Gastric cancer is one of the leading causes of cancer-related deaths worldwide. Over the past few decades, the incidence and mortality rates of gastric cancer have been declining in Western countries, whereas in other regions, they have either increased or remained stable [1]. According to 2015 cancer statistics in China, gastric cancer ranked second in both incidence and mortality rates among malignant tumors [2]. Currently, the primary treatment for gastric cancer is surgery, supplemented by perioperative adjuvant therapies. From the successful implementation of single-port laparoscopic distal gastrectomy from 2011–2015 [3–5] to the smooth completion of single-port laparoscopic proximal gastrectomy in 2016 [6], single-port laparoscopic techniques have rapidly developed.

Nevertheless, due to the "coaxial effect" [7] associated with single-port laparoscopic surgery (SILS), instrument interference remains a significant challenge. Compared to the conventional five-port laparoscopic approach, single-port surgery is associated with limited surgical field exposure and increased technical difficulty [8], hindering its widespread and rational application at this stage. However, the emergence of dual-port laparoscopic radical distal gastrectomy (DPLRDG) has effectively addressed these limitations. DPLRDG builds on the single-port approach by creating an independent main operating port and incorporating appropriate laparoscopic suspension techniques. This modification significantly improves surgical field exposure, minimizes interference between the surgeon and the scope assistant, and simplifies the surgical workflow, while maintaining the advantages of minimally invasive surgery. Additionally, the placement of a drainage tube through the main operating port ensures adequate drainage without compromising the minimally invasive benefits, thereby enhancing procedural safety. From a clinical perspective, DPLRDG allows for specimen retrieval through a transumbilical or periumbilical incision, preserving abdominal wall integrity, reducing postoperative pain and minimizing the impact on gastrointestinal function. This approach facilitates rapid recovery, ultimately reducing patient trauma and discomfort [9].

The procedural standardization of surgical steps divides the operation into multiple phases, which are executed sequentially according to a predefined plan. The close collaboration of the surgical assistant and the consistent field of view and angles provided by the scope assistant achieve seamless integration among all three components. Furthermore, the proceduralized approach systematically segments lymph node dissection into distinct parts, aiding the surgeon in maintaining a smooth surgical workflow while ensuring more thorough lymph node clearance, thereby enhancing surgical safety [10]. At our General Surgery Clinical Center, we have developed a standardized seven-step protocol for laparoscopic or robot-assisted distal gastrectomy for gastric cancer. To evaluate its short-term efficacy, we analyzed patients with distal gastric cancer who underwent DPLRDG at the General Surgery Center of Gansu Provincial Hospital between January 2020 and January 2022.

Data were analyzed using SPSS ver. 25.0. Continuous variables are expressed as the mean ± standard deviation (x̅ ± s) and were compared using the independent samples t-test, assuming a normal distribution and homogeneity of variance. Non-normally distributed data are presented as median values. Categorical variables are summarized as frequencies and percentages. A significance level of α = 0.05 was used.

This study included 22 patients, whose baseline characteristics are summarized in Table 1. All patients successfully underwent distal gastrectomy with radical resection for gastric cancer using the dual-port laparoscopic seven-step method. Billroth II anastomosis was used for digestive tract reconstruction in all cases. During surgery, a urinary catheter and a single abdominal drainage tube were routinely placed, while nasogastric and enteral nutrition tubes were not routinely utilized. Intraoperative details are given in Table 2.

On the first postoperative day, patients were encouraged to mobilize early based on their individual conditions, with urinary catheters removed promptly. Small amounts of water were permitted to be imbibed and routine intravenous nutritional support was provided. Postoperative management included Zusanli (ST36) acupuncture point massage, rectal administration of glycerin enemas and other interventions to facilitate bowel function recovery and spontaneous flatus. Patients were transitioned to clear fluids and small amounts of a liquid diet as soon as possible. The abdominal drainage tube was removed once the daily drainage volume was less than 100 mL for two consecutive days. Postoperative outcomes are summarized in Table 3.

D2 radical gastrectomy for gastric cancer involves an extensive surgical field and complex lymphadenectomy, posing significant technical challenges for surgeons. It demands not only proficient laparoscopic surgical skills but also a thorough understanding of the anatomical structures under laparoscopy [14]. Furthermore, laparoscopic surgery eliminates tactile feedback, limits the surgical field of view due to insufficient retractor exposure and confines operations within a narrow and restricted visual space, factors which make gastric mobilization and lymph node dissection more challenging than traditional laparotomy. Therefore, close collaboration among the surgeon, first assistant and scope assistant is essential [15].

