Single-Operator Multi-Port Cholecystectomy (SOMP) – Technique, Safety, and Efficacy

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The Single-Operator Multi-Port (SOMP) technique, wherein the surgeon independently manipulates all four ports using self-retaining retractors, remains poorly characterized in the literature. Aim : To describe the SOMP cholecystectomy technique and evaluate its feasibility, safety, and efficacy through analysis of surgical outcomes. Methods: We performed a retrospective review of consecutive laparoscopic cholecystectomies from July 2022 to April 2025, by a single surgeon who routinely uses the SOMP technique except when self-retaining retractors are unavailable. Patient demographics, surgical indications, operative time, estimated blood loss, conversion to open surgery, reoperation rate, 30-day readmission, and 30-day mortality were evaluated. Results: Among 124 consecutive laparoscopic cholecystectomies, 92 cases (74.2%) used the SOMP technique. In the SOMP cohort, the median age was 48, and 67 (72.8%) were female. Thirty-three procedures (35.9%) were elective. Surgical indications included symptomatic cholelithiasis (n=69), chronic cholecystitis (n=39), choledocholithiasis (n=25), biliary pancreatitis (n=16), and acute cholecystitis (n=14). Additional port placement for better retraction was needed in eight patients (8.7%). Median operative time was 75 minutes, with a median estimated blood loss of 25 mL. Four patients (4.3%) required readmission within 30 days. There were no reoperations or mortalities within 30 days. Multivariate analysis demonstrated that the SOMP technique was an independent factor associated with lower operative time (β for MOMP =41.2, p<0.001) and conversion rate to open approach (OR for MOMP = 20.4, p<0.001). Conclusion: The SOMP technique using self-retaining retractors is a safe and efficient approach to laparoscopic cholecystectomy, with possible benefits in improved ergonomics, reduced costs, and staffing needs. Trial Registration (Clinical trial details) : not applicable Laparoscopic cholecystectomy Single-operator surgery Surgical technique Self-retaining retractor Minimally invasive surgery Figures Figure 1 Figure 2 Introduction Laparoscopic cholecystectomy is established as the gold standard technique for surgical removal of the gallbladder, offering superior outcomes compared to open surgery, including reduced morbidity, shorter hospital stays, and accelerated recovery. 1 The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and other professional societies have endorsed routine clinical implementation of the laparoscopic technique for gallbladder removal. 2 Conventional laparoscopic cholecystectomy is a 4-port configuration that requires two operators – the primary operating surgeon, and a surgical assistant, who may be a surgical technologist, surgical trainee, or medical student. 3 This four-port configuration includes (a) a periumbilical port for the laparoscopic camera, (b) a port in the left upper quadrant for the surgeon’s right hand (employing the dominant surgical dissectors), (c) a right-sided port for constantly moving instrument for grasping assistance and (d) a right sided port for stable gallbladder fundus retraction. This typical configuration has inherent challenges: the operators must either cross their hands if the surgeon chooses to use both hands for dissection, or the surgeon must operate with the right hand only, while holding the camera with the left hand. Furthermore, reliance on a surgical assistant increases staffing needs or multitasking of the surgical technologist between the operating table and the back table, which are particularly problematic in the post-pandemic era of nationwide healthcare personnel shortages. Additionally, multiple studies have documented increased physical strain and reduced operational efficiency associated with suboptimal positioning, underscoring the imperative for enhanced ergonomic solutions. 4 , 5 Robot-assisted cholecystectomy represents an alternative approach designed to optimize surgeon comfort and precision. 6 However, this approach also requires an additional assistant at the operating table to change robotic instruments, staffing with robotic-trained personnel, high capital costs for robotic platform availability, and steeper learning curves without demonstrable meaningful advantages to the laparoscopic approach in terms of operative time, readmission rates, length of stay, or 30-day reoperation rates. 7 , 8 Here, we investigate the technical feasibility, success rate, and safety of a simplified solution to the limitations of the standard laparoscopic cholecystectomy technique by the routine use of laparoscopic self-retaining metal retractors for two of the four ports: for steady gallbladder retraction and stable camera holding. This Single-Operator Multi-Port (SOMP) technique enables the surgeon to operate without using a surgical assistant, while also enhancing ergonomics, reducing workspace crowding, and reducing staffing needs for laparoscopic cholecystectomy. Methods Study design and patient selection We conducted a single-center retrospective cohort study at a tertiary care institution. The study period extended from July 2022 to April 2025, and all patients undergoing cholecystectomy were performed by a single surgeon who used the Single-Operator Multi-Port (SOMP) technique routinely as the initial approach for all cholecystectomies. At times of instrument unavailability of the self-retaining metal retractors, the standard conventional technique of at least 2 operators handling the four ports was used. The latter conventionally used technique is referred to as the Multi-Operator Multi-Port (MOMP) technique in this study. The study protocol was reviewed and approved by the Institutional Review Board at Cape Fear Valley Health System, Fayetteville, North Carolina, USA. After approval, all data were obtained retrospectively from electronic medical records (EMR). Description of the SOMP technique After induction of the general anesthesia, a urinary catheter and an orogastric tube were placed. A footboard was placed, and the patient was securely strapped to the operating room table. The main laparoscopic tower was positioned on the left head end of the patient, and the slimmer remote monitor was positioned on the right head end of the patient. The electocautery console and suction devices were positioned at the foot end of the table. The primary operator (surgeon) would stand on the left side of the patient, and the surgical technologist on the left foot end of the table. The abdomen was prepped and draped in a sterile fashion. After a time-out was performed, the procedure was begun with a Veress needle entry in the left upper quadrant, where a 5mm port was inserted under direct laparoscopic vision after insufflation. A 10mm port was placed in the periumbilical area. A 5mm port was placed about 4–5 fingerbreaths lateral to the periumbilical port on the right abdomen. After the usual survey of the peritoneal cavity and any necessary lysis of adhesions to expose the gallbladder, the optimal positioning of the