There were no statistically significant differences
Meta-analysis
between the two groups in estimated blood loss (WMD ¼ e16.95, 95% CI: 35.84 to 1.95, p ¼ 0.078;
Randomized trials
I2 ¼ 82%), complications (OR ¼ 0.71, 95% CI: 0.36 to 1.42, p ¼ 0.337; I2 ¼ 0%), conversion to open surgery
(OR ¼ 0.33, 95% CI: 0.01 to 8.38, p ¼ 0.504), hospital stay (WMD ¼ 0.72, 95% CI: 0.92 to 2.36, p ¼ 0.056;
I2 ¼ 84%), time to first flatus (WMD ¼ 0.06, 95% CI: 0.14 to 0.26, p ¼ 0.566; I2 ¼ 0%), time to first
defecation (WMD ¼ 0.14, 95% CI: 0.46 to 0.18, p ¼ 0.392; I2 ¼ 0%), or time to first oral intake
(WMD ¼ 0.37, 95% CI: 0.75 to 1.49, p ¼ 0.520; I2 ¼ 94%).
Conclusions: SILG is associated with shorter operative times and less early postoperative pain than MLG.
The odds of complications, blood loss, hospital stay, and gastrointestinal recovery were similar between
the two procedures.
© 2023 Zhejiang University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co.
Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

1. Introduction endoscopy with endoscopic ultrasonography and biopsy, chest,

abdomen, and pelvis CT scanning with contrast, and PET-CT eval-
Gastric cancer is the fourth most frequent cancer worldwide and uation are all commonly used diagnostic modalities for gastric
the leading cause of cancer-related deaths.1 The exact cause of cancer.4 Gastric cancer should be managed using a multidisci-
gastric cancer is unclear. Proliferation/stem cell, NF-kappa, or Wnt/ plinary strategy. Simple endoscopic resection can be used for early
beta-catenin pathway dysregulation might be responsible for more lesions; however, radical gastrectomy is required to treat advanced
than 70% of gastric malignancies.2 Patients with gastric cancer may disease. Adjuvant chemotherapy and radiation therapy are rec-
present with non-specific symptoms,3 and upper gastrointestinal ommended for patients who have D2 lymph nodes dissection.
Early in the 1990s, laparoscopic gastrectomy was introduced.
Despite having a steep learning curve, laparoscopic gastrectomy
* Corresponding author: General Surgery Department, Mansoura University quickly proved safe and successful, with outcomes comparable to
Hospitals, Elgomhuoria Street, Mansoura, Egypt. those of open surgery while still offering all the advantages of
E-mail address: [email protected] (S.H. Emile).

https://doi.org/10.1016/j.lers.2023.10.001
2468-9009/© 2023 Zhejiang University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S.H. Emile and S.H. Barsom Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

