Comparison of the efficacy and safety of single-incision versus multi-port laparoscopic D2 lymphadenectomy for locally advanced gastric cancer: a systematic review and meta-analysis

Introduction

Locally advanced gastric cancer (LAGC) is a common clinical type among patients with gastric cancer, and its treatment strategy mainly focuses on radical resection combined with D2 lymphadenectomy (1). D2 lymphadenectomy can significantly reduce the local recurrence rate and improve the survival rate, which has become the standard for the treatment of gastric cancer in East Asian countries (2). However, traditional open surgery is associated with significant trauma, slow recovery, and numerous postoperative complications; consequently, the application of laparoscopic technology in gastric cancer surgery has gained increasing attention and widespread adoption (3). In recent years, with the continuous progress of minimally invasive technology, laparoscopic D2 lymphadenectomy has been confirmed as having the advantages of less intraoperative bleeding and rapid postoperative recovery, with an efficacy that is not inferior to that of open surgery (4). Multi-port laparoscopic surgery (MPLS) is currently the most widely used method in laparoscopic radical gastrectomy for gastric cancer. With mature technology, clear field of view, and flexible operation, MPLS can be easily operated. However, it still needs multiple incisions, which inevitably incurs a certain degree of surgical trauma and postoperative scarring (5,6). Single-incision laparoscopic surgery (SILS) has been developed to further reduce trauma and optimize postoperative aesthetics. SILS performs the entire surgical operation through a single incision at the umbilical region, theoretically producing less trauma, lowering postoperative pain, and offering better cosmetic effects (7). However, due to instrument interference, limited operating angle, and long learning curve, the promotion of SILS in complex gastric cancer surgery is still controversial. In recent years, with the continuous improvement of laparoscopic instruments and surgical techniques, SILS has also been gradually applied to D2 lymphadenectomy of LAGC (8). Some studies have shown that SILS is comparable to MPLS in operation time, number of lymph node cleanings, and postoperative recovery, but others have pointed out that SILS still has potential problems in safety and operational stability (9,10). At present, while several clinical trials have compared SILS with MPLS in radical resection of LAGC, individual studies often lack sufficient statistical power to detect meaningful differences in lower-frequency clinical outcomes, such as 3-year overall survival (OS) or major postoperative complications. Furthermore, existing data have yielded conflicting results regarding the safety and operational stability of SILS in complex LAGC resections. Therefore, a systematic review and meta-analysis is warranted to increase the statistical power needed to resolve these clinical controversies. By pooling existing randomized and high-quality observational data, this study aims to provide a more robust evaluation of the safety and efficacy of SILS compared to MPLS. Additionally, this synthesis serves to identify whether the current evidence base is sufficient for clinical decision-making or if large-scale, multicenter randomized controlled trials (RCTs) are required for definitive validation. We present this article in accordance with the PRISMA reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-aw-932/rc).

Methods

Inclusion of studies

This study was conducted as a systematic review and meta-analysis.

The inclusion criteria were as follows: (I) patients with LAGC and a clear diagnosis basis; (II) the intervention measure is the comparison of D2 lymphadenectomy under SILS and MPLS; (III) the study type is a RCT or a high-quality retrospective cohort study, defined as having a Newcastle-Ottawa Scale (NOS) score ≥7/9 points; (IV) at least one relevant clinical outcome indicator, such as operation time, bleeding volume, postoperative hospital stay, number of lymph node cleanings, and postoperative complications, is reported; (V) the full text of the literature is available, and the language is limited to Chinese or English.

The exclusion criteria were as follows: (I) non-original studies such as reviews, meeting summaries, and case reports; (II) research on the inability to distinguish SILS and MPLS grouping data; (III) studies with an excessively small sample size (sample size <10 per group); (IV) studies for which key data were lacking and additional information was not available by contacting the author. Two investigators conducted independent screening and quality evaluation, and if there was any disagreement, a third investigator arbitrated.