other 5 mm right-sided port for gallbladder retraction was assessed. Accordingly, the latter port was placed, and the gallbladder was retracted cranially and laterally to expose the hepatocystic triangle. At this point, a self-retaining laparoscopic metal retractor was used to hold the port for gallbladder retraction in place ( Fig. 1 ). Then, the optimal position of the 10 mm, 30-degree camera positioning was assessed, and another self-retaining laparoscopic metal retraction was used to stabilize the camera in this position ( Fig. 2 ). The dissection of the gallbladder was begun by dissecting the soft tissues of the hepatocystic triangle, after which the inferior third of the gallbladder was mobilized from the gallbladder fossa. After the critical view of safety with the cystic artery and cystic duct being the only two structures connecting the gallbladder to the porta hepatis was visualized, the cystic artery and the cystic duct (in that order) were ligated between metallic clips. The gallbladder was then dissected away from the gallbladder fossa using a bipolar sealing device. Once the specimen was detached from the liver, it was placed in a specimen bag. At this point, the self-retaining metal retractors were detached, and the specimen bag was retrieved from the peritoneal cavity, following which the peritoneal cavity was desufflated. Upon reinflation, hemostasis was ensured. The port site fascial and skin incisions were closed using standard closure techniques. Of note, detaching or repositioning of the self-retaining retractors during dissection was rarely needed. The standard 4-port technique, referred to as the MOMP technique in this study, utilized similar port placement locations and differed only in the absence of the use of self-retaining metal retractors. In these cases, the surgeon used the left upper quadrant port with the right hand and the right-sided port adjacent to the periumbilical port with the left hand for two-handed dissection. The assistant stood on the right side of the patient, holding the camera with the right hand and the right-sided port for steady gallbladder retraction with the left hand. Occasionally, if an additional assistant was available, one of them would stand on the right side of the patient retracting the gallbladder, while the other assistant stood on the left side of the patient, towards the foot of the patient, holding the camera. With both SOMP and MOMP techniques, additional ports were used in certain cases for retraction of redundant liver or retraction of swollen retroperitoneal tissue from pancreatitis to assist in exposure. Data Collection Data pertaining to patient demographics, surgical indications, intraoperative parameters, conversion rates, and 30-day outcomes were extracted from the electronic medical records. Patient demographics collected included age, sex, body mass index, and American Society of Anesthesiologists classification. Surgery indication parameters collected included the presence of one or more of the following: symptomatic cholelithiasis, choledocholithiasis, cholecystitis (acute, acute on chronic, or chronic), or pancreatitis. Patients operated emergently or during the same admission after ER presentation were classified as ‘urgent’, while patients scheduled electively as an outpatient were classified as ‘elective’. Intraoperative parameters collected included operative time (skin incision to skin closure), operating room time (anaesthesia start to case close), estimated blood loss, total number of ports used, and conversion to open surgery. 30-day outcome parameters collected included mortality rate, reoperation (return to the operating room), and re-admission. Statistical analysis. Continuous variables were reported as mean ± standard deviation or median with interquartile range, and categorical variables as frequencies and percentages. Comparative analyses employed chi-square tests for categorical data and independent sample t-tests for continuous variables. Statistical significance was defined as p < 0.05. Analyses were performed using SPSS statistical software. Results During the study period, 124 consecutive laparoscopic cholecystectomies were performed, with 92 cases (74.2%) utilizing the SOMP technique and 32 cases (25.8%) employing the conventional MOMP approach. Baseline demographic and clinical characteristics are summarized in Table 1 . Table 1 Patient demographics and baseline characteristics. This table presents the demographic and clinical characteristics of patients undergoing laparoscopic surgery, stratified by surgical approach. Variable SOMP Group (n = 92) MOMP Group (n = 32) p-value Age, median 48 51 0.464 SEX (F/M) 66/ 26 15/17 0.011 BMI, median 31.8 31.65 0.550 ASA Classification, n (%) - I 2 (2.2) 2 (6.3) 0.184 - II 46 (49.5) 10 (31.3) - III 36 (38.7) 18 (56.3) - IV 9 (9.7) 2 (6.3) Elective surgery/Urgent n 33/59 8/24 0.260 The median age, body mass index, and ASA classification distribution were comparable between study groups. The proportion of urgent cases was notably lower in the SOMP group (64.1% vs. 75.0%); however, this difference was not statistically significant (p = 0.26). The groups differed significantly in sex distribution, with a higher proportion of females in the SOMP group (71.7% vs. 46.9%, p = 0.01). Among surgical indications, there was a higher prevalence of choledocholithiasis in the SOMP group (27.2% vs. 3.1%, p = 0.003), while acute-on-chronic cholecystitis was more prevalent in the MOMP group (37.5% vs. 4.3%, p = 0.007). The prevalence of symptomatic cholelithiasis and history of pancreatitis were similar between groups. Surgical indications are summarized in Table 2 . Table 2 Surgical Indication by Group. This table represents univariate comparisons between the distribution of diagnoses associated with cholecystectomy. Surgical Indication SOMP Group (n = 92) MOMP Group (n = 32) p-value Choledocholithiasis 25 1 0.004 Pancreatitis 15 4 0.607 Symptomatic Cholelithiasis 68 19 0.122 Chronic Cholecystitis (including acute on chronic) 38 17 0.246 Acute on Chronic Cholecystitis 4 12 0.008 Acute Cholecystitis 14 7 0.387 Port utilization patterns were similar between groups (p = 0.26). Intraoperative cholangiography was performed less frequently in the SOMP group compared to the MOMP group (3.2% vs. 18.8%, p = 0.004). Operative time was significantly shorter with the SOMP technique compared to the MOMP technique (75 minutes vs. 110 minutes, p < 0.001). Similarly, total operating room time was reduced in the SOMP cohort (90 minutes vs. 135 minutes, p < 0.001). Median estimated blood loss was significantly lower in the SOMP group (25 mL vs. 50 mL, p < 0.001). No conversions to open surgery occurred in the SOMP group, whereas 6 cases (18.8%) in the MOMP group required conversion to laparotomy, representing a statistically significant difference (p < 0.001). Intraoperative outcomes are summarized in Table 3 . Table 3 Intraoperative Parameters. This table represents the univariate analysis of intraoperative outcomes associated with the study groups. Variable SOMP (n = 92) MOMP (n = 32) p-value Case Close time (min) 75 110 0.000 Case finish