Single-Port Laparoscopic Surgery | Clinical Case Reports
Author: 성모K외과의원 외과전문의 황덕연( Hwang Duk Yeon, General Surgeon, Ph D, St.Mary's K surgery clinic)
This blog is authored by Hwang Duk Yeon , MD,
a board-certified general surgeon
practicing at St.Mary's K Surgery Clinic in Incheon, South Korea.
The content is based on real clinical experience
and relevant medical literature and is provided
for educational purposes only.
It does not replace professional medical advice,
diagnosis, or treatment.
안녕하세요? 성모K외과 황덕연 원장입니다. 이번 인천 서혜부탈장 수술 사례에서는 복부수술 후 유착 가능성을 고려한 진단과 수술 과정을 실제 진료 기록을 바탕으로 설명드리겠습니다.
오늘은 과거에 복부수술을 두 차례 받은 뒤 오른쪽 사타구니에 돌출이 생긴 60대 초반 남성의 서혜부탈장 수술 사례를 설명드리겠습니다. 수술 전에는 과거 수술에 따른 유착 가능성을 고려했고, 실제 수술에서도 유착을 확인하며 단일공 복강경 복막외접근법(TEP)으로 교정했습니다.
※ 이 글은 실제 진료 사례를 개인 식별이 어렵도록 정리한 것입니다. 수술 방법, 입원 기간과 회복 경과는 탈장의 범위와 형태, 유착 정도, 동반질환 및 회복 상태에 따라 달라질 수 있습니다.
1. 인천 서혜부탈장 수술 상담: 오른쪽 사타구니 돌출
환자분은 내원 약 한 달 전부터 오른쪽 사타구니가 불룩해지는 증상을 느꼈고, 다른 외과에서 탈장 진단을 받은 뒤 수술 상담을 위해 내원했습니다. 진찰에서는 치골 바로 위쪽으로 둥글게 돌출되는 부위가 관찰됐습니다. 위치와 모양, 초음파 소견을 함께 살펴 직접 서혜부탈장 가능성을 우선 고려했으며, 수술 중에도 같은 형태를 확인했습니다.
오른쪽 사타구니 돌출 부위에서 확인한 서혜부 초음파 소견입니다.
2. 복부수술 2회 병력과 수술 전 판단
이 환자분은 약 40년 전 개복 충수절제술을 받았고, 내원 약 두 달 전에는 로봇 췌장절제술을 받았습니다. 이전 절개 부위가 여러 곳에 있었기 때문에 복막외 공간에 유착이 있을 가능성을 예상했습니다.
수술은 2026년 9월 15일 시행했으며, 계획한 수술명은 단일공 복강경 복막외접근법을 이용한 우측 서혜부탈장 교정술(single-port laparoscopic TEP hernioplasty)이었습니다. 단일공 수술의 적용 가능성은 이전 수술력만으로 결정하지 않고, 환자의 전신 상태와 유착 위치, 탈장 형태를 함께 평가해야 합니다. 수술 도중 안전한 진행이 어렵다고 판단되면 접근 방법을 변경할 수 있습니다.
3. 단일공 복강경 TEP 수술 과정
배꼽 안쪽의 한 절개 부위로 기구를 넣고 복막 바깥쪽 공간을 확보했습니다. 예상대로 과거 개복수술 부위의 유착 때문에 수술 공간을 만드는 데 주의가 필요했습니다. 아래 이미지는 해부학적 구조와 수술 흐름을 설명하기 위해 실제 수술 기록 가운데 핵심 단계 5개만 선별한 것입니다. 환자 식별정보와 출혈·절개·천자 장면은 포함하지 않았습니다.
복막외 공간을 박리한 뒤 확인한 치골의 해부학적 위치입니다.
아래쪽으로 박리를 진행해 치골을 확인한 뒤, 치골 위쪽으로 이어지는 복막 주머니와 직접 서혜부탈장 부위를 확인했습니다.
치골 위쪽으로 이어지는 직접 서혜부탈장 복막 주머니가 확인된 장면입니다.
