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.

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. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article 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. Jianlin Xiao, Wenjian Meng, Qingbin Wu, Xuyang Yang, Mingtian Wei, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6465204/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract 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 in 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 underwent three phases of refinement: Initially, posterior component separation was performed using finger dissection. The mesh was then placed either in a preperitoneal position (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 perioperative and postoperative complications and outcomes were prospectively recorded and reported following the IDEAL frameworks (I-IIa stage). Results 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 compared to those in the Lap-RM group (54.5%, 44% vs. 13.3%). None of the patients who received mesh placement developed parastomal hernia during a median follow-up of 24 (12–35) months. However, 15 patients who were not considered for or failed this procedure had a recurrence rate of 26.6%. 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. Laparoscopic abdominoperineal resection Parastomal hernia Permanent colostomy Mesh case series Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Parastomal hernia (PSH) is the most common long-term complication following permanent end colostomy. [ 1 ] Systematic reviews have reported an incidence of up to 58% after long-term follow-up, as outlined in European guidelines. [ 2 – 4 ] PSH can cause minor discomforts such as pouching difficulties, leakage, and skin irritation, as well as more severe conditions like bowel prolapse, obstruction, and strangulation, necessitating emergent surgical intervention. [ 5 ] Over 25% of patients clinically diagnosed with PSH eventually require surgical repair. [ 6 ] However, repairing PSH is a technically demanding procedure, often complicated by a significant recurrence rate and mesh-related infections. [ 7 – 9 ] Consequently, prophylactic mesh placement offers a straightforward solution for PSH prevention. Commonly used prophylactic techniques include the keyhole mesh in retro-muscular or retroperitoneal positions, the modified Sugarbaker technique, and a funnel-shaped mesh. [ 10 – 13 ] Previous meta-analyses have demonstrated the safety and efficacy of mesh reinforcement at the permanent colostomy site for PSH prevention. [ 2 , 3 , 14 , 15 ] Prophylactic mesh placement has also been associated with reduced surgical repair needs despite existing PSH. Delayed occurrence of PSH has been observed. Accordingly, the European Hernia Association recommends using a synthetic, non-absorbable mesh prophylactically during elective permanent end colostomy construction. [ 16 ] However, a recent meta-analysis, which included eight clinical trials with longer follow-ups, failed to conclusively prove the effectiveness of prophylactic mesh in reducing PSH or hernia repair rates. [ 17 ] Other recent reviews echo this sentiment, suggesting that routine mesh recommendation for prevention based on short-term outcomes may not be warranted. [ 4 , 18 – 20 ] It is worth noting that most trials focused on PSH prevention have predominantly employed the keyhole mesh technique. In contrast, the Sugarbaker technique, although less commonly used for PSH prevention, shows promise due to its association with a reduced rate of PSH. [ 21 ] The theoretical advantage lies in the comprehensive coverage of the colostomy with an intact mesh. However, two major concerns surround the Sugarbaker technique: the selection of optimal material and adhesion. [ 22 , 23 ] This is because the mesh is typically placed in an intraperitoneal position. In this study, we present our efforts in developing a novel technique for preperitoneal or retro-muscular mesh placement within the Sugarbaker configuration. To achieve this, we combine posterior component separation with the extraperitoneal route for end sigmoid colostomy. Method Patients The novel technique was performed in our center. Inclusion criteria: eligible patients included those undergoing abdominoperineal resection who expressed a desire for parastomal hernia (PSH) prevention. Initial inclusion criteria encompassed patients requiring laparoscopic permanent colostomy for various diseases. Excluded were patients with non-curative resection, temporary colostomy, laparotomy, or emergency operations. Between November 2021 and October 2023, 58 patients meeting the inclusion criteria were enrolled in the study, and their characteristics and outcomes were documented in supplementary. This is a prospective single-arm study at the development phase and fulfills the requirement of IDEAL framework stage II. [ 24 ] Informed consent was obtained from each patient. The study has been reported in line with the PROCESS criteria. [ 25 ] Intraoperative Decision The decision regarding mesh placement was left to the surgeon’s discretion. Typically, this procedure was not considered for patients with dense mesenteric adhesions, bulky mesentery, and a high risk of mesenteric vasculature tearing. Reasons for not attempting mesh placement and instances of procedure failure were prospectively recorded. Baseline Characteristics and Outcomes Demographic and perioperative data, including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, aperture size, rectus abdominis muscle thickness, abdominal subcutaneous fat, neoadