Beyond the Traditional Learning Curve: Evidence of Technical Expansion Pattern in Single-Port Laparoscopic Surgery

Single-Port Laparoscopy in Gynecologic Surgery: A 130-Case Consecutive Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Port Laparoscopy in Gynecologic Surgery: A 130-Case Consecutive Series Mingchuan Guo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9849292/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract Background: Most reports of single-port laparoscopic surgery (SPLS) describe a gradual adoption process beginning with selected simple cases. This study reports a 130-case consecutive unselected series of benign gynecologic laparoscopic surgeries performed by a single surgeon transitioning to single-port practice at a newly established hospital. Methods: A retrospective analysis was performed on 130 consecutive benign gynecologic laparoscopic surgeries completed by the same surgeon between June 2023 and November 2025. Two cases with preoperative diagnosis of malignancy were excluded per ethics approval. All surgeries were attempted via a single-port approach. An internally developed surgical difficulty scoring system (GSDS) was applied post hoc to describe the distribution of case complexity across four grades: low (0–2 points), moderate (3–5 points), high (6–8 points), and extreme (≥9 points). Operative outcomes were analyzed, including completion rate, conversion rate, operative time, blood loss, and adverse events. Results: Pure single-port completion was achieved in 127 cases (97.7%). Two cases (1.5%) required one additional port for teaching purposes, and 1 case (0.8%) was performed via a multiport approach utilizing the patient's prior surgical scar. No conversion to laparotomy was required. The series included 54 (41.5%) emergency cases and 44 (33.8%) patients with prior abdominal surgery. GSDS grade distribution: low 39 (30.0%), moderate 59 (45.4%), high 23 (17.7%), and extreme 9 (6.9%). Mean operative time was 129.0 ± 62.0 minutes; mean blood loss was 88.6 ± 142.5 mL. Five adverse events occurred (3.8%): three surgery-related and two disease-related. Conclusions: An experienced multiport laparoscopic surgeon can safely adopt single-port laparoscopy in unselected benign gynecologic surgery, maintaining acceptable outcomes across the full spectrum of case complexity in this series, including emergency presentations, severe adhesive disease, and large uterine specimens. Surgery Obstetrics & Gynecology Surgical Obstetrics & Gynecology single-port laparoscopic surgery learning curve LESS consecutive series gynecologic surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Full Text Additional Declarations The authors declare no competing interests. Supplementary Files S1Data.xlsx Supplementary File S1: Complete GSDS scoring schema and anonymized individual patient data (n=130) and representative complex cases Cite Share Download PDF Status: Posted Version 2 posted You are reading this latest preprint version Show more versions 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9849292","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":656349610,"identity":"cc3ffb3b-9dea-4d7f-9326-c566e52d453e","order_by":0,"name":"Mingchuan Guo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACfv72gw8+GNjU8xOtRXLGmWTDGQVpCZINxGoxaEgwk+b4cCjB4ADRWhgOJEgzGBzIMz6evIHhR8U2wlrMmRsPGBcY3Ck2O/OsgLHnzG3CWiwbDiQkzzB4xrjtRo4BM2MbEVoMDiQYHOYxOMy4eQYJWgybgVoSN0gQqwUUyIwzDNKMJYB+OUiUX4BRefzHhz82cvztyRsf/KggQgsSICFqEFpI1TEKRsEoGAUjBAAA4UVEPopZuPQAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-4693-7125","institution":"South China Hospital, Medical School, Shenzhen University, Shenzhen, Guangdong, P.R. China","correspondingAuthor":true,"prefix":"","firstName":"Mingchuan","middleName":"","lastName":"Guo","suffix":""}],"badges":[],"createdAt":"2026-05-28 21:14:50","currentVersionCode":2,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-9849292/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-9849292/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":111761371,"identity":"98e45b9d-9e85-400e-8dea-94145e794278","added_by":"auto","created_at":"2026-06-10 17:12:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":10023914,"visible":true,"origin":"","legend":"\u003cp\u003eBasic statistical profile of 130 GSDS-scored cases. (A) Core difficulty score distribution (n=130). (B) BMI versus operative time with regression line (r=0.229). (C) Distribution of procedure types with case counts (top 8). (D) Preoperative hemoglobin distribution by GSDS grade (stacked, overall mean=120.8 g/L). (E) Operative time boxplot stratified by GSDS grade (H=33.6, eta²=0.260, P\u0026lt;0.001). (F) Age distribution by grade (stacked, mean=35.8 yr, range=11–86 yr).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2/d2246d8577f3d32ad44390be.png"},{"id":111761352,"identity":"65a85f76-b4f2-4245-a573-b25c2bef9c45","added_by":"auto","created_at":"2026-06-10 17:12:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":9122031,"visible":true,"origin":"","legend":"\u003cp\u003eGrading validation analysis. (A) Operative time by BMI category (H=4.1). (B) GSDS grade distribution with counts and percentages (Low 39/30.0%, Moderate 59/45.4%, High 23/17.7%, Extreme 9/6.9%). (C) Blood loss versus hemoglobin change (r=0.080). (D) Proportion of high-extreme difficulty cases over sequential case groups with percentage labels. (E) Core difficulty score distribution with grading threshold lines (2.5, 5.5, 8.5). (F) Blood loss by GSDS grade (H=49.0).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2/beb7b327903d5d35436f9f07.png"},{"id":111761375,"identity":"a0ec4887-27eb-4c0e-8d8f-8f72da4529a1","added_by":"auto","created_at":"2026-06-10 17:12:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11614380,"visible":true,"origin":"","legend":"\u003cp\u003eCase complexity and special case analysis. (A) Stacked bar chart showing complexity evolution over 10 sequential case groups (n=130). (B) Hysteroscopy combination rate by grade. (C) Violin plots of operative time by procedure type with sample sizes (top 6). (D) Core score versus blood loss (rho=0.662). (E) Allogeneic transfusion rate by grade (total n=13/130=10.0%, with individual grade percentages labeled). (F) Preoperative versus postoperative hemoglobin correlation (r=0.770).