Since early 2017, our surgical team has developed and refined a "Seven-Step" procedural approach for laparoscopic D2 radical gastrectomy, introducing a structured and standardized concept [10]. This method segments lymphadenectomy into a series of orderly steps, which helps the surgeon maintain a clear operative strategy and ensures more thorough lymph node dissection, ultimately enhancing surgical safety [9]. Proceduralized surgery encompasses both the systematic organization of surgical steps and the coordinated efforts of the surgical team [16]. By adhering to this systematic approach, the surgeon and assistants remain aligned in their strategies and actions throughout the procedure. This standardized surgical model offers multiple advantages. It minimizes intraoperative manipulation and clamping of the remnant stomach and intestines, thereby promoting postoperative gastrointestinal recovery [17]. Additionally, improved exposure and team coordination shorten operation times, prevent damage to adjacent organs, reduce the incidence of postoperative complications and accelerate patient recovery [18, 19]. The implementation of standardized and structured procedures simplifies the surgical process, ensures clear and organized anatomical exposure, reduces surgical complexity and improves operational efficiency. Furthermore, this approach facilitates learning and dissemination in primary healthcare settings, promoting the adoption of advanced surgical techniques, optimizing the allocation of medical resources and enabling broader clinical applications.

Since Kitano first introduced laparoscopic techniques for the treatment of gastric cancer, this approach has garnered widespread attention and led to significant advances [20–22]. With the growing adoption of Enhanced Recovery After Surgery (ERAS) principles and an increasing demand for minimally invasive procedures, SILS has rapidly developed due to its minimally invasive advantages. However, SILS faces technical challenges, including the "chopstick effect," "coaxial effect," and difficulties in digestive tract reconstruction, which limit its broader application. To address these limitations, the dual-port laparoscopic technique has emerged as an effective alternative. By isolating the primary operating port, the dual-port approach minimizes instrument interference, enabling smoother surgical maneuvers and providing improved access for digestive tract reconstruction. Additionally, the independent drainage port eliminates the need for extra incisions, thereby reducing the postoperative burden on patients.

Lymph node dissection remains a critical focus in radical gastrectomy for gastric cancer. Compared to the conventional five-port laparoscopic approach, this study reduces the number of trocar ports without compromising the use of surgical instruments. The procedure's success relies on seamless collaboration between the assistant and the lead surgeon. By implementing a standardized and streamlined surgical protocol, each region's exposure and dissection were performed in a systematic and efficient manner. Furthermore, the independent placement of the primary operating port below the left costal margin provided greater maneuverability, enhancing operational precision and flexibility. The dual-port approach, combined with the seven-step method for laparoscopic radical gastrectomy, optimized the surgical pathway and refined the sequence of lymph node dissection, significantly reducing the complexity of the procedure. The number of dissected lymph nodes in this study (30.23 ± 4.99) was comparable to that achieved using the five-port seven-step robot-assisted radical gastrectomy technique (30.3 ± 2.5) [10]. However, the limited sample size and lack of a control group in the present study necessitates further research and validation to confirm and expand upon the findings.

The core principle of ERAS is to optimize perioperative management through multidisciplinary collaboration and evidence-based practices, aiming to facilitate rapid recovery, early discharge and a reduction in postoperative complications [23]. Postoperative pain is one of the primary stressors for patients [24]. The DPLRDG offers advantages such as smaller incisions and fewer wounds. Additionally, routine local anesthetic blockade around the wound at the end of the surgery significantly alleviates postoperative pain. This approach enables patients to ambulate earlier, promotes gastrointestinal function recovery and aligns well with the principles of ERAS.

Postoperative complications are key indicators for evaluating surgical outcomes and recovery. The present study included 22 patients, among whom 1 developed a small amount of pleural effusion after surgery, which resolved after oral diuretic treatment. Another patient experienced both hypoproteinemia and wound infection, treated successfully with albumin supplementation and wound care. One patient had hypoproteinemia alone and recovered after receiving human albumin supplementation. Additionally, 1 patient developed deep vein thrombosis (DVT), which was managed with the placement of an inferior vena cava filter. The occurrence of DVT may be attributed to the patient’s long-standing history of hypertension and diabetes, along with limited daily activity after first ambulating 53 h postoperatively. Importantly, no surgery-related complications such as anastomotic leakage or intra-abdominal bleeding were observed in the 22 patients. The overall complication rate was 18.18%, consistent with previously reported rates of complications in reduced-port laparoscopic radical gastrectomy for gastric cancer (4.1–42.9%) [25–27].

Wound aesthetics are a significant advantage of the dual-port laparoscopic surgery. Compared to the conventional five-port approach, the dual-port method reduces the number of incisions and employs subcutaneous cosmetic suturing, thereby minimizing the risk of prominent scar formation. Among the 22 patients in the present study, 18 reported high satisfaction with their postoperative wounds. One patient experienced subcutaneous fat liquefaction, requiring daily wound dressing for one week. Although the wound eventually healed, this patient reported lower satisfaction.

In summary, the dual-port laparoscopic approach, combined with the seven-step method is a viable option for radical distal gastrectomy. Preliminary studies suggest that its short-term efficacy and safety are comparable to those of the conventional five-port approach. Moreover, the reduced-port technique promotes faster recovery, less postoperative pain, and higher patient satisfaction with wound outcomes, aligning with ERAS principles. However, this study's small sample size and single-center design necessitate further multicenter, large-scale studies to validate its long-term efficacy and safety.

The seven-step method for dual-port laparoscopic radical distal gastrectomy is safe and feasible, offering minimal postoperative pain, favorable cosmetic outcomes and rapid recovery.