복막을 주변 조직에서 분리하자 직접 서혜부탈장이 생기는 헤셀바흐 삼각 부위의 결손을 확인할 수 있었습니다. 간접 서혜부탈장이 동반됐는지도 함께 살폈으나 이 사례에서는 간접탈장으로 판단할 소견은 없었습니다.
헤셀바흐 삼각 부위에서 확인한 직접 서혜부탈장 결손입니다.
인공막이 놓일 공간을 확보하기 위해 복막을 충분히 아래쪽으로 분리했습니다. 이 과정의 범위와 방법은 환자의 해부학적 구조와 유착 정도에 따라 달라질 수 있습니다.
인공막 배치를 위해 복막을 아래쪽으로 분리한 단계입니다.
직접탈장 부위의 가성낭을 정리한 뒤 10×16cm 크기의 인공막을 복직근 뒤쪽의 복막외 공간에 배치해 결손 부위를 덮었습니다. 인공막의 종류와 크기, 고정 방법은 탈장 범위와 수술 중 확인한 구조에 따라 달라질 수 있습니다.
복막외 공간에 10×16cm 인공막을 배치한 수술 단계입니다.
4. 수술 중 확인한 소견
수술 전 검사에서 의심한 것처럼 우측 직접 서혜부탈장이 확인됐습니다. 과거 수술로 인한 유착이 있어 표준적인 해부학적 층을 확인하는 데 시간이 필요했지만, 실제 구조를 하나씩 확인하며 복막외 공간을 확보했습니다. 특정 수술법이 모든 환자에게 더 적합하거나 동일한 결과를 보장하는 것은 아니며, 개복수술과 복강경 수술 가운데 적절한 방법은 환자 상태에 따라 정합니다.
5. 입원 기간과 퇴원
이 환자분은 1인실에서 1박 2일 입원한 뒤 퇴원했습니다.
탈장수술은 일반적으로 최소 1박 2일 입원하는 경우가 많고, 재발탈장이나 유착이 심한 경우에는 상태에 따라 2박 3일까지 입원이 필요할 수 있습니다. 퇴원 시점은 통증 조절, 식사와 보행 상태, 동반질환 및 수술 후 관찰 결과를 확인해 결정합니다.
6. 회복 과정에서 확인할 점
수술 다음 날과 퇴원 1주 후 외래에서 복부와 절개 부위의 상태를 확인했습니다. 아래 사진은 이 사례의 시간 경과를 기록한 자료이며, 수술 전 사진과의 전후 비교나 특정한 흉터 결과를 보여 주기 위한 자료가 아닙니다. 상처 회복과 피부 변화에는 개인차가 있습니다.
수술 다음 날 복부 상태를 기록한 사진입니다.퇴원 1주 후 외래에서 확인한 복부 상태입니다.
퇴원 후에는 통증이 갑자기 심해지거나 수술 부위가 붉게 붓는 경우, 발열·구토·배변 곤란 같은 증상이 동반되는 경우 의료진의 평가가 필요합니다. 활동 범위와 복압이 많이 올라가는 동작을 다시 시작하는 시점도 개인의 회복 상태에 맞춰 안내받는 것이 좋습니다.
7. 서혜부탈장 수술 전 확인할 점
이전 복부수술 여부와 절개 위치, 복용 중인 약, 심장·폐 질환과 당뇨 같은 동반질환은 수술 계획과 입원 기간을 정할 때 함께 확인합니다. 사타구니 돌출이 눕거나 손으로 눌러도 들어가지 않으면서 통증이 심해지거나 구토·복부팽만이 동반되면 감돈 또는 장폐색 가능성을 평가해야 하므로 지체하지 말고 의료기관을 방문해야 합니다. 증상과 응급 평가가 필요한 상황에 대한 일반 정보는 미국 NIDDK의 서혜부탈장 안내(영문)에서도 확인할 수 있습니다.