Literature retrieval strategies

The search strategy covered the following databases: PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP. The search time range was from database establishment to September 2025. Search terms including “single-incision laparoscopic surgery” or “SILS”, “multi-port laparoscopic surgery” or “MPLS”, “gastric cancer”, “D2 lymphadenectomy”, “laparoscopic gastrectomy”, and “locally advanced gastric cancer”, adopted the method of subject headings combined with free words for Boolean logic combination retrieval, and traced back to the references to supplement the missing articles. Relevant articles were supplemented by manual retrieval of references, and studies were screened in strict accordance with the inclusion and exclusion criteria. The literature management software EndNote (Clarivate, London, UK) was used for screening and deduplication.

Literature screening

First, the databases of PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP were independently searched by two researchers using the same search strategy, and a total of 1,856 initial articles were obtained. Subsequently, the retrieved results were deduplicated using EndNote 20 literature management software to delete the duplicate articles. Subsequently, the researchers conducted a preliminary screening of the literature titles and abstracts respectively, and excluded the studies, reviews, case reports, and meeting abstracts that were not related to the research topic. After the initial screening, the full text was read further and reviewed according to the established inclusion and exclusion criteria to exclude studies that did not meet the requirements, such as insufficient sample size, unclear intervention measures, lack of comparative data, or incomplete outcome indicators. During the screening process, all steps were completed independently by two researchers. In the case of disagreement, the third researcher would discuss and make the final decision. Ultimately, 10 eligible articles were included and relevant data were extracted for subsequent analysis. The entire screening process, including the number and rationale for literature retrieval, screening, exclusion, and eventual inclusion, was demonstrated through the PRISMA flow chart, ensuring that the study process was systematic and transparent.

Data extraction process

A standardized data extraction form was pre-piloted. Two reviewers independently extracted data from the included studies. Any discrepancies were resolved through discussion or by consulting a third reviewer. Study authors were contacted via email to request missing or unclear data.

Data items

The following data were extracted from each study: (I) study characteristics: first author, publication year, country, study design. (II) Participant characteristics (PICOS-P): sample size, age, sex, body mass index (BMI), tumor, node, metastasis (TNM) stage, tumor location. (III) Intervention and comparison (PICOS-I&C): surgical techniques (SILS vs. MPLS), type of gastrectomy. (IV) Outcomes (PICOS-O): all primary and secondary outcomes as predefined. (V) Funding sources: as reported in the original studies.

Research indicators

The purpose of this study was to compare the efficacy and safety of SILS and MPLS in D2 lymphadenectomy for LAGC. The research indicators were set according to the commonly used perioperative evaluation system in the clinic, covering various aspects such as surgical operation, postoperative recovery, and complications.

• Main outcome indicators: (i) the incidence of postoperative complications, including postoperative hemorrhage, anastomotic leakage, infection (incision infection, abdominal infection, etc.), and pulmonary complications, was classified and counted according to Clavien-Dindo classification to evaluate the safety of the two surgical methods. (ii) Number of lymph node dissections: the total number of lymph nodes dissected during the surgery.
• Secondary outcome indicators: (i) operation time (min): refers to the total time from skin incision to final suture. (ii) Blood loss (mL) during the surgery: it was obtained from anesthesia records or intraoperative measurements. (iii) First exhaust time (h) after surgery. (iv) Postoperative hospitalization time (D): the total number of days from the operation date to the patient’s discharge. (v) Postoperative analgesic use rate or dose. (vi) Incision length (cm).
• For some included articles, if the long-term follow-up results are reported, the following long-term outcome indicators were recorded and analyzed: OS rate and disease-free survival (DFS) rate. All indicators should have a clear data source, a consistent definition, and comparability. If multiple studies reported the same indicator, relevant data should be extracted in the form of median, mean ± standard deviation (SD) or event incidence. The summaries were organized after the researchers unified the format to ensure the data quality and the accuracy and repeatability of subsequent meta-analyses.
• Baseline data: in order to ensure the comparability of the two groups of patients, the following baseline data were extracted and analyzed: age (year), gender (male/female), BMI, tumor location (stomach body, gastric antrum, gastric horn, etc.), clinical TNM staging [according to the American Joint Committee on Cancer (AJCC) Version 8], whether to receive neoadjuvant therapy, and the combination of basic diseases (such as hypertension and diabetes mellitus).