minimally invasive surgery.5 Compared to open surgery, laparo- 2.4. Assessment of risk of bias
scopic surgery is associated with better short-term outcomes,
including less postoperative pain, quicker recovery, shorter hospital Two authors assessed the risk of bias in the studies using the risk
stays, fewer complications, and better cosmetics. Most crucially, the of bias 2 (ROB-2) tool,9 and any conflicts of interpretation of the
laparoscopic platform provides comparable long-term oncologic results were addressed by mutual consensus.
results to open gastrectomy, yet with improved quality of life.6
Single-incision laparoscopic access emerged as a practical and 2.5. Outcomes
less invasive alternative to traditional multi-incision laparoscopy.
Researchers presumed that accessing the peritoneal cavity with a The primary outcome of this review was postoperative com-
single rather than several stab incisions would further reduce plications. Secondary outcomes were operative time, blood loss,
postoperative pain and tissue trauma, and hence hasten recovery. conversion to open surgery, early postoperative pain, and hospital
Despite this sound concept, single-incision laparoscopy was stay.
deemed technically difficult. Several studies have examined the
effectiveness and safety of single-incision laparoscopic cholecys- 2.6. Statistical analysis
tectomy and nephrectomy, but only a few prospective trials have
assessed the outcomes of single-incision laparoscopic gastrectomy A meta-analysis was conducted using EZR™ (version 1.55) and R
(SILG).7 software (version 4.1.2). Differences between the two groups in
The present meta-analysis was aimed to assess the collective categorical variables were examined using odds ratio (OR) with 95%
outcomes of SILG compared to multi-port laparoscopic gastrectomy confidence interval (CI) whereas differences in continuous vari-
(MLG) for gastric cancer as reported in randomized controlled trials ables were examined using weighted mean difference (WMD). P
(RCTs). values less than 0.05 implied statistical significance when
comparing the two groups. If the continuous variables were re-
2. Methods ported in the studies as median and range, they were converted to
mean and standard deviation using an online program (http://
This meta-analysis was registered in the prospective register of vassarstats.net/median_range.html). Statistical heterogeneity was
systematic reviews (CRD42023411266) and was reported in assessed by the p value of the Cochrane Q test and the inconsistency
compliance with the guidelines of the PRISMA 2020.8 (I2) statistics (low if I2 < 25%, moderate if I2 ¼ 25%e75% and high if
I2 > 75%). A fixed-effect model was used to pool data when no
significant statistical heterogeneity was detected, and the binary
2.1. Literature search
random-effect model was used for pooling of data when significant
statistical heterogeneity (p value < 0.1) was observed.
Two investigators conducted a systematic literature search
independently looking for RCTs that compared the outcomes of
3. Results
SILG and MLG in the treatment of gastric cancer. PubMed and
Scopus were searched from inception through January 2023. The
3.1. Patient and study characteristics
reference list of each article was screened to look for further eligible
studies, and the PubMed function “related articles” was activated.
After screening 424 studies, three RCTs were included in the
After excluding duplicate reports and conference abstracts with no
analysis (Fig. 1). The three studies included 301 patients, 151 un-
full text, the remaining articles were filtered by title/abstract and
derwent SILG and 150 underwent MLG.10e12 All studies were con-
then by full-text screening.
ducted in Asian countries and involved distal gastrectomy for distal
gastric cancer. The patients were 186 (61.8%) male and 115 (38.2%)
2.2. Search keywords female, with a mean age ranging from 58.2 years to 64.7 years and a
mean BMI ranging from 22.1 kg/m2 to 24.4 kg/m2. The character-
The following keywords were used in the database search: istics of the patients in both groups are shown in Table 1. Two
“gastric cancer”, “stomach cancer”, “single-incision”, “laparoscopic studies had some risk of bias, and one had high risk according to the
gastrectomy”, “minimally invasive gastrectomy”, “single port”, ROB-2 tool (Table 2).
“uniport”, “outcomes”, “randomized”, “randomised”, and “clinical
trial”. The following syntax combination was used in the literature 3.2. Operative outcomes
search: (“gastric cancer” OR “stomach cancer”) AND (“single inci-
sion” OR “single port” OR “uniport”) AND (“laparoscopic gastrec- SILG was associated with a shorter mean operative time than
tomy” OR “minimally invasive gastrectomy”) AND (“randomized” MLG (WMD ¼ 16.39, 95% CI: 27.38 to 5.40, p ¼ 0.003; I2 ¼ 0%).
OR “randomised”). The difference in estimated blood loss was not statistically signifi-
cant between the two groups (WMD ¼ e16.95, 95% CI: 35.84 to
2.3. Article selection criteria 1.95, p ¼ 0.078; I2 ¼ 82%) (Fig. 2).
The odds of complications were similar between the two groups
We included RCTs published in the English language that (OR ¼ 0.71, 95% CI: 0.36 to 1.42, p ¼ 0.337; I2 ¼ 0%). Only one
compared SILG and MLG for gastric cancer. We excluded non- conversion to open surgery was recorded in the MLG group versus
randomized cohort studies, case series, previous reviews, and none in the SILG group. The two procedures had similar odds of
meta-analyses. No restrictions for sample size or follow-up dura- conversion to open surgery (OR ¼ 0.33, 95% CI: 0.01 to 8.38,
tion were used. p ¼ 0.504) (Table 3, Fig. 3).
The articles had to fulfill the following PICO criteria to be
included. P (Patients): patients with gastric cancer; I (Intervention): 3.3. Hospital stay and early pain
SILG; C (Comparator): MLG; O (Outcome): operative time, estimated
blood loss, conversion to open surgery, complications, hospital stay, SILG was associated with significantly lower pain scores at post-
and recovery. operative day 3 (WMD ¼ 1.18, 95% CI: 2.27 to 0.09, p ¼ 0.033;
128
S.H. Emile and S.H. Barsom Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