time (min) 90 135 0.000 Estimated blood loss, mL 25 50 0.000 Ports Used 0.262 4 or less 85 28 5 6 2 6 1 2 Conversion to open, n (%) 0 (0) 6 (18.8) 0.000 Intraoperative cholangiogram, n (%) 3 (3.2) 6 (18.8) 0.004 There were no reoperations, mortalities, or bile duct injuries in either group. The 30-day readmission rate was lower in the SOMP group (3.2% vs. 12.5%); however, this difference did not reach statistical significance (p = 0.05). Post-operative outcomes are summarized in Table 4 . Table 4 Thirty-Day Postoperative Outcomes. This table represents the univariate analysis of the comparison of postoperative outcomes between the study cohorts. Outcome SOMP (n = 93) MOMP (n = 32) p-value Readmission 3 (3.2%) 4 (12.5%) 0.051 Reoperation 0 0 - Mortality 0 0 - Postoperative complications 0 0 - Multivariate regression analyses were conducted to identify independent factors associated with specific operative outcomes, namely operative time and conversion rate to an open approach (Table 5 ). Sex, BMI, and port utilization were not independently associated with operative time or conversion rate to open surgery. ASA classifications did not demonstrate an association with the conversion rate; however, higher ASA classes (III and IV) were correlated with increased operative times. The elective versus urgent scheduling of the procedure was not associated to the conversion rate; however, urgent scheduling was independently associated with prolonged operative time (β = 27.9, p < 0.001). Table 5 Mutivariate analysis associated with surgical outcomes. This table represents the multivariate analyses to determine the independent factors associated with operative time and conversion rate to open approach between the study cohorts. Variable Operative Time: β [95% CI] p-value Conversion to Open: OR [95% CI] p-value Female 1 (Reference) – 1 (Reference) – Male 2.5 [-7.0 to 12.0] 0.61 0.89 [0.38 to 3.33] 0.83 Age 0.31 [0.03 to 0.59] 0.03 1.02 [0.97 to 1.07] 0.42 BMI 0.11 [-0.33 to 0.55] 0.62 1.04 [0.99 to 1.09] 0.11 Elective 1 (Reference) – 1 (Reference) – Urgent 27.9 [11.8 to 44.0] < 0.001 1.93 [0.62 to 6.04] 0.25 I 1 (Reference) – 1 (Reference) – II 9.7 [-1.9 to 21.3] 0.10 1.39 [0.21 to 9.04] 0.73 III 15.8 [3.0 to 28.6] 0.016 2.93 [0.52 to 16.38] 0.22 IV 20.4 [1.8 to 39.0] 0.032 4.01 [0.53 to 30.58] 0.18 ≤4 1 (Reference) – 1 (Reference) – >4 3.0 [-3.9 to 9.9] 0.40 0.92 [0.38 to 2.22] 0.85 SOMP 1 (Reference) – 1 (Reference) – MOMP 41.2 [27.3 to 55.1] < 0.001 20.4 [4.7 to 88.5] < 0.001 In comparison to the SOMP technique, the conventional MOMP technique was independently associated with a markedly increased operative times (β = 41.2, p < 0.001) and a higher conversion rate to open approach (OR = 20.4, p < 0.001). Discussion This study addresses the inherent frustration arising from the ergonomic and operational challenges associated with conventional laparoscopic cholecystectomy. The traditional multi-operator technique inevitably necessitates hands crossing, workspace crowding, and suboptimal positioning that can compromise surgical precision. 9 These limitations are particularly pronounced in teaching environments, where attending surgeons must simultaneously manage camera control, tissue retraction, and trainee supervision 10 . The reliance on assistants for camera manipulation often introduces unwanted movement and instability to variable degrees, creating a steep learning curve for maintaining steady visualization. 11 Some surgeons have resorted to a single-handed operation while controlling the camera, which contradicts fundamental surgical principles emphasizing bimanual traction and counter-traction techniques. At our institution, the SOMP technique was routinely employed for all cholecystectomies by the corresponding author, unless self-retaining retractors were unavailable due to concurrent use, sterilization requirements, or contamination. Our findings demonstrated that this approach maintains the established excellent safety profile of the standard multi-operator technique, with zero mortality, bile duct injuries, or reoperations in the SOMP cohort. The observed demographic differences between groups reflect the author’s approach of reverting to the MOMP technique only during instrument unavailability. Such circumstances typically occur during on-call days or post-call days when procedures are performed as ‘add-ons’ to existing elective schedules. This explains the higher prevalence of acute cholecystitis and subsequent increased rates of open conversion and intraoperative cholangiography in the MOMP group. Conversely, the SOMP cohort demonstrated a higher proportion of female patients and elective procedures, consistent with the typical demographics of symptomatic cholelithiasis. These case mix differences also explain the higher estimated blood loss observed in the MOMP group. While demographic differences may partially explain the shorter operative times with the SOMP technique, our study demonstrates that routine SOMP implementation does not compromise efficiency. The stable camera positioning enabled by self-retaining retractors facilitated more expeditious surgical progress in the primary surgeon's experience. These findings provide adequate empirical evidence supporting SOMP as a feasible, safe, and technically streamlined alternative to conventional multi-operator laparoscopic cholecystectomy. Multivariate analyses demonstrated that the SOMP technique was associated with operative times and conversion rate, not greater than the MOMP technique. This study's limitations include its single-surgeon design and retrospective data collection methodology. 12 Potential advantages not quantified in this analysis include cost savings through reduced staffing requirements for laparoscopic cholecystectomy. 6 , 13 , 14 In the author's experience, the SOMP technique significantly enhances surgical education by eliminating distractions associated with unnecessary instrument manipulation, allowing trainees to focus on critical operative steps. Future investigations should explore comparative learning curves between SOMP and conventional MOMP techniques, as well as economic analyses quantifying potential cost reductions. We conclude that the single-operator technique utilizing two self-retaining metal retractors (commonly available laparoscopic instruments) represents a simplified solution to the ergonomic challenges and operator dependency inherent in standard laparoscopic cholecystectomy. This approach demonstrates adequate feasibility, safety, and efficacy while potentially offering significant operational advantages in contemporary surgical practice. Declarations Ethics approval and consent to participate: The study protocol was reviewed and approved by the Institutional Review Board at Cape Fear Valley Health System, Fayetteville, North Carolina, USA. The need for informed consent was waived due to the retrospective nature of the study. The study was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. Consent for publication : Not applicable. Availability of data and materials : The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Authors’ contributions N.B – study design, data analysis, manuscript drafting, critical revision, final approval. H.C – data collection, literature review, statistical analysis, final approval. K.E – data collection, literature review, final approval. W.B – data collection, manuscript editing, final approval. I.A – data collection, manuscript editing, final approval. P.T – conceptualization, supervision, critical revision of manuscript, final approval. Acknowledgements Not applicable. Corresponding author Niraj Balakrishnan ( [email protected] ) Clinical Trial Details Not a clinical trial Clinical trial number Not applicable Conflict of Interest The authors declare no conflicts of interest. References Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy: the new 'gold standard'? 