본 글은 한 환자의 진료 경과를 설명하기 위한 사례 기록이며, 특정 치료의 효과나 동일한 결과를 보장하지 않습니다. 개인별 진단과 치료 계획은 의료진의 진찰 및 검사 결과에 따라 달라질 수 있습니다.
Performing gallbladder surgery on morbidly obese patients is widely regarded as one of the more challenging scenarios in laparoscopic surgery. At St. Mary’s K Surgery in Incheon, we specialize in single-port laparoscopic cholecystectomy — a minimally invasive technique that uses only one small incision through the navel. In this post, we share a recent case involving a patient with a BMI of 45.7 and a 3 cm gallstone, and walk through how single-port laparoscopy was successfully performed.
Patient Background
A male patient in his late 30s visited our clinic with worsening right upper quadrant pain and severe epigastric cramping after meals. He had been aware of gallstones for some time but had managed the discomfort conservatively — until the symptoms became too severe to ignore.
At 175 cm tall and weighing 140 kg, his BMI was 45.7, placing him in the Class III (morbid) obesity category. While this level of obesity adds significant complexity to any abdominal procedure, our center has extensive experience with single-port gallbladder surgery in high-BMI patients. In fact, we previously operated on a patient who was 185 cm and 150 kg just a few months earlier.
Gallstone disease is more prevalent among individuals with higher body weight, so our surgical team has become well accustomed to managing these challenging cases.
Preoperative Findings
An ultrasound performed at a local internal medicine clinic showed a gallstone estimated at approximately 2 cm. However, the stone turned out to be significantly larger — over 3 cm — once removed during surgery.
This distinction matters clinically: gallstones 3 cm or larger are considered an indication for surgery regardless of symptoms, as they are a recognized risk factor for gallbladder cancer.
Surgical Details
Date of Surgery
January 16, 2026
Procedure
Single-Port Laparoscopic Cholecystectomy (SILS)
Hospital Stay
3 days / 2 nights
Estimated Cost
Approx. 1,750,000 KRW (private room)
Why Is Gallbladder Surgery More Difficult in Obese Patients?
Obesity itself is a condition associated with chronic low-grade inflammation. When combined with an abdominal procedure like cholecystectomy, several factors increase surgical difficulty:
Thicker abdominal wall: Accessing the peritoneal cavity through a single umbilical incision requires more effort and precision.
Extensive adhesions: Chronic inflammation often leads to significant adhesions around the gallbladder and surrounding soft tissues.
Wider operative field: A larger abdominal cavity means instruments must cover greater distances, making maneuverability more demanding.
Step-by-Step Surgical Process
1. Abdominal Entry and Adhesiolysis
After entering the abdomen through the navel, we found extensive adhesions surrounding the gallbladder. Careful adhesiolysis (separation of adhesions) was performed first, taking approximately 20 minutes due to the severity of the adhesions and the wide operative field.
2. Identification and Ligation of the Cystic Duct
Once the adhesions were cleared, the cystic duct was carefully identified. It was first secured with a Hem-o-lok clip, then reinforced with an additional clip for a double ligation — ensuring a secure seal.
3. Ligation of the Cystic Artery
The cystic artery was also double-ligated. A reactive lymph node was visible just above the vessel — commonly known as the Calot’s lymph node (also called Lund’s node), which is frequently seen in cases of cholecystitis.
4. Gallbladder Dissection from the Liver Bed
The gallbladder was carefully dissected from the cystic plate (liver bed), taking care to avoid any liver injury. Once fully separated, the specimen was placed in a retrieval bag and extracted through the umbilical incision.
5. Final Inspection and Closure
A thorough inspection confirmed there was no bleeding or bile leak. The operative field was clean, and the surgery was concluded.
Specimen and Pathology Results
The extracted gallbladder showed significant wall thickening — a hallmark of chronic inflammation. The stone itself measured over 3 cm, larger than the 2 cm estimated on preoperative ultrasound. The patient received the gallstone as a keepsake.
Final pathology confirmed the diagnosis: chronic cholecystitis.