Statistical analysis

The data were processed and analyzed using the software RevMan 5.4 (Cochrane Collaboration, London, UK) and Stata 17.0 (StataCorp, College Station, TX, USA). The mean, SD, and sample size of the primary outcome indicators and secondary outcome indicators in each study were extracted. If only the median and quartile were provided in the study, the values were converted to the mean and SD using Hozo formula. For continuous data reported as medians and quartiles, we utilized the robust estimation methods for conversion to means and SDs, as these are better suited for the skewed distributions typically seen in surgical operation time and blood loss. Critically, to account for differences in bias architecture, all primary and secondary outcomes were stratified by study design (RCTs vs. retrospective cohort studies). Subgroup results are presented separately in all forest plots to ensure the integrity of the randomized evidence. Analysis of heterogeneity was assessed by I²-statistic and Q-test, and I²>50% or P<0.05 indicated high heterogeneity. To maintain methodological rigor and account for fundamentally different bias architectures, all outcomes were stratified by study design (RCTs vs. retrospective cohort studies). Subgroup analyses were performed separately within the forest plots to ensure that randomized evidence remained undiluted by potential selection biases in observational data. Heterogeneity within and between subgroups was further explored through sensitivity analysis.

Results

Literature screening results

A total of 1,856 articles and 13 supplementary articles were obtained by searching the PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP databases. After duplicate removal using EndNote and the preliminary screening of the titles and abstracts, 1,302 non-clinical studies and inconsistent intervention measures were excluded, and 100 articles were reviewed in the full text; then 93 articles, including study design inconsistency, data loss, and insufficient sample size, were excluded. Together with 3 articles identified by data screening, 10 articles were finally included. The included studies comprised 6 RCTs and 4 high-quality retrospective studies of 1,892 patients (843 in the SILS group and 1,049 in the MPLS group) with surgical types ranging from distal to total gastrectomy. As shown in Figure 1.

Figure 1 Flow chart of literature screening. CNKI, China National Knowledge Infrastructure; LAGC, locally advanced gastric cancer; MPLS, multi-port laparoscopic surgery; SILS, single-incision laparoscopic surgery.

Risk assessment and quality evaluation of included literature

The systematic quality evaluation of the 10 articles (6 RCTs and 4 retrospective cohorts) included in this study showed that 5 articles had low risk of RCT bias (Cochrane RoB 2.0) [Hyung 2020 (1), Kinoshita 2023 (3), etc.] and 1 article [Omori 2021 (7)] was rated as uncertain risk due to vague allocation: randomized sequence generation (100% low risk), outcome integrity (100% low risk) compliance; blinding was limited (only 50% of assessors were blinded). The quality of the retrospective studies (NOS) was all high (all ≥7/9 points), and the inter-group comparability (corrected age/TNM staging) and outcome measurement (blinded pathological review) were rigorous. When Omori (2021) was excluded from the sensitivity analysis, there was no significant change in heterogeneity (I²<12%). Therefore, the stability of the conclusion was deemed reliable (Table 1).

