Purpose: Conventional multiport laparoscopic cholecystectomy (CMLC) is the gold standard for benign gallbladder disease. Single-incision laparoscopic cholecystectomy (SILC) offers superior cosmesis but has limited adoption due to technical challenges. We introduce the Ewha Method, a modified SILC technique using an articulating instrument to improve visualization, ergonomics, and safety. Methods: We retrospectively analyzed 530 patients who underwent SILC between November 2023 and August 2024.Surgical outcomes were compared between senior (n = 338) and junior (n = 192) surgeons. Difficult surgery (DS) was defined as conversion to CMLC or operative time >60 minutes. Multivariable analysis identified risk factors for DS, and the learning curve was evaluated. Results: The junior surgeon group included more high-risk patients, with higher proportions of elderly (≥65 years, 42.2% vs. 12.7%), male (53.6% vs. 29.9%), comorbidities, preoperative percutaneous transhepatic gallbladder drainage (PTGBD;30.7% vs. 0.0%), and gangrenous cholecystitis (7.3% vs. 0.3%). The conversion rate was higher for junior surgeons (10.4% vs. 0.3%), but the severe complication rate was similar (0.5% vs. 0.0%). No bile duct injuries or incisional hernias occurred.Independent predictors of DS included diabetes mellitus (hazard ratio [HR], 4.045), preoperative PTGBD (HR, 5.780), leukocytosis (HR, 7.457), impacted stones (HR, 7.913), and gangrenous cholecystitis (HR, 38.736). The learning curve plateaued after 38 cases in low-risk patients. Conclusion The Ewha Method standardizes SILC, ensuring safety and efficiency with a short learning curve and minimal complications. It may serve as a viable alternative to CMLC, warranting further validation in diverse clinical settings.

Purpose: The impact of conversion on perioperative and long-term oncologic outcomes is controversial. Thus, we compared these outcomes between laparoscopic (Lap), unplanned conversion (Conversion), and planned open (Open) liver resection for hepatocellular carcinoma (HCC) located in anterolateral (AL) liver segments and aimed to identify risk factors for unplanned conversion. Methods: We retrospectively studied 374 patients (Lap, 299; Open, 62; Conversion, 13) who underwent liver resection for HCC located in AL segments between 2004 and 2018. Results: Compared to the Lap group, the Conversion group showed greater values for operation time (p < 0.001), blood loss (p = 0.021), transfusion rate (p = 0.009), postoperative complication rate (p = 0.008), and hospital stay (p = 0.040), with a lower R0 resection rate (p < 0.001) and disease-free survival (p = 0.001). Compared with the Open group, the Conversion group had a longer operation time (p = 0.012) and greater blood loss (p = 0.024). Risk factors for unplanned conversion were large tumor size (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.05–1.74; p = 0.020), multiple tumors (OR, 5.95; 95% CI, 1.45–24.39; p = 0.013), and other organ invasion (OR, 15.32; 95% CI, 1.80–130.59; p = 0.013). Conclusion In conclusion, patients who experienced unplanned conversion during LLR for HCC located in AL segments showed poor perioperative and long-term outcomes compared to those who underwent planned laparoscopic and open liver resection. Therefore, open liver resection should be considered in patients with risk factors for unplanned conversion.