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Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy. Am J Surg . 1993 Apr;165(4):466–71. doi:10.1016/S0002-9610(05)80942-0 American College of Surgeons. Robotic cholecystectomy incurs more disposable cost than laparoscopic with similar outcomes. ACS Brief . 2025 Apr 8 [cited 2025 Jul 22]. Available from: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/acs-brief/april-8-2025-issue/robotic-cholecystectomy-incurs-more-disposable-cost-than-laparoscopic-with-similar-outcomes/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Dec, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 29 Oct, 2025 Reviews received at journal 29 Oct, 2025 Reviews received at journal 29 Oct, 2025 Reviews received at journal 27 Oct, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviewers agreed at journal 25 Oct, 2025 Reviews received at journal 21 Oct, 2025 Reviewers agreed at journal 19 Oct, 2025 Reviewers agreed at journal 18 Oct, 2025 Reviewers agreed at journal 17 Oct, 2025 Reviews received at journal 09 Oct, 2025 Reviewers agreed at journal 02 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers invited by journal 01 Oct, 2025 Editor assigned by journal 01 Oct, 2025 Editor invited by journal 29 Sep, 2025 Submission checks completed at journal 29 Sep, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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06:43:40","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69953,"visible":true,"origin":"","legend":"","description":"","filename":"dec347a74045438aae585248877308021structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7513603/v1/7aedaae361663979a77f76db.xml"},{"id":93556605,"identity":"34a1c67b-23d7-4eb8-8e56-93c4641f1381","added_by":"auto","created_at":"2025-10-15 06:43:40","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76729,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7513603/v1/c45f28f498cda51bdedd337f.html"},{"id":93556596,"identity":"417dc1b9-64f8-45b3-ab70-01b60e01e299","added_by":"auto","created_at":"2025-10-15 06:43:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":814725,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePlacement of self-retaining retractors. (A) Retractor used for retracting the gallbladder fundus. (B) Retractor used for holding the camera.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7513603/v1/4f83e65e0fe79029e6ad5907.png"},{"id":93556595,"identity":"4bfc8ed8-8805-4504-985c-0fe627fbea00","added_by":"auto","created_at":"2025-10-15 06:43:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":111584,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurgeon positioning during the procedure, illustrating ergonomic comfort and lack of crowding.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7513603/v1/30876f66f056798dd0db6632.png"},{"id":99172856,"identity":"26917fcd-6a19-4f3e-bcfe-fc43691ad8e9","added_by":"auto","created_at":"2025-12-29 16:11:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1733727,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7513603/v1/02cc4b98-34bf-4947-af9d-9d5a2c990bdd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Operator Multi-Port Cholecystectomy (SOMP) – Technique, Safety, and Efficacy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLaparoscopic cholecystectomy is established as the gold standard technique for surgical removal of the gallbladder, offering superior outcomes compared to open surgery, including reduced morbidity, shorter hospital stays, and accelerated recovery.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and other professional societies have endorsed routine clinical implementation of the laparoscopic technique for gallbladder removal.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eConventional laparoscopic cholecystectomy is a 4-port configuration that requires two operators \u0026ndash; the primary operating surgeon, and a surgical assistant, who may be a surgical technologist, surgical trainee, or medical student.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This four-port configuration includes (a) a periumbilical port for the laparoscopic camera, (b) a port in the left upper quadrant for the surgeon\u0026rsquo;s right hand (employing the dominant surgical dissectors), (c) a right-sided port for constantly moving instrument for grasping assistance and (d) a right sided port for stable gallbladder fundus retraction. This typical configuration has inherent challenges: the operators must either cross their hands if the surgeon chooses to use both hands for dissection, or the surgeon must operate with the right hand only, while holding the camera with the left hand. Furthermore, reliance on a surgical assistant increases staffing needs or multitasking of the surgical technologist between the operating table and the back table, which are particularly problematic in the post-pandemic era of nationwide healthcare personnel shortages. Additionally, multiple studies have documented increased physical strain and reduced operational efficiency associated with suboptimal positioning, underscoring the imperative for enhanced ergonomic solutions.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRobot-assisted cholecystectomy represents an alternative approach designed to optimize surgeon comfort and precision.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e However, this approach also requires an additional assistant at the operating table to change robotic instruments, staffing with robotic-trained personnel, high capital costs for robotic platform availability, and steeper learning curves without demonstrable meaningful advantages to the laparoscopic approach in terms of operative time, readmission rates, length of stay, or 30-day reoperation rates.