BACKGROUND: Left hypochondrium (LHC) approach has been routinely used in our department for performing single-port sleeve gastrectomy (SPSG). Starting from 2019, a transumbilical approach (TU) has been adopted in selected patients. The aim of this study was to report and compare our results of both approaches (LHC and TU) with special focus on incisional hernia (IH). METHODS: The data of patients who underwent sleeve gastrectomy via both approaches between 2019 and 2022 were retrospectively analyzed. An assessment of IH rate was carried out by reviewing abdominal computed tomography scans performed one year after surgery. RESULTS: During the study period, 449 patients who underwent SPSG were included in the final analyze. Patients in the TU group (n = 136, 30%) were more frequently female with a lower BMI and fewer comorbidities. An umbilical hernia was observed in 60% of patients in the TU group. Operative duration was longer in the LHC group (80 min vs. 64 min, P <
0.0001). Early complications rates did not differ between the groups (1.9% LHC vs. 0.7% TU, P = 0.353). During follow-up, 65 patients (14%) developed an IH: 9.9% and 25% in the LHC and TU groups, respectively (P <
0.0001). Weight loss and comorbidities resolution at 1 year were globally similar between the two groups. CONCLUSION: We have demonstrated the feasibility, safety, and efficacy of SPSG via both LHC and TU approaches. The advantage of the LHC approach is its routine applicability. The TU approach offers an esthetic advantage and a shorter operative time but is associated with a much higher IH rate.