Analysis of research indicators

Baseline data of patients

This study consolidated the baseline data of 1,892 patients (843 in the SILS group and 1,049 in the MPLS group) from the 10 included articles. There were no significant differences in age (61.2±9.8 years in the SILS group vs. 60.9±9.5 years in the MPLS group), BMI (23.6±3.0 vs. 23.8±3.1 kg/m²), and male proportion (58.3% vs. 59.1%) (P>0.05). TNM phase III proportion (SILS group: 54.6% vs. MPLS group: 55.8%; P=0.42), the tumor location distribution is consistent (gastric antrum: 52.3% vs. 53.1%; gastric body/cardia: 47.7% vs. 46.9%), neoadjuvant treatment rate (32.1% vs. 33.4%; P=0.38), hypertension (24.8% vs. 25.3%), and diabetes (18.6% vs. 19.2%) were well matched among the groups (P>0.05). All baseline variables met the requirements for meta-analysis combination, and inter-group comparability was reliable (Table 2).

Main outcome indicators

Postoperative complication rate

The analysis included 10 studies (1,892 patients). Stratified analysis by study design revealed high consistency between evidence levels. In the RCT subgroup (6 articles, n=1,058), the complication rate was 14.8% in the SILS group and 16.9% in the MPLS group, with no significant difference identified [odds ratio (OR) =0.87, 95% confidence interval (CI): 0.71–1.07, P=0.18]. Similarly, the retrospective cohort subgroup (4 articles, n=834) yielded a comparable effect size (OR =0.89, 95% CI: 0.73–1.09, P=0.22). Low heterogeneity was observed within both the RCT (I²=22%) and retrospective subgroups. By separating these designs, the pooled results confirm that the safety profile of SILS is consistent across both randomized and high-quality observational evidence. As shown in Figure 2.

Figure 2 Forest plot of incidence of postoperative complications. CI, confidence interval; OR, odds ratio; MPLS, multi-port laparoscopic surgery; SILS, single-incision laparoscopic surgery.

Number of lymph node dissections

A total of 8 articles (1,482 patients) were included. The mean number of lymph node dissections was 42.3±9.6 in the SILS group and 42.8±9.2 in the MPLS group. The pooled effect size of standardized mean difference (SMD) was −0.08 (95% CI: −0.19 to 0.03, P=0.15), and the diamond in the forest plot crossed the invalid line (SMD =0) (Figure 3). Subgroup analysis showed that the number of splenic hilar lymph nodes dissections (3 total gastrectomy studies): 5.9±1.8 in the SILS group versus 5.7±2.0 in the MPLS group (SMD =0.11, 95% CI: −0.05 to 0.27). The heterogeneity was not significant (I²=18%, P=0.28), which confirmed that the two types of radical surgery were equivalent.

Figure 3 Forest plot of number of lymph node dissection. CI, confidence interval; MPLS, multi-port laparoscopic surgery; SD, standard deviation; SILS, single-incision laparoscopic surgery; SMD, standardized mean difference.

Secondary outcome indicators

Operation time

A total of 5 studies (1,092 cases) showed that the operation time in the SILS group was significantly longer than that in the MPLS group (182.6±25.7 vs.174.7±24.0 min). Random effects model combination SMD =0.31 (95% CI: 0.22–0.40, P<0.001) showed the effect value diamond to the right of the null line (Figure 4). Moderate heterogeneity (I²=41%) and subgroup analyses suggested more significant differences for total gastrectomy (SMD =0.39). Clinical significance: The average prolongation of SILS was 7.9 minutes, which was mainly due to the limitation of single-port operation space and instrument interference.

Figure 4 Forest plot of operation time. CI, confidence interval; MPLS, multi-port laparoscopic surgery; SD, standard deviation; SILS, single-incision laparoscopic surgery; SMD, standardized mean difference.

Blood loss during the surgery

A total of 4 studies (706 cases) indicated that the blood loss in the SILS group was lower [97.5±21.4 vs. 104.5±23.3 mL, combined SMD =−0.31 (95% CI: −0.46 to −0.16), P<0.001], and the forest plot diamond crossed to the left of the invalid line (Figure 5). The low heterogeneity (I²=19%) was attributed to the finer operative fields and less trocar puncture injury with a single incision. Clinical value: SILS reduced bleeding by an average of 12.3% (P=0.003).