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHere, we investigate the technical feasibility, success rate, and safety of a simplified solution to the limitations of the standard laparoscopic cholecystectomy technique by the routine use of laparoscopic self-retaining metal retractors for two of the four ports: for steady gallbladder retraction and stable camera holding. This Single-Operator Multi-Port (SOMP) technique enables the surgeon to operate without using a surgical assistant, while also enhancing ergonomics, reducing workspace crowding, and reducing staffing needs for laparoscopic cholecystectomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and patient selection\u003c/h2\u003e\u003cp\u003eWe conducted a single-center retrospective cohort study at a tertiary care institution. The study period extended from July 2022 to April 2025, and all patients undergoing cholecystectomy were performed by a single surgeon who used the Single-Operator Multi-Port (SOMP) technique routinely as the initial approach for all cholecystectomies. At times of instrument unavailability of the self-retaining metal retractors, the standard conventional technique of at least 2 operators handling the four ports was used. The latter conventionally used technique is referred to as the Multi-Operator Multi-Port (MOMP) technique in this study.\u003c/p\u003e\u003cp\u003e The study protocol was reviewed and approved by the Institutional Review Board at Cape Fear Valley Health System, Fayetteville, North Carolina, USA. After approval, all data were obtained retrospectively from electronic medical records (EMR).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDescription of the SOMP technique\u003c/h3\u003e\n\u003cp\u003eAfter induction of the general anesthesia, a urinary catheter and an orogastric tube were placed. A footboard was placed, and the patient was securely strapped to the operating room table. The main laparoscopic tower was positioned on the left head end of the patient, and the slimmer remote monitor was positioned on the right head end of the patient. The electocautery console and suction devices were positioned at the foot end of the table. The primary operator (surgeon) would stand on the left side of the patient, and the surgical technologist on the left foot end of the table. The abdomen was prepped and draped in a sterile fashion. After a time-out was performed, the procedure was begun with a Veress needle entry in the left upper quadrant, where a 5mm port was inserted under direct laparoscopic vision after insufflation. A 10mm port was placed in the periumbilical area. A 5mm port was placed about 4\u0026ndash;5 fingerbreaths lateral to the periumbilical port on the right abdomen. After the usual survey of the peritoneal cavity and any necessary lysis of adhesions to expose the gallbladder, the optimal positioning of the other 5 mm right-sided port for gallbladder retraction was assessed. Accordingly, the latter port was placed, and the gallbladder was retracted cranially and laterally to expose the hepatocystic triangle. At this point, a self-retaining laparoscopic metal retractor was used to hold the port for gallbladder retraction in place \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Then, the optimal position of the 10 mm, 30-degree camera positioning was assessed, and another self-retaining laparoscopic metal retraction was used to stabilize the camera in this position \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e The dissection of the gallbladder was begun by dissecting the soft tissues of the hepatocystic triangle, after which the inferior third of the gallbladder was mobilized from the gallbladder fossa. After the critical view of safety with the cystic artery and cystic duct being the only two structures connecting the gallbladder to the porta hepatis was visualized, the cystic artery and the cystic duct (in that order) were ligated between metallic clips. The gallbladder was then dissected away from the gallbladder fossa using a bipolar sealing device. Once the specimen was detached from the liver, it was placed in a specimen bag. At this point, the self-retaining metal retractors were detached, and the specimen bag was retrieved from the peritoneal cavity, following which the peritoneal cavity was desufflated. Upon reinflation, hemostasis was ensured. The port site fascial and skin incisions were closed using standard closure techniques. Of note, detaching or repositioning of the self-retaining retractors during dissection was rarely needed.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe standard 4-port technique, referred to as the MOMP technique in this study, utilized similar port placement locations and differed only in the absence of the use of self-retaining metal retractors. In these cases, the surgeon used the left upper quadrant port with the right hand and the right-sided port adjacent to the periumbilical port with the left hand for two-handed dissection. The assistant stood on the right side of the patient, holding the camera with the right hand and the right-sided port for steady gallbladder retraction with the left hand. Occasionally, if an additional assistant was available, one of them would stand on the right side of the patient retracting the gallbladder, while the other assistant stood on the left side of the patient, towards the foot of the patient, holding the camera.\u003c/p\u003e\u003cp\u003eWith both SOMP and MOMP techniques, additional ports were used in certain cases for retraction of redundant liver or retraction of swollen retroperitoneal tissue from pancreatitis to assist in exposure.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData pertaining to patient demographics, surgical indications, intraoperative parameters, conversion rates, and 30-day outcomes were extracted from the electronic medical records. Patient demographics collected included age, sex, body mass index, and American Society of Anesthesiologists classification. Surgery indication parameters collected included the presence of one or more of the following: symptomatic cholelithiasis, choledocholithiasis, cholecystitis (acute, acute on chronic, or chronic), or pancreatitis. Patients operated emergently or during the same admission after ER presentation were classified as \u0026lsquo;urgent\u0026rsquo;, while patients scheduled electively as an outpatient were classified as \u0026lsquo;elective\u0026rsquo;. Intraoperative parameters collected included operative time (skin incision to skin closure), operating room time (anaesthesia start to case close), estimated blood loss, total number of ports used, and conversion to open surgery. 30-day outcome parameters collected included mortality rate, reoperation (return to the operating room), and re-admission.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis.\u003c/h2\u003e\u003cp\u003eContinuous variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median with interquartile range, and categorical variables as frequencies and percentages. Comparative analyses employed chi-square tests for categorical data and independent sample t-tests for continuous variables. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analyses were performed using SPSS statistical software.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, 124 consecutive laparoscopic cholecystectomies were performed, with 92 cases (74.2%) utilizing the SOMP technique and 32 cases (25.8%) employing the conventional MOMP approach. Baseline demographic and clinical characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePatient demographics and baseline characteristics.\u003c/b\u003e This table presents the demographic and clinical characteristics of patients undergoing laparoscopic surgery, stratified by surgical approach.