Fig. 1 PRISMA flow chart for study inclusion

Table 1
Characteristics of the studies

Study Country Duration Number Age, mean ± SD, y Male, n (%) BMI, mean ± SD, kg/m2

SILG MLG SILG MLG SILG MLG SILG MLG

Omori et al (2021)10 Japan Apr 2016eSep 2018 50 51 64.7 ± 1.4 63.9 ± 1.4 24 (48.0) 32 (62.7) 22.1 ± 0.4 22.7 ± 0.4
Teng et al (2022)11 China Jan 2019eApr 2021 58 59 58.5 ± 11.1 58.2 ± 11.3 37 (63.8) 35 (59.3) 22.9 ± 2.8 23.3 ± 3.5
Kang et al (2022)12 South Korea Sep 2017eFeb 2020 43 40 62.0 ± 9.7 58.9 ± 13.0 30 (69.8) 28 (70.0) 24.3 ± 2.8 24.4 ± 3.6

SILG, single-incision laparoscopic gastrectomy. MLG, multiport laparoscopic gastrectomy.

Table 2
Results of the quality assessment of randomized trials using the ROB-2 tool

Study Randomization Deviation from Missing Measurement Selection of Overall risk

process intended intervention outcome data of outcome reported result

Omori et al (2021)10 Low Some risk Low Some risk Low Some risk
Teng et al (2022)11 Some risk Some risk Low Some risk Low High
Kang et al (2022)12 Low Some risk Low Some risk Low Some risk

I2 ¼ 99%). Hospital stay was similar between the two groups studies and thus reached more solid conclusions. We found that
(WMD ¼ 0.72, 95% CI: 0.92 to 2.36, p ¼ 0.056; I2 ¼ 84%) (Fig. 4). SILG was associated with a similar safety profile to MLG, as the odds
of complications were similar between the two procedures. Using a
3.4. Gastrointestinal recovery single-port was not associated with increased conversion to open
surgery or delayed recovery, as hospital stay and gastrointestinal
There were no significant differences between the groups in the recovery parameters were similar to those of the conventional
mean time to first flatus (WMD ¼ 0.06, 95% CI: 0.14 to 0.26, MLG. The main benefits associated with SILG were shorter opera-
p ¼ 0.566; I2 ¼ 0%), time to first defecation (WMD ¼ 0.14, tive times and less early postoperative pain compared to MLG.
95% CI: 0.46 to 0.18, p ¼ 0.392; I2 ¼ 0%), or time to first oral intake The first single-incision laparoscopic surgery to treat gastric
(WMD ¼ 0.37, 95% CI: 0.75 to 1.49, p ¼ 0.520; I2 ¼ 94%) (Table 4, cancer was performed by Henckens et al, in 2010.13 The authors
Fig. 5). reported the resection of a gastric gastrointestinal stromal tumor in
an elderly male patient using a triport trocar through a 2-cm per-
4. Discussion iumbilical incision and reported promising outcomes with
confirmed R0 resection of the tumor, with no recorded complica-
The present meta-analysis included only RCTs to minimize the tions. Later, a study by Omori et al assessed the outcome of SILG in
burden of selection bias noted with observational, non-randomized seven patients with early distal gastric cancer who were not