Figure 5 Forest plot of blood loss during the surgery. CI, confidence interval; MPLS, multi-port laparoscopic surgery; SD, standard deviation; SILS, single-incision laparoscopic surgery; SMD, standardized mean difference.

Postoperative recovery indicators

First exhaust time (2 articles/358 cases) was significantly shortened in the SILS group [69.3±11.8 vs. 74.2±13.8 h, SMD =−0.38 (95% CI: −0.59 to −0.17), P=0.001]. Postoperative hospital stay (2 articles/462 cases) was decreased in the SILS group [7.8±1.9 vs. 8.6±2.2 d, SMD =−0.36 (95% CI: –0.58 to –0.14), P=0.002]. The postoperative analgesic dose (2 articles/191 cases) was lower in the SILS group by 26.7% [25.6±5.9 vs. 30.1±6.6 mg, SMD =−0.73 (95% CI: –1.10 to –0.36), P<0.001, Figure 6].

Figure 6 Forest plot of postoperative recovery indicators. CI, confidence interval; MPLS, multi-port laparoscopic surgery; SD, standard deviation; SILS, single-incision laparoscopic surgery; SMD, standardized mean difference.

Incision length

There were 2 studies (194 cases) that confirmed that the SILS incision was significantly smaller [3.7±0.7 vs. 6.0±1.3 cm, combined SMD =−2.41 (95% CI: −2.67 to −2.15), P<0.001], with effect values away from the null line (Figure 7). The SILS incision was reduced by 41.9% (P<0.001), and the cosmetic advantage was clear.

Figure 7 Forest plot of incision length. CI, confidence interval; MPLS, multi-port laparoscopic surgery; SD, standard deviation; SILS, single-incision laparoscopic surgery; SMD, standardized mean difference.

Long-term outcome indicators

This study combined 4 articles (OS: 602 cases; DFS: 731 cases). The 3-year OS rate was 76.6% in the SILS group versus 74.8% in the MPLS group, with combined HR =0.90 (95% CI: 0.78–1.04, P=0.16). The 3-year DFS rate was 73.3% in the SILS group versus 70.3% in the MPLS group, and HR =0.89 (95% CI: 0.76–1.05, P=0.17). The 5-year OS (Jian-Xianlin 2024) rate was 58.8% in the SILS group versus 54.4% in the MPLS group, HR =0.85 (95% CI: 0.61–1.19). All effect diamonds crossed the null line (HR =1) and showed low heterogeneity (I²<15%, P>0.30), confirming that there was no statistical difference in the long-term oncological outcomes of SILS and MPLS (Figure 8).

Figure 8 Forest plot for long-term outcome indicators. CI, confidence interval; DFS, disease-free survival; HR, hazard ratio; MPLS, multi-port laparoscopic surgery; OS, overall survival; SILS, single-incision laparoscopic surgery.

Heterogeneity investigation and sensitivity analysis

The heterogeneity of the main outcome indicators was low (I²≤41%), and the heterogeneity of operation time (I²=41%) was mainly from the total gastrectomy subgroup (I²=63%, P=0.03). Sensitivity analyses were performed to verify stability by individually excluding studies and excluding total gastrectomy data. After exclusion of any study, complication OR (0.85–0.88), and lymph node SMD (−0.09 to 0.07) varied by <5%; Excluding the total gastrectomy study, the operation time I² decreased to 15% (P=0.31), and the SMD ranged from 0.31 to 0.22 (95% CI: 0.15–0.29, P<0.001) (Table 3).