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2/b1a50e838a5fc79fdf7ff653.png"},{"id":111761383,"identity":"f2214277-63e1-4f42-b07d-ff715c60276f","added_by":"auto","created_at":"2026-06-10 17:12:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":10737480,"visible":true,"origin":"","legend":"\u003cp\u003eLearning curve and validation analysis. (A) Case complexity evolution with 10-case moving average (n=129). (B) Standard CUSUM analysis excluding case #3 (peak at case #6, trough at case #65). (C) Risk-adjusted CUSUM incorporating GSDS score. (D) Mean core difficulty score evolution. (E) ROC curve for predicting operative time \u0026gt;180 minutes (AUC=0.824, 95% CI 0.752-0.896, cutoff=5.5). (F) Blood loss distribution by GSDS grade (stacked, excluding case #3, H=49.0).\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2/004be0b1b3ee33392fb2b9d2.png"},{"id":111761340,"identity":"4997b288-baa9-4d9f-90c5-b7485181e592","added_by":"auto","created_at":"2026-06-10 17:12:35","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":12330056,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariable analysis and feature importance. (A) Core difficulty score versus operative time (r=0.580, 95% CI 0.453-0.684, P\u0026lt;0.001, y=15.4x+65.1). (B) Core score versus blood loss (rho=0.662). (C) Predicted versus actual operative time. (D) Feature impact on operative time by procedure type (color gradient: red=longer OT, green=shorter OT). (E) Spearman correlation matrix. (F) GSDS performance summary.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2/c424698ed6cf0455469ede7c.png"},{"id":112327480,"identity":"bce4b80e-83c2-4ff5-8fd7-80a270633e7e","added_by":"auto","created_at":"2026-06-17 10:36:53","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10242101,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptPreprintV3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2_covered_3959d295-69cb-4951-96d1-b3d3eb7afe97.pdf"},{"id":111859856,"identity":"b49074ce-b2bf-44c5-987e-8fa970999abb","added_by":"auto","created_at":"2026-06-11 15:58:21","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39611,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary File S1: Complete GSDS scoring schema and anonymized individual patient data (n=130) and representative complex cases\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"S1Data.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-9849292/v2/bcb26cca196a9c0ce88242d6.xlsx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSingle-Port Laparoscopy in Gynecologic Surgery: A 130-Case Consecutive Series\u003c/strong\u003e\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"South China Hospital, Medical School, Shenzhen University, Shenzhen, Guangdong, P.R. China","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"single-port laparoscopic surgery, learning curve, LESS, consecutive series, gynecologic surgery","lastPublishedDoi":"10.21203/rs.3.rs-9849292/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9849292/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMost reports of single-port laparoscopic surgery (SPLS) describe a gradual adoption process beginning with selected simple cases. This study reports a 130-case consecutive unselected series of benign gynecologic laparoscopic surgeries performed by a single surgeon transitioning to single-port practice at a newly established hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective analysis was performed on 130 consecutive benign gynecologic laparoscopic surgeries completed by the same surgeon between June 2023 and November 2025. Two cases with preoperative diagnosis of malignancy were excluded per ethics approval. All surgeries were attempted via a single-port approach. An internally developed surgical difficulty scoring system (GSDS) was applied post hoc to describe the distribution of case complexity across four grades: low (0–2 points), moderate (3–5 points), high (6–8 points), and extreme (≥9 points). Operative outcomes were analyzed, including completion rate, conversion rate, operative time, blood loss, and adverse events.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ePure single-port completion was achieved in 127 cases (97.7%). Two cases (1.5%) required one additional port for teaching purposes, and 1 case (0.8%) was performed via a multiport approach utilizing the patient's prior surgical scar. No conversion to laparotomy was required. The series included 54 (41.5%) emergency cases and 44 (33.8%) patients with prior abdominal surgery. GSDS grade distribution: low 39 (30.0%), moderate 59 (45.4%), high 23 (17.7%), and extreme 9 (6.9%). Mean operative time was 129.0 ± 62.0 minutes; mean blood loss was 88.6 ± 142.5 mL. Five adverse events occurred (3.8%): three surgery-related and two disease-related.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAn experienced multiport laparoscopic surgeon can safely adopt single-port laparoscopy in unselected benign gynecologic surgery, maintaining acceptable outcomes across the full spectrum of case complexity in this series, including emergency presentations, severe adhesive disease, and large uterine specimens.\u003c/p\u003e","manuscriptTitle":"Single-Port Laparoscopy in Gynecologic Surgery: A 130-Case Consecutive Series","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2026-06-10 17:10:47","doi":"10.21203/rs.3.rs-9849292/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2026-06-01 17:47:30","doi":"10.21203/rs.3.rs-9849292/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c2e638a-85da-4c54-af61-637b411f2f04","owner":[],"postedDate":"June 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":69880729,"name":"Surgery"},{"id":69880730,"name":"Obstetrics \u0026 Gynecology"},{"id":69880731,"name":"Surgical Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2026-06-11T16:08:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-06-10 17:10:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-9849292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9849292","identity":"rs-9849292","version":["v2"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}