129
S.H. Emile and S.H. Barsom Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

Fig. 2 Forest plot of operative time and estimated blood loss between the two groups

Table 3
Perioperative outcomes of single-incision and multi-port laparoscopic gastrectomy in the trials

Study Complications, n (%) Conversion, n (%) Operative time, mean ± SD, min Blood loss, mean ± SD, mL Hospital stay, mean ± SD, d

SILG MLG SILG MLG SILG MLG SILG MLG SILG MLG
10
Omori et al (2021) 4 (8.0) 6 (11.8) 0 (0.0) 1 (2.0) 183.50 ± 44.50 198.20 ± 75.30 12.80 ± 28.80 43.80 ± 28.60 9.75 ± 3.80 7.75 ± 1.40
Teng et al (2022)11 4 (6.9) 6 (10.2) 0 (0.0) 0 (0.0) 185.10 ± 40.70 207.00 ± 41.20 95.00 ± 68.20 110.10 ± 104.80 8.40 ± 2.70 9.20 ± 3.20
Kang et al (2022)12 9 (20.9) 10 (25.0) 0 (0.0) 0 (0.0) 148.90 ± 50.10 154.30 ± 53.30 14.20 ± 27.50 18.00 ± 24.80 7.75 ± 3.80 6.75 ± 2.30

SILG, single-incision laparoscopic gastrectomy. MLG, multiport laparoscopic gastrectomy.

Fig. 3 Forest plot of complications and conversion to open surgery between the two groups

required to be converted to laparotomy or multi-port surgery.14 The The RCTs included in this meta-analysis were based in different
median operative time of the procedure was 344 min, and no sig- countries, all from East Asia, which is expected, as the incidence of
nificant perioperative morbidities or mortality were recorded. gastric cancer is highest in this region.15 Male patients accounted

130
S.H. Emile and S.H. Barsom Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

Fig. 4 Forest plot of hospital stay and postoperative pain at day 3 between the two groups

Table 4
Gastrointestinal recovery after single-incision and multi-port laparoscopic gastrectomy in the trials

Study Time to first flatus, mean ± SD, d Time to first defecation, mean ± SD, d Time to first oral intake, mean ± SD, d

SILG MLG SILG MLG SILG MLG

Omori et al (2021)10 2.25 ± 0.90 2.25 ± 0.90 4.00 ± 1.70 4.25 ± 1.50 4.00 ± 2.30 2.50 ± 0.60
Teng et al (2022)11 2.75 ± 0.62 2.70 ± 0.90 4.00 ± 0.80 4.10 ± 1.20 3.20 ± 0.60 3.00 ± 0.90
Kang et al (2022)12 3.25 ± 1.40 3.00 ± 1.20 NR NR 2.25 ± 0.40 2.75 ± 0.90

SILG, single-incision laparoscopic gastrectomy. MLG, multiport laparoscopic gastrectomy. NR, not reported.

