Comparison of Paramedian Versus Midline Extraction Sites in Elective Laparoscopic Right Colectomy: A Propensity-Matched Study of Postoperative Ventral Hernia Development

TL;DR

Using a paramedian extraction site during laparoscopic right colectomy reduces the risk of postoperative ventral hernias compared to midline sites.

Contribution

This study provides evidence that paramedian extraction sites lower hernia risk and identifies modifiable risk factors like chronic cough and constipation.

Findings

Paramedian extraction sites had a 2.3% POVH rate versus 11.3% for midline sites.

Midline extraction was a strong independent predictor of POVH (aOR 30.3).

Chronic cough and constipation were also significant predictors of POVH.

Abstract

Background: Postoperative ventral hernia (POVH) remains a significant complication following laparoscopic colectomy despite minimally invasive approaches. Extraction site selection may influence POVH incidence, yet optimal location remains controversial. Methods: This retrospective cohort study analyzed 550 patients undergoing elective laparoscopic right colectomy (2009–2024) at a single center. After exclusions for anastomotic leak and loss to follow-up, 266 patients were propensity-matched 1:1 comparing paramedian (n = 133) versus midline (n = 133) extraction sites. The primary outcome was POVH incidence at 36 months. Secondary outcomes included risk factor identification using multivariate logistic regression and Firth penalized methods. Results: POVH occurred in 3/133 (2.3%) paramedian versus 15/133 (11.3%) midline patients (p = 0.007). Multivariate analysis identified midline extraction (aOR 30.3, 95% CI: 3.34–969, p < 0.001), chronic cough (aOR 25.6, 95% CI: 3.56–287, p = 0.001), and constipation (aOR 10.1, 95% CI: 1.60–70.7, p = 0.015) as independent POVH predictors. Patient comorbidities showed stronger associations than surgical factors in univariate analysis. The number needed to treat with paramedian extraction to prevent one POVH was 11.1. Conclusions: Paramedian extraction sites significantly reduce POVH incidence compared to midline approaches in laparoscopic right colectomy. The identification of modifiable physiological risk factors, particularly conditions causing increased intra-abdominal pressure (chronic cough, constipation), suggests that comprehensive perioperative optimization targeting these specific factors may further reduce POVH risk.

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