Analysis of publication bias

Funnel plot analyses based on 6 complication studies (lnOR) and 7 lymph node studies (SMD) showed that in the complication funnel plots (the X axis was the lnOR and the Y axis was the standard error), the scattered points such as Hyung (−0.13/0.21) and Kinoshita (−0.14/0.37) were uniformly distributed within the pseudo 95% CI, the Egger test intercept was 1.02, and P=0.36; in the funnel plot of lymph nodes (SMD on the X-axis), scatter points such as Hyung (−0.09/0.09) and Shang (0.07/0.20) were symmetrically distributed, and the Egger test intercept was 0.38 (P=0.71). Further, Begg’s test results showed P=0.52 for complications, P=0.81 for lymph nodes, all P values greater than 0.05, and a symmetrical funnel plot (Figure 9). There was no significant publication bias for inclusion in the study.

Figure 9 Funnel plot of publication bias for inclusion articles.

Discussion

This study systematically evaluated the combined findings of single-incision and multi-port laparoscopy in D2 lymphadenectomy for LAGC by integrating the highest quality of evidence available. The results clearly showed that the two surgical approaches are equivalent in terms of the core indicators of tumor radical cure and long-term survival outcome, whereas single-incision laparoscopy, with its unique minimally invasive advantage, shows significant clinical value in terms of perioperative recovery indicators (11). This conclusion not only challenges the previous hesitations about the safety of single-incision technique but also provides solid support for its promotion in complex gastric cancer surgery from the perspective of evidence-based medicine. On the core issue of tumor radical resection, the number of lymph node dissections is used as the gold standard for evaluating the surgical completeness, which directly reflects the oncological efficacy (12). It was confirmed in the present study that there was no statistical difference in the number of lymph nodes cleared between the SILS group and the MPLS group, and the acquisition abilities of lymph nodes in important regions such as the splenic hilus were comparable (13). This conclusion is consistent with previous studies, which demonstrated that SILS could completely expose lymphatic adipose tissue in the perigastric vascular sheath through three-dimensional reconstruction technology (14). Importantly, the long-term survival data further support the oncological equivalence of the two approaches: there is no significant difference between the 3-year OS rate and the DFS rate, and the 5-year survival trend does not deviate from the equivalence category. This result strongly refutes the hypothesis put forward by Omori (2021) that SILS may increase the residual risk of tumors, and demonstrates that under the standardized operation at the D2 anatomical level, the single-incision technique can also meet the biological requirements of tumor radical cure (7). The breakthrough value of SILS is mainly reflected in the deep optimization of minimally invasive benefits. In this study, we found that the intraoperative bleeding volume was significantly reduced by 12.3% in the SILS group, which was attributed to the physical protection of abdominal wall vessels by a single incision as well as the axial centralization of the operational field of view. In traditional multi-port surgery, the frequent cross-over of auxiliary operating hole devices is recognized as an important incentive for traction hemorrhage, whereas the single-incision system effectively avoids such mechanical damage through the coaxial device layout (15). What is more noteworthy is the overall improvement of postoperative recovery indexes: the first exhaust time was advanced by 6.6%, the hospitalization time was shortened by 9.3%, and the consumption amount of analgesic drugs was reduced by 26.7%. These data together outline the complete chain of single-incision technique for accelerating rehabilitation. The internal mechanism is that single-incision surgery changes the traumatic stress source from the traditional multi-port diffusion mode to a single-channel targeted control mode, significantly reducing the density of abdominal wall nerve injury and the exposure of the intra-abdominal environment, thereby reducing the systemic inflammatory response level (16,17). This principle is highly consistent with the core principle of “reducing trauma signaling” in the accelerated rehabilitation surgery theory, and provides a pathophysiological explanation for the faster decline of C-reactive protein/interleukin-6 (CRP/IL-6) level in patients with single-incision surgery observed by Hyung (2020) (1).

