With the continuous promotion and popularization of thoracoscopy, thoracic surgeons continue to make breakthroughs based on previous surgical techniques, and incisions are becoming smaller. In particular, the previous four-port surgery in lung resection has gradually transitioned to three-, two-, and single-port surgery, which is currently widely performed [12]. A multicenter open-label randomized controlled trial reported a lower incidence of postoperative short-term pulmonary infections, shorter hospital stay, and better short-term quality of life in patients undergoing MIE than in those undergoing open esophagectomy [13]. Breakthroughs in MIE to further reduce operative scar formation and surgical trauma under the premise of radical treatment of esophageal tumors are needed in thoracic surgery.

Recently, an increasing number of general surgeons have successfully completed cholecystectomy, appendectomy, radical resection of colon cancer, and even radical resection of gastric cancer with a 3–4-cm incision at the lower umbilical margin, thus resulting in reduced trauma and pain, rapid recovery, and improved esthetic appearance [14, 15]. However, because the laparoscope and operator’s instruments entering the abdominal cavity through a single-hole puncture device, the operator’s manipulation may cause the endoscope to shake, resulting in unstable screen display; therefore, the laparoscopic assistant should firmly support the endoscope with both hands, keep the lens stable, flexibly adjust the lens angle, avoid the operator’s instruments, prevent collisions, keep the operator’s instruments located in front of the endoscope, avoid frequent lens swing, and minimize the operator’s dizziness and eye fatigue. The laparoscopic assistant should be familiar with the surgical steps and have long-term experience in cooperating with the surgeon. To avoid obstruction of the visual field by the liver, purse suture is often used to lift the liver lobes and fix them in vitro, thus providing good exposure for dissociating the stomach and dissecting abdominal lymph nodes.

In common MIE abdominal procedures, a 4-cm incision is made in the middle epigastrium of the subxiphoid to remove the esophageal tumor, construct a tubular stomach, and guide the placement of the nasointestinal tube. Therefore, in this study, considering the relevant experience of the general surgeon and characteristics of esophageal surgery in the thoracic cavity, we attempted to take maximum advantage of the small incision and made all operation ports, except the endoscopic observation ports, through the small incision. Previously, the endoscopic observation port was usually placed at the lower margin of the umbilicus; however, in the modified “two-port method,” the observation port was selected at 3 cm to the left of the umbilicus, which could avoid interference from the endoscope and operating instrument; simultaneously, the ultrasonic knife could be inserted into the observation port to dissect the short gastric vessels more conveniently. Moreover, if necessary, a latex drainage tube can be placed using the observation port. Ultimately, PSM to compare the short-term outcomes of the 182 patients revealed no significant differences in the laparoscopic operative time, blood loss during laparoscopic surgery, number of dissected lymph nodes, and pain score on postoperative day 1 between the two groups. The complication rate, postoperative length of hospital stay, and, more importantly, the total hospitalization cost did not differ significantly between the two groups. Moreover, no postoperative deaths occurred in either group.

Some advantages of this approach should not be overlooked. During abdominal surgery, we first established a small incision in the epigastric abdomen, which can determine the presence of adhesion in the abdominal cavity under direct vision; subsequently, a disposable multichannel single-port laparoscopic puncture device was placed to establish the pneumoperitoneum, thereby avoiding the risk of intestinal injury and bleeding caused by a pneumatic needle or direct penetration of the puncture. Simultaneously, the operation can be immediately converted to open surgery. Although the position of the three puncture ports on the airtight cover is relatively fixed, we can rotate the airtight cover according to the needs of the operation and adjust the relative position of each puncture port to facilitate the operation. Additionally, the instrument and lens can be freely moved between the two ports depending on the surgical area and operative requirements, thus reducing the difficulty associated with the surgery. During the surgery, we selected a disposable multichannel single-hole laparoscopic puncture device with a diameter of 7 cm, which was slightly larger than the abdominal incision of 4 cm, causing difficulty in removing the puncture device through the surgical incision. This led to the establishment of a more reliable pneumoperitoneum and expansion of the operating space for surgery. After completing the laparoscopic surgery, the airtight cover was removed and the esophageal tumor and stomach were dragged out under the protection and along the extension of the incision via a laparoscopic puncture instrument, thereby avoiding the possibility of abdominal incision implantation of the tumor. This makes it easier to release the adhesion connective tissue around the pylorus and place the prepared tubular stomach into the abdominal cavity. When the surgery was completed, the airtight cover was applied again to rapidly establish a pneumoperitoneum, and the abdominal cavity was examined for active bleeding via laparoscopy.

The modified two-port McKeown procedure for esophageal cancer may exhibit a certain degree of difficulty during the initial application. We optimized the surgical ideas and methods according to our own experience in the following manner: (1) the previously used operation sequence involved the abdomen followed by the neck; we adjusted this sequence by disconnecting the esophagus in the neck and then performing abdominal surgery. In this way, the lower esophagus and cardia can be fully dissociated after abdominal dissociation of the stomach as well as when the short gastric or posterior gastric vessels are obstructed. Thus, dragging the lower esophagus into the abdominal cavity and then treating the blood vessels from the rear side can greatly reduce the difficulty associated with surgery and risk of bleeding. (2) Instead of the entire palm, the right middle and index fingers were used to guide the nasointestinal tube through the small abdominal incision.

The following problems should also be noted: first, patients should be carefully selected in the early stage of the technology. It is recommended to select patients with no history of abdominal surgery, slim build, and long epigastric length to reduce the difficulty and risk of surgery. Second, in case of difficulties, laparotomy should be performed as soon as possible or an operative port should be added. The quality and time of surgery should not be neglected to complete the procedure. During our procedure, a 12-mm auxiliary port was added to the right side of the umbilicus in one patient because of extensive adhesion in the abdominal cavity after previous open cholecystectomy. For patients with obesity or severe adhesions around the pylorus, a small incision in the abdomen can be appropriately extended to 5 cm to achieve direct vision for separating the remaining parts, which is convenient for exposure, preventing injury to the right gastro-omental artery, and adequately releasing the adhesions.

However, our study has some limitations. First, this was a retrospective study involving only one surgeon, and no randomized approach was used for the selection of patients in both groups. In addition, according to the Clavien–Dindo complication grading system, both groups were classified as grade I and could not be studied further [16]. Therefore, the study findings cannot be generalized to large populations or other centers. Second, although we utilized PSM to minimize the effects of confounding factors, the predominant histologic tumor type was squamous cell carcinoma. Finally, owing to the relatively short study duration, complete data on long-term survival and recurrence were not available. Therefore, further prospective and multicenter clinical studies are warranted to clarify these aspects.

In summary, this study revealed that the modified “two-port method” in MIE exhibits good operability and safety in lymph node dissection and gastric dissociation, and surgical trauma is reduced following the principle of tumor-free operation and standard lymph node dissection. Currently, single-port and reduced-port laparoscopy is the most popular minimally invasive technology, which not only indicates the origin and innovation of the traditional five-port laparoscopic technology but also represents the direction of the development of precision minimally invasive technology. Moreover, single-port and reduced-port laparoscopic techniques meet the development needs of the contemporary concept of ERAS. Considering the lower invasiveness and better cosmetic outcomes of the modified two-port method, this approach is expected to be the next step in reduced-port laparoscopy.