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSOMP Group (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMOMP Group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, median\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.464\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSEX (F/M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66/ 26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI, median\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.550\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA Classification, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.184\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (49.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (31.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (38.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (56.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (6.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElective surgery/Urgent n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33/59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8/24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.260\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe median age, body mass index, and ASA classification distribution were comparable between study groups. The proportion of urgent cases was notably lower in the SOMP group (64.1% vs. 75.0%); however, this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.26). The groups differed significantly in sex distribution, with a higher proportion of females in the SOMP group (71.7% vs. 46.9%, p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003eAmong surgical indications, there was a higher prevalence of choledocholithiasis in the SOMP group (27.2% vs. 3.1%, p\u0026thinsp;=\u0026thinsp;0.003), while acute-on-chronic cholecystitis was more prevalent in the MOMP group (37.5% vs. 4.3%, p\u0026thinsp;=\u0026thinsp;0.007). The prevalence of symptomatic cholelithiasis and history of pancreatitis were similar between groups. Surgical indications are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eSurgical Indication by Group.\u003c/b\u003e This table represents univariate comparisons between the distribution of diagnoses associated with cholecystectomy.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Indication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSOMP Group (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMOMP Group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholedocholithiasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.607\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptomatic Cholelithiasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic Cholecystitis (including acute on chronic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.246\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute on Chronic Cholecystitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute Cholecystitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.387\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePort utilization patterns were similar between groups (p\u0026thinsp;=\u0026thinsp;0.26). Intraoperative cholangiography was performed less frequently in the SOMP group compared to the MOMP group (3.2% vs. 18.8%, p\u0026thinsp;=\u0026thinsp;0.004). Operative time was significantly shorter with the SOMP technique compared to the MOMP technique (75 minutes vs. 110 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, total operating room time was reduced in the SOMP cohort (90 minutes vs. 135 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Median estimated blood loss was significantly lower in the SOMP group (25 mL vs. 50 mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eNo conversions to open surgery occurred in the SOMP group, whereas 6 cases (18.8%) in the MOMP group required conversion to laparotomy, representing a statistically significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Intraoperative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative Parameters.\u003c/b\u003e This table represents the univariate analysis of intraoperative outcomes associated with the study groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSOMP (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMOMP (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase Close time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase finish time (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEstimated blood loss, mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePorts Used\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.262\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4 or less\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion to open, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative cholangiogram, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere were no reoperations, mortalities, or bile duct injuries in either group. The 30-day readmission rate was lower in the SOMP group (3.2% vs. 12.5%); however, this difference did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.05). Post-operative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eThirty-Day Postoperative Outcomes.\u003c/b\u003e This table represents the univariate analysis of the comparison of postoperative outcomes between the study cohorts.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSOMP (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMOMP (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReadmission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReoperation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultivariate regression analyses were conducted to identify independent factors associated with specific operative outcomes, namely operative time and conversion rate to an open approach (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Sex, BMI, and port utilization were not independently associated with operative time or conversion rate to open surgery. ASA classifications did not demonstrate an association with the conversion rate; however, higher ASA classes (III and IV) were correlated with increased operative times. The elective versus urgent scheduling of the procedure was not associated to the conversion rate; however, urgent scheduling was independently associated with prolonged operative time (β\u0026thinsp;=\u0026thinsp;27.9, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eMutivariate analysis associated with surgical outcomes.\u003c/b\u003e This table represents the multivariate analyses to determine the independent factors associated with operative time and conversion rate to open approach between the study cohorts.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOperative Time: β [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConversion to Open: OR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5 [-7.0 to 12.