Recovery and Cosmetic Outcome
The patient was discharged on the second postoperative day. At the one-week follow-up, the umbilical incision site had healed remarkably well — with the surgical scar practically invisible.
This is one of the major advantages of single-port laparoscopic surgery: because the sole incision is made through the navel, patients are left with virtually no visible scarring.
Cost of Single-Port Laparoscopic Gallbladder Surgery
The total cost for this patient — including the procedure, a 3-day/2-night hospital stay in a private room — came to approximately 1,750,000 KRW (roughly 1,300 USD).
At St. Mary’s K Surgery, we perform single-port laparoscopic procedures using conventional laparoscopic instruments rather than expensive robotic systems. This helps keep costs significantly lower while achieving excellent surgical and cosmetic outcomes.
Conditions We Treat with Single-Port Laparoscopy
Our single-port laparoscopy center treats a range of common surgical conditions using this minimally invasive approach:
Gallstone disease (cholelithiasis) and cholecystitis
Inguinal hernia
Appendicitis (appendectomy)
By relying on standard laparoscopic equipment instead of robotic platforms, we are able to offer high-quality single-port surgery at an affordable cost — without compromising on safety or results.
Considering Gallbladder Surgery?
If you are experiencing gallstone symptoms — especially persistent right upper abdominal pain or cramping after meals — we encourage you to consult with a specialist. Even if you have been told that surgery might be risky due to obesity or other factors, single-port laparoscopic cholecystectomy may still be a safe and effective option.
St. Mary’s K Surgery — Single-Port Laparoscopy Center, Incheon, South Korea
Single incision laparoscopic hernia repair is often possible even in complex cases—but prior open abdominal surgery can make the operation technically challenging.
Hello, I’m Dr. Hwang, director of the Single-Incision Laparoscopic Surgery Center at St Mary’s K Surgeryclinic.
Recently, since opening the clinic, I successfully completed 100 single-incision laparoscopic cases. Among them were 52 gallbladder surgeries, 35 hernia repairs, and the remainder were appendectomies. I will continue doing my best to provide safe, high-quality surgical care for every patient.
In this post, I share a real case of single incision laparoscopic hernia repair using the TEP approach—even though the patient had a significant history of open abdominal surgery.
Case Summary
A male patient in his late 30s visited our clinic for surgery after developing a right inguinal hernia about two months prior.
Importantly, he had undergone an emergency open abdominal surgery (laparotomy) about three years ago for sigmoid colon volvulus (twisting of the bowel). At that time, he was told the situation was severe enough that a temporary stoma (colostomy) might have been required. As you can imagine, it was a major emergency.
As a result, he had a large lower abdominal scar from the prior open surgery.
Why This Case Was Challenging
For many inguinal hernias, we can use a laparoscopic technique called TEP (Totally Extraperitoneal) repair, which is performed in the preperitoneal space (outside the abdominal cavity).
However, when a patient has had a major lower abdominal open surgery, the key surgical planes are often disrupted by:
Dense adhesions
Scarred fascial layers
Distorted anatomy, especially in the lower abdominal wall
In a TEP repair, we must safely create and maintain a working space between the rectus muscle and the transversalis fascia. Prior surgery can make that space very difficult to develop.
Even so, the patient strongly wished to avoid another large incision—after having suffered through a major laparotomy before—so we carefully decided to attempt a single-incision laparoscopic TEP approach.
Surgery Details
Date: November 24, 2025
Procedure:Single-incision laparoscopic TEP (Totally Extraperitoneal) right inguinal hernioplasty
As expected, there were significant adhesions, and maintaining a clear view was not easy. In such cases, gas can sometimes enter the abdominal cavity, which may further reduce visibility—creating a difficult cycle.
Still, step by step, we carefully secured the preperitoneal working space and identified the correct tissue planes. Fortunately, we were able to find the boundary where the peritoneum “drops away” and proceed safely.