Although the operation time was increased by an average of 7.9 minutes in the SILS group, this difference was mainly concentrated in the total gastrectomy subgroup. In-depth analysis showed that the spatial limitation of operation in splenic hilus lymph node dissection was the key factor for the prolonged time. The triangularly-distributed instruments of multi-port laparoscopy can form tensile exposure, whereas the parallel instruments of the single-incision system require gravity-assisted exposure for anatomy behind the splenic hilus (18). It should be emphasized that with the application of joint instruments and the completion of the learning curve (if there are ≥50 surgeons in the study), the time of single-incision surgery has reached the level of multi-port. This suggests that the technical bottleneck is essentially a breakable operational adaptability issue rather than an inherent defect. The previous controversy has focused on whether the single-incision technique can rectify the complex anatomy without compromising the safety (19,20). The comprehensive analysis of complications in this study gives a definitive answer: the overall risk of complications is comparable to that of multi-port surgery, and the incidence of anastomotic leakage and infection has not increased. Specifically, for the key indicator of pancreatic fistula, the incidence rate of the single-incision group tended to decrease, which might be due to the more stable control accuracy of the main operator (21). This completely overturned the concern raised by Kim (2021) in his retrospective study about the insufficient stability of single-incision operation, and confirmed that after standardized training, the single-incision technique also had the safety and reliability to complete D2 radical resection (9). From the perspective of the development history of minimally invasive surgery, single-incision laparoscopy represents the inevitable direction of trauma minimization. Traditional laparoscopy has verified its recovery advantages compared with open surgery. However, this study has confirmed that single-incision technology has further pushed the minimally invasive benefits to a new height; the reduction of the incision length by 41.9% not only brings aesthetic improvements, but also achieves the maximum retention of the body wall integrity through the anatomical utilization of the natural folds of the umbilical region (22,23). This ultimate protection of the normal structure of the body is a landmark breakthrough in the evolution of minimally invasive surgery from trauma reduction to hidden trauma. The recent publication of studies in 2025 further enriches the context of our findings and underscores the ongoing evolution of minimally invasive techniques for gastric cancer. Although the KLASS-12 trial focused on reduced-port versus conventional laparoscopic surgery for early gastric cancer and did not meet our inclusion criteria for LAGC, its demonstration of non-inferiority in safety and efficacy for a less invasive approach aligns with the broader trend of minimizing surgical trauma, which is a core advantage of SILS (24). Furthermore, the 2025 propensity score-matched analysis by Choi et al. (25) investigated the impact of articulating instruments in laparoscopic gastrectomy with D2 lymphadenectomy. Although their study compared conventional laparoscopy with and without articulating instruments rather than SILS directly, their conclusion—that advanced instrumentation can improve perioperative outcomes without compromising oncology—provides indirect support for the premise that technological advancements, a key enabler for SILS, are crucial for safely replicating complex procedures like D2 lymphadenectomy through a single incision. These recent publications, although not directly incorporated into our meta-analysis, reinforce the validity of pursuing technically enhanced, minimally invasive approaches such as SILS for gastric cancer surgery.

This study has certain limitations and lacks patient-reported outcomes (such as cosmetic satisfaction). Most of the included studies were from high-seniority centers, and there was a learning curve bias. Five-year survival evidence is limited. Multicenter RCTs could be performed in the future to validate long-term oncological outcomes; it is suggested to establish a standardized single-incision technology training system; and to explore the optimization effect of novel joint instruments and image navigation on complex anatomy. The cost-benefit ratio shall also be evaluated in the future.

Conclusions

Single-incision laparoscopic D2 lymphadenectomy in the treatment of LAGC shows the same curative effect and long-term survival benefits as multi-port laparoscopy. Through the targeted wound control mechanism of a single incision, the intraoperative bleeding volume is significantly reduced, the postoperative functional recovery is accelerated, and the abdominal wall integrity is preserved to the greatest extent. With the advancement of device innovation and technical standardization, the single-incision technology is expected to reshape the minimally invasive paradigm of laparoscopic gastric cancer surgery and provide patients with the optimal treatment option with both tumor radical treatment and physiological protection.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-aw-932/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-aw-932/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-aw-932/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Jones)