Standardised Pfannenstiel versus supraumbilical muscle-sparing transverse extraction sites in colon cancer surgery: An IDEAL stage 4 report

AIM: To compare long-term incisional hernia (IH) risk between Pfannenstiel and supraumbilical muscle-sparing transverse extraction sites following minimally invasive colon cancer surgery with standardised fascial closure. Reported according to the IDEAL framework (Stage 4).

METHOD: This single-centre study included patients (Stages I-III colon adenocarcinoma, 2014-2017) undergoing laparoscopic resection via Pfannenstiel or supraumbilical incisions. Fascial closure used continuous slowly absorbable poly-4-hydroxybutyrate sutures (ratio ≥ 4:1). The primary endpoint was CT-verified IH at the extraction site at 5 years. Inverse Probability of Treatment Weighting (IPTW) adjusted for baseline covariates.

RESULTS: The final cohort comprised 245 patients (Pfannenstiel, n = 141; supraumbilical, n = 104). The median follow-up was 5.3 and 5.6 years, respectively. In the unadjusted analysis, the 5-year IH risk was 15.4% (95% CI: 9.5-21.3) for Pfannenstiel and 18.8% (95% CI: 11.2-26.4) for supraumbilical incisions (p = 0.49). Following IPTW adjustment, the estimated risks were 14.6% (95% CI: 8.9-20.3) and 13.6% (95% CI: 7.7-19.4), respectively (adjusted risk difference - 1.0%; 95% CI: -9.2-7.2, p = 0.81). Only two (0.8%) of the 245 patients underwent surgical hernia repair.

CONCLUSION: The IH risk seems not associated with the extractions site incision, Pfannenstiel and supraumbilical muscle-sparing transverse extraction sites, when standardised closure techniques are applied. These findings challenge the assumption that Pfannenstiel sites are inherently superior for hernia prevention. The choice of extraction site based on anastomosis technique may not be justified; instead, it should be guided by oncological requirements and procedural ergonomics rather than perceived differences in hernia risk.

TRIAL REGISTRATION: Danish Patient Safety Authority (#31-1522-51).