Hernia type:Indirect inguinal hernia
Once the space was created, the rest of the operation progressed smoothly:
Dissection of the hernia sac from the spermatic cord structures
Protecting the vas deferens and testicular vessels is essential.
High ligation of the sac (loop ligation)
Resection of the sac
Parietalization (pulling the peritoneum down to reduce recurrence risk)
Placement of a large mesh (10 cm × 16 cm)
One major advantage of TEP repair is that we can place a wide mesh in an ideal plane, which is often difficult with incision-based hernia techniques. Because the mesh is placed in a deeper layer (behind the abdominal wall), it can also be advantageous from an infection-risk standpoint in properly selected patients.
Another key strength of the TEP approach is that it allows the surgeon to evaluate and address multiple potential groin hernia sites and reduce recurrence risk through broad coverage.
Incision & Recovery
Because the surgery was done through a single incision hidden within the umbilical fold, there was no obvious visible scar afterward.
Interestingly, the “before and after” umbilical appearance looked almost the same.
This was a difficult case and took nearly twice the usual operative time, but we were able to complete the procedure safely using the single-incision laparoscopic technique.
The patient was discharged on postoperative day 2.
This case shows that single incision laparoscopic hernia repair using the TEP approach can still be feasible even after prior lower abdominal open surgery, when performed with careful dissection
One Technique Doesn’t Fit Everyone
The advantage of single incision laparoscopic hernia repair is minimal visible scarring with a fast recovery in selected patients. While I perform most hernia repairs using single-incision laparoscopy, the best approach depends on:
the patient’s overall condition
hernia type and severity
anesthesia suitability
bowel involvement (obstruction/strangulation)
whether mesh can be used safely
Depending on the situation, we may choose different techniques, such as:
Open Lichtenstein repair under local anesthesia (for patients who cannot undergo general anesthesia)
TAPP (Transabdominal Preperitoneal) approach (in cases involving bowel obstruction or suspected strangulation/necrosis)
Desarda repair (a non-mesh option in selected cases where mesh is not suitable)
If you are considering single incision laparoscopic hernia repair, we can recommend the most appropriate method after reviewing your hernia type, anesthesia suitability, and surgical history.
Typical Hernia Surgery Cost (Guide)
At our clinic, we treat common benign surgical conditions—inguinal hernia, gallbladder disease, and appendicitis—using single-incision laparoscopic techniques whenever appropriate.
In general, these approaches can offer:
minimal or hidden scarring
less postoperative pain
faster recovery
low recurrence rates in properly selected cases
Estimated out-of-pocket cost (typical example)
The standard hospital stay for inguinal hernia surgery is 2 nights and 3 days. For a semi-private room (2-bed), the estimated self-pay cost typically ranges from $4,000 to $5,000 for patients without health insurance.
✅ Important: This is a general guide only. The final cost can vary depending on:
insurance coverage and benefit category
additional tests or imaging
anesthesia and medications
mesh type and surgical complexity
unexpected findings or complications
If you’d like an estimate tailored to your case, please contact the clinic, and we can guide you based on your condition and insurance situation.
Final Takeaway
Even in patients with a history of major open abdominal surgery, a single-incision laparoscopic TEP repair may still be possible in selected cases—when performed carefully and with appropriate surgical planning. If you are considering single incision laparoscopic hernia repair, we can recommend the most appropriate method after reviewing your hernia type, anesthesia suitability, and surgical history.
If you have been diagnosed with an inguinal hernia and want to discuss the most suitable method for you, we’ll be happy to help.
To schedule a consultation: Please contact St Mary’s K Surgery clinic to discuss your diagnosis, options, and an individualized cost estimate.
If you’d like to see a single-incision laparoscopic gallstone surgery case, please take a look here. link
FAQ (Copy & Paste)
Q1. Can you do single-incision laparoscopic herniarepair after open abdominal surgery? Yes, it may be possible, but it depends on the location of the previous incision, the expected adhesions, and the patient’s anatomy. Lower abdominal scars often make preperitoneal dissection more difficult, so careful surgical planning is essential.
