A novel retro-muscular Sugarbaker technique for parastomal hernia prevention in end colostomy: combination of laparoscopic posterior component separation and extraperitoneal bowel pull-through—a prospective, single-arm study using the IDEAL framework

BACKGROUND: Parastomal hernia (PSH) is a common complication following stoma formation. Although prophylactic mesh placement initially showed promise, recent long-term follow-up randomized trials have demonstrated its ineffectiveness. To enhance PSH prevention, modifications to techniques and mesh selection are necessary. METHOD: This study aims to develop a novel technique for prophylactic retro-muscular mesh placement in a Sugarbaker configuration. The proposed solution involves a combination of posterior component separation and an extraperitoneal route for end sigmoidal colostomy. The technique has undergone three phases of refinement: Initially, posterior component separation was performed using finger dissection. The mesh was then placed in either a preperitoneal (Open-PP) or a retro-muscular position (Open-RM). Finally, laparoscopic separation with mesh placement in the retro-muscular position (Lap-RM) was performed. The peri- and postoperative complications and outcomes were prospectively recorded and reported following the IDEAL frameworks (I-IIa stage). RESULTS: From a total of 58 patients, 43 successfully received prophylactic mesh placement: 8 via Open-PP, 20 via Open-RM, and 15 via Lap-RM. Patients in the Open-PP and Open-RM groups experienced more peritoneal ruptures than those in the Lap-RM group (54.5%, 44% vs. 13.3%). Two (2/43) of the patients who received mesh placement developed parastomal hernia during a median follow-up of 30 (18-42) months. However, 15 patients who were not considered for or failed this procedure had an incidence of 33.3%. Additionally, one patient experienced a mesh-related infection. CONCLUSION: Prophylactic retro-muscular mesh placement in a Sugarbaker configuration, achieved by combining single-port laparoscopic separation and an extraperitoneal route for colostomy, appears technically safe and feasible. The approach holds theoretical promise and likely results in a reduction in the incidence of PSH.