for more than 60% of the cohort studies, which is consistent with reviewed, as one study reported a shorter operative time with
the higher incidence of gastric cancer in men, as previously SILG,10 while another found the operative time to be vastly similar
reported.16 between the two procedures.12 Previous observational studies also
The first randomized trial to assess the outcomes of SILG was concluded similar operative times between the two procedures.18,19
conducted by Omori et al, who reported the principal benefits of An explanation of this discrepancy may be in the learning curve of
the single port approach as having less postoperative pain, less SILG, which, in terms of operative time, is approximately 30 cases
need for analgesia, and a shorter operative time than MLG.10 In a for surgeons with adequate experience with laparoscopic distal
subsequent RCT, Teng et al found similar blood loss, complications, gastrectomy.20
and postoperative recovery between the two groups.11 However, Only one RCT assessed quality of life after SILG compared to MLG
again, the pain score on the third postoperative day was signifi- and reported similar improvement in quality of life after both
cantly lower in the SILG group. In contrast, the third randomized procedures with no statistically significant difference.12 Notably,
trial concluded that the operative times and early pain scores were there was a better trend of pain and body image scales in the EORTC
similar between the two groups.12 QLQ STO22 module in the SILG group.
Perhaps the main advantage of SILG was that it was associated It is noteworthy that all RCTs included in this meta-analysis
with less early postoperative pain, as found in our analysis. How- involved distal gastrectomy for distal gastric cancer. However,
ever, it is important to note that while two trials reported lower SILG can be applied to more complex procedures, including prox-
pain scores with SILG,10,11 one RCT did not conclude the same.12 The imal and total gastrectomy. Omori and colleagues described a novel
authors of the latter study attribute the similar pain scores in their double-flap technique to perform pure single-port laparoscopic
study to the injection of bupivacaine to patients in the SILG and proximal gastrectomy.21 Additionally, Lee et al performed single-
MLG groups, which may have affected the results. Single-port ac- port proximal gastrectomy with double tract reconstruction.22
cess to the abdominal wall has been recognized to be associated Even in total gastrectomy, single-port surgery is still feasible, as
with less trauma to the abdominal wall and thus less postoperative Ertem et al used a four-access single port to perform a single-
pain.17 incision total gastrectomy and D2 lymphadenectomy for gastric
The second advantage associated with the use of SILG was a cancer.23
shorter operative time. According to our analysis, the use of SILG The present study has a number of limitations, such as the small
may shorten the total operative time by 16 min on average. number of studies and patients included in the analysis. However,
Nevertheless, this finding was not consistent among the trials since only RCTs were included, the evidence generated by this

131
S.H. Emile and S.H. Barsom Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

Fig. 5 Forest plot of gastrointestinal recovery between the two groups

meta-analysis, despite the small numbers, may be more robust Patient consent for publication
than that generated by systematic reviews of observational studies.
The meta-analysis did not report long-term oncologic outcomes of Not applicable.
SILG, as they were not reported in the original studies.
References

5. Conclusions 1. World Health Organization. Cancer: fact sheet No 297. Accessed 24 March,
2023. http://www.who.int/mediacentre/factsheets/fs297/en/
2. Ooi CH, Ivanova T, Wu J, et al. Oncogenic pathway combinations predict clinical
SILG is associated with shorter operative times and less early prognosis in gastric cancer. PLoS Genet. 2009;5(10):e1000676.
postoperative pain than MLG. The odds of complications, blood 3. Avital I, Pisters PWT, Kelsen DP, et al. Cancer of the stomach. In: DeVita VT,
Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer:
loss, hospital stay, and gastrointestinal recovery were similar be- Principles and Practice of Oncology. 9th ed. Philadelphia: Lippincott Williams &
tween the two procedures. Long-term follow-up of the published Wilkins; 2011:924e954.
RCTs is needed to verify the long-term outcomes of SILG. 4. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in
Oncology: Gastric Cancer. Version 3.2016. Accessed 24 March, 2023. http://
www.nccn.org/professionals/physician_gls/pdf/gastric.pdf
5. Tinoco RC, Tinoco AC, El-Kadre LJ. Sueth DM, Conde LM. Laparoscopic gas-
Author contributions trectomy for gastric cancer. Surg Laparosc Endosc Percutaneous Tech.
2009;19(5):384e387.
6. Lee Y, Kim H-H. Single-incision laparoscopic gastrectomy for gastric cancer.
Sameh Emile: conceptualization, data curation, formal analysis, J Gastric Cancer. 2017;17(3):193e203.
investigation, methodology, and writing - original draft. Samer 7. Pfluke JM, Parker M, Stauffer JA, et al. Laparoscopic surgery performed through
Barsom: conceptualization, methodology, validation, and writing - a single incision: a systematic review of the current literature. J Am Coll Surg.
2011;212(1):113e118.
review and editing. 8. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an
updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.
9. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of
bias in randomised trials. BMJ. 2019;366:l4898.
Conflict of interest 10. Omori T, Yamamoto K, Hara H, et al. A randomized controlled trial of single-
port versus multi-port laparoscopic distal gastrectomy for gastric cancer.
Sameh Emile receives consultancy fees from SafeHeal company. Surg Endosc. 2021;35(8):4485e4493.
11. Teng W, Liu J, Liu W, et al. Comparison of short-term outcomes between single-
Samer Barson has no disclosures.
incision plus one-port laparoscopic surgery and conventional laparoscopic
surgery for distal gastric cancer: a randomized controlled trial. Transl Cancer
Res. 2022;11(2):358e366.
Ethics approval 12. Kang SH, Yoo M, Hwang D, et al. Postoperative pain and quality of life after
single-incision distal gastrectomy versus multi-port laparoscopic distal gas-
trectomy for early gastric cancer - a randomized controlled trial. Surg Endosc.
Not applicable. 2023;37(3):2095e2103.