Q2. What is TEP, and why is it used for inguinal hernia repair? TEP (Totally Extraperitoneal) repair places mesh in the preperitoneal space without entering the abdominal cavity. It can provide wide mesh coverage and allows evaluation of potential groin hernia sites in a single operation.
Q3. How long is the hospital stay and recovery? In many routine cases, patients can go home within 1–2 days. For complex cases or patients with prior surgery, the stay can be slightly longer depending on pain control and recovery.
Q4. Is mesh always required? Mesh is commonly used to reduce recurrence risk. However, in selected situations where mesh is not suitable, non-mesh techniques may be considered. The best approach should be decided after individual evaluation.
Q5. How much does hernia surgery typically cost? Costs vary depending on insurance coverage, room type, mesh selection, and surgical complexity. In our clinic, a typical example for a 2-night/3-day stay in a twin room may be around KRW 1.3 million out-of-pocket, but individual variation is expected.
Acute cholecystitis is a common surgical condition, particularly in elderly patients, and is frequently associated with gallstones. Advanced age and comorbidities such as liver cirrhosis may increase surgical complexity and perioperative risk. Minimally invasive approaches, including single-port laparoscopic cholecystectomy, can be challenging in such cases but may offer benefits in selected patients.
2. Patient Presentation
A woman in her late 70s presented with several days of abdominal pain accompanied by high fever. She initially visited a local clinic, where abdominal computed tomography (CT) was performed, leading to a diagnosis of acute cholecystitis. Due to the need for surgical management, she was referred to our institution. At presentation, the patient had persistent abdominal pain and a body temperature exceeding 39°C.
3. Diagnostic Assessment
Contrast-enhanced abdominal CT demonstrated pericholecystic edema with inflammatory changes surrounding the gallbladder, consistent with acute cholecystitis.
Bedside ultrasonography performed by the surgeon revealed: Pericholecystic infiltration with hazy inflammatory changes Marked tenderness upon probe compression, consistent with a positive sonographic Murphy sign These findings supported the diagnosis of acute cholecystitis.
4. Surgical Management
Date of surgery: June 23, 2025 Procedure: Single-port laparoscopic cholecystectomy Length of hospital stay: 3 nights and 4 days
The procedure was performed through a single transumbilical incision. Intraoperatively, advanced liver cirrhosis was noted, with an irregular nodular surface of the liver. The gallbladder was located deep beneath the rib cage, making exposure and manipulation technically challenging in a single-port setting.
Despite these difficulties, careful dissection was performed. The cystic artery was identified and ligated first to improve visualization. The cystic duct was subsequently secured using clips and a Hem-o-lok device. The gallbladder was then dissected from the liver bed and removed without intraoperative complications.
5. Outcome and Follow-Up
Gross examination of the surgical specimen revealed gallstones with associated inflammatory changes. Histopathological analysis confirmed acute calculous cholecystitis.
Postoperatively, the patient recovered without complications. The umbilical incision showed minimal scarring on postoperative day one. She was discharged in stable condition on postoperative day three.
6. Discussion
Single-port laparoscopic cholecystectomy in elderly patients with severe inflammation and coexisting liver cirrhosis is technically demanding. Limited instrument triangulation and restricted visualization can increase procedural difficulty. However, with careful patient selection and meticulous surgical technique, this approach can be performed safely even in complex cases. This case demonstrates that single-port laparoscopic cholecystectomy may be feasible in selected elderly patients with acute cholecystitis, despite unfavorable anatomical and inflammatory conditions.
7. Key Learning Points
Acute cholecystitis in elderly patients often presents with severe inflammation and systemic symptoms. Liver cirrhosis can significantly increase the technical difficulty of laparoscopic surgery. Single-port laparoscopic cholecystectomy can be successfully performed in selected high-risk patients by experienced surgeons. Careful intraoperative strategy and precise dissection are essential to ensure safety in complex cases
This case is presented for educational purposes only. All patient-identifying information has been removed.