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.89 [0.38 to 3.33]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.31 [0.03 to 0.59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.02 [0.97 to 1.07]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.11 [-0.33 to 0.55]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.04 [0.99 to 1.09]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrgent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.9 [11.8 to 44.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.93 [0.62 to 6.04]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.7 [-1.9 to 21.3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.39 [0.21 to 9.04]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.8 [3.0 to 28.6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.93 [0.52 to 16.38]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.4 [1.8 to 39.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.01 [0.53 to 30.58]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.0 [-3.9 to 9.9]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.92 [0.38 to 2.22]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSOMP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (Reference)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMOMP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.2 [27.3 to 55.1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.4 [4.7 to 88.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn comparison to the SOMP technique, the conventional MOMP technique was independently associated with a markedly increased operative times (β\u0026thinsp;=\u0026thinsp;41.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a higher conversion rate to open approach (OR\u0026thinsp;=\u0026thinsp;20.4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study addresses the inherent frustration arising from the ergonomic and operational challenges associated with conventional laparoscopic cholecystectomy. The traditional multi-operator technique inevitably necessitates hands crossing, workspace crowding, and suboptimal positioning that can compromise surgical precision.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e These limitations are particularly pronounced in teaching environments, where attending surgeons must simultaneously manage camera control, tissue retraction, and trainee supervision\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The reliance on assistants for camera manipulation often introduces unwanted movement and instability to variable degrees, creating a steep learning curve for maintaining steady visualization.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Some surgeons have resorted to a single-handed operation while controlling the camera, which contradicts fundamental surgical principles emphasizing bimanual traction and counter-traction techniques.\u003c/p\u003e\u003cp\u003eAt our institution, the SOMP technique was routinely employed for all cholecystectomies by the corresponding author, unless self-retaining retractors were unavailable due to concurrent use, sterilization requirements, or contamination. Our findings demonstrated that this approach maintains the established excellent safety profile of the standard multi-operator technique, with zero mortality, bile duct injuries, or reoperations in the SOMP cohort.\u003c/p\u003e\u003cp\u003eThe observed demographic differences between groups reflect the author\u0026rsquo;s approach of reverting to the MOMP technique only during instrument unavailability. Such circumstances typically occur during on-call days or post-call days when procedures are performed as \u0026lsquo;add-ons\u0026rsquo; to existing elective schedules. This explains the higher prevalence of acute cholecystitis and subsequent increased rates of open conversion and intraoperative cholangiography in the MOMP group. Conversely, the SOMP cohort demonstrated a higher proportion of female patients and elective procedures, consistent with the typical demographics of symptomatic cholelithiasis. These case mix differences also explain the higher estimated blood loss observed in the MOMP group.\u003c/p\u003e\u003cp\u003eWhile demographic differences may partially explain the shorter operative times with the SOMP technique, our study demonstrates that routine SOMP implementation does not compromise efficiency. The stable camera positioning enabled by self-retaining retractors facilitated more expeditious surgical progress in the primary surgeon's experience. These findings provide adequate empirical evidence supporting SOMP as a feasible, safe, and technically streamlined alternative to conventional multi-operator laparoscopic cholecystectomy.\u003c/p\u003e\u003cp\u003eMultivariate analyses demonstrated that the SOMP technique was associated with operative times and conversion rate, not greater than the MOMP technique.\u003c/p\u003e\u003cp\u003eThis study's limitations include its single-surgeon design and retrospective data collection methodology.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Potential advantages not quantified in this analysis include cost savings through reduced staffing requirements for laparoscopic cholecystectomy.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In the author's experience, the SOMP technique significantly enhances surgical education by eliminating distractions associated with unnecessary instrument manipulation, allowing trainees to focus on critical operative steps. Future investigations should explore comparative learning curves between SOMP and conventional MOMP techniques, as well as economic analyses quantifying potential cost reductions.\u003c/p\u003e\u003cp\u003eWe conclude that the single-operator technique utilizing two self-retaining metal retractors (commonly available laparoscopic instruments) represents a simplified solution to the ergonomic challenges and operator dependency inherent in standard laparoscopic cholecystectomy. This approach demonstrates adequate feasibility, safety, and efficacy while potentially offering significant operational advantages in contemporary surgical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study protocol was reviewed and approved by the Institutional Review Board at Cape Fear Valley Health System, Fayetteville, North Carolina, USA. The need for informed consent was waived due to the retrospective nature of the study. The study was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e:\u003cbr\u003e\u0026nbsp;The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eN.B \u0026ndash; study design, data analysis, manuscript drafting, critical revision, final approval.\u003cbr\u003e\u0026nbsp;H.C \u0026ndash; data collection, literature review, statistical analysis, final approval.\u003cbr\u003e\u0026nbsp;K.E \u0026ndash; data collection, literature review, final approval.\u003cbr\u003e\u0026nbsp;W.B \u0026ndash; data collection, manuscript editing, final approval.\u003cbr\u003e\u0026nbsp;I.A \u0026ndash; data collection, manuscript editing, final approval.