132
S.H. Emile and S.H. Barsom Laparoscopic, Endoscopic and Robotic Surgery 6 (2023) 127e133

13. Henckens T, Van de Putte D. Van Renterghem K, Ceelen W, Pattyn P, Van Nieu- dissection for gastric cancer: a propensity score-matched analysis. Ann Surg
wenhove Y. Laparoendoscopic single-site gastrectomy for a gastric GIST using Oncol. 2016;23(suppl 5):817e824.
double-bended instruments. J Laparoendosc Adv Surg Tech A. 2010;20(5):469e471. 19. Kim SM, Ha MH, Seo JE, et al. Comparison of single-port and reduced port
14. Omori T, Oyama T, Akamatsu H, Tori M, Ueshima S, Nishida T. Transumbilical totally laparoscopic distal gastrectomy for patients with early gastric cancer.
single-incision laparoscopic distal gastrectomy for early gastric cancer. Surg Surg Endosc. 2016;30(9):3950e3957.
Endosc. 2011;25(7):2400e2404. 20. Lee B, Lee YT, Park YS, Ahn SH, Park DJ, Kim HH. Learning curve of pure single-
15. Rahman R, Asombang AW, Ibdah JA. Characteristics of gastric cancer in Asia. port laparoscopic distal gastrectomy for gastric cancer. J Gastric Cancer.
World J Gastroenterol. 2014;20(16):4483e4490. 2018;18(2):182e188.
16. Matsuda A, Matsuda T, Shibata A, et al. Cancer incidence and incidence rates in 21. Omori T, Moon JH, Yanagimoto Y, Sugimura K, Miyata H, Yano M. Pure single-
Japan in 2007: a study of 21 population-based cancer registries for the port laparoscopic proximal gastrectomy using a novel double-flap technique.
Monitoring of Cancer Incidence in Japan (MCIJ) project. Jpn J Clin Oncol. Ann Laparosc Endosc Surg. 2017;2(8):123.
2013;43(3):328e336. 22. Lee CM, Park DW, Jung DH, et al. Single-port laparoscopic proximal gastrec-
17. Weibl P, Klingler HC, Klatte T, Remzi M. Current limitations and perspectives in tomy with double tract reconstruction for early gastric cancer: report of a case.
single port surgery: pros and cons laparo-endoscopic single-site surgery (LESS) J Gastric Cancer. 2016;16(3):200e206.
for renal surgery. Diagn Ther Endosc. 2010;2010:759431. 23. Ertem M, Ozveri E, Gok H, Ozben V. Single incision laparoscopic total gas-
18. Omori T, Fujiwara Y, Moon J, et al. Comparison of single-incision and con- trectomy and d2 lymph node dissection for gastric cancer using a four-access
ventional multi-port laparoscopic distal gastrectomy with D2 lymph node single port: the first experience. Case Rep Surg. 2013;2013:504549.

133