\u003cbr\u003e\u0026nbsp;P.T \u0026ndash; conceptualization, supervision, critical revision of manuscript, final approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNiraj Balakrishnan ([email protected])\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot a clinical trial\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSoper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy: the new \u0026apos;gold standard\u0026apos;? \u003cem\u003eArch Surg\u003c/em\u003e. 1992;127(8):917\u0026ndash;923. doi:10.1001/archsurg.1992.01420080051008\u003c/li\u003e\n\u003cli\u003eSociety of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the clinical application of laparoscopic biliary tract surgery [Internet]. Los Angeles: SAGES; 2002 [cited 2025 Jul 22]. Available from: https://www.sages.org/publications/guidelines/guidelines-for-the-clinical-application-of-laparoscopic-biliary-tract-surgery/\u003c/li\u003e\n\u003cli\u003eChiu A, Bowne WB, Sookraj KA, Zenilman ME, Fingerhut A, Ferzli GS. The role of the assistant in laparoscopic surgery: important considerations for the apprentice-in-training. \u003cem\u003eSurg Innov\u003c/em\u003e. 2008 Sep;15(3):229\u0026ndash;36. doi:10.1177/1553350608323061. PMID: 18757384\u003c/li\u003e\n\u003cli\u003eLee G, Youssef Y, Carswell M, Hui-Lio C, George I, Park A. Ergonomic safety of surgical techniques and standing positions associated with laparoscopic cholecystectomy. In: \u003cem\u003e53rd Human Factors and Ergonomics Society Annual Meeting 2009, HFES 2009\u003c/em\u003e. Human Factors and Ergonomics Society Inc.; 2009. p. 723\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSupe AN, Kulkarni GV, Supe PA. Ergonomics in laparoscopic surgery. \u003cem\u003eJ Minim Access Surg\u003c/em\u003e. 2010 Apr;6(2):31\u0026ndash;6. doi:10.4103/0972-9941.65161. PMID: 20814508; PMCID: PMC2924545\u003c/li\u003e\n\u003cli\u003eGantschnigg A, Koch OO, Singhartinger F, Tschann P, Hitzl W, Emmanuel K, Presl J. Short-term outcomes and costs analysis of robotic-assisted versus laparoscopic cholecystectomy\u0026mdash;a retrospective single-center analysis. \u003cem\u003eLangenbecks Arch Surg\u003c/em\u003e. 2023 Aug 8;408(1):299. doi:10.1007/s00423-023-03037-6. PMID: 37552295; PMCID: PMC10409838\u003c/li\u003e\n\u003cli\u003eKalteis M, Pistrich R, Schimetta W, P\u0026ouml;lz W. Laparoscopic cholecystectomy as solo surgery with the aid of a robotic camera holder: a case-control study. \u003cem\u003eSurg Laparosc Endosc Percutan Tech\u003c/em\u003e. 2007 Aug;17(4):277\u0026ndash;82. doi:10.1097/SLE.0b013e31806030ae. PMID: 17710048\u003c/li\u003e\n\u003cli\u003eOhmura Y, Nakagawa M, Suzuki H, Kotani K, Teramoto A. Feasibility and usefulness of a joystick-guided robotic scope holder (Soloassist) in laparoscopic surgery. \u003cem\u003eVisc Med\u003c/em\u003e. 2018;34(1):37\u0026ndash;44. doi:10.1159/000488957\u003c/li\u003e\n\u003cli\u003eRaval MV, Wang X, Cohen ME, Ingraham AM, Bentrem DJ, Dimick JB. The influence of resident involvement on surgical outcomes. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 2011;212(5):889\u0026ndash;98. doi:10.1016/j.jamcollsurg.2010.12.029\u003c/li\u003e\n\u003cli\u003eLelovic N, Reif R, Jensen H, Villafranca AA, Kimbrough MK, Sexton K. Resident level is associated with operative time in laparoscopic cholecystectomy. \u003cem\u003eSurg Pract Sci\u003c/em\u003e. 2024 May 23;17:100251. doi:10.1016/j.sipas.2024.100251. PMID: 39845635; PMCID: PMC11749952\u003c/li\u003e\n\u003cli\u003eHewitson CL, Shukur ST, Cartmill J, Crossley MJ, Kaplan DM. Camera realignment imposes a cost on laparoscopic performance. \u003cem\u003eSci Rep\u003c/em\u003e. 2021 Sep 3;11(1):17634. doi:10.1038/s41598-021-96965-6. PMID: 34480047; PMCID: PMC8417100\u003c/li\u003e\n\u003cli\u003eVandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. \u003cem\u003ePLoS Med\u003c/em\u003e. 2007;4(10):e297. doi:10.1371/journal.pmed.0040297\u003c/li\u003e\n\u003cli\u003eBass EB, Pitt HA, Lillemoe KD. Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy. \u003cem\u003eAm J Surg\u003c/em\u003e. 1993 Apr;165(4):466\u0026ndash;71. doi:10.1016/S0002-9610(05)80942-0\u003c/li\u003e\n\u003cli\u003eAmerican College of Surgeons. Robotic cholecystectomy incurs more disposable cost than laparoscopic with similar outcomes. \u003cem\u003eACS Brief\u003c/em\u003e. 2025 Apr 8 [cited 2025 Jul 22]. Available from: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/acs-brief/april-8-2025-issue/robotic-cholecystectomy-incurs-more-disposable-cost-than-laparoscopic-with-similar-outcomes/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic cholecystectomy, Single-operator surgery, Surgical technique, Self-retaining retractor, Minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-7513603/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7513603/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The Standard technique of laparoscopic cholecystectomy requires four ports and at least two operators (surgeon and assistant). The Single-Operator Multi-Port (SOMP) technique, wherein the surgeon independently manipulates all four ports using self-retaining retractors, remains poorly characterized in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To describe the SOMP cholecystectomy technique and evaluate its feasibility, safety, and efficacy through analysis of surgical outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe performed a retrospective review of consecutive laparoscopic cholecystectomies from July 2022 to April 2025, by a single surgeon who routinely uses the SOMP technique except when self-retaining retractors are unavailable. Patient demographics, surgical indications, operative time, estimated blood loss, conversion to open surgery, reoperation rate, 30-day readmission, and 30-day mortality were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 124 consecutive laparoscopic cholecystectomies, 92 cases (74.2%) used the SOMP technique. In the SOMP cohort, the median age was 48, and 67 (72.8%) were female. Thirty-three procedures (35.9%) were elective. Surgical indications included symptomatic cholelithiasis (n=69), chronic cholecystitis (n=39), choledocholithiasis (n=25), biliary pancreatitis (n=16), and acute cholecystitis (n=14). Additional port placement for better retraction was needed in eight patients (8.7%). Median operative time was 75 minutes, with a median estimated blood loss of 25 mL. Four patients (4.3%) required readmission within 30 days. There were no reoperations or mortalities within 30 days. Multivariate analysis demonstrated that the SOMP technique was an independent factor associated with lower operative time (β for MOMP =41.2, p\u0026lt;0.001) and conversion rate to open approach (OR for MOMP = 20.4, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe SOMP technique using self-retaining retractors is a safe and efficient approach to laparoscopic cholecystectomy, with possible benefits in improved ergonomics, reduced costs, and staffing needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration (Clinical trial details)\u003c/strong\u003e: not applicable\u003c/p\u003e","manuscriptTitle":"Single-Operator Multi-Port Cholecystectomy (SOMP) – Technique, Safety, and Efficacy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 06:43:35","doi":"10.21203/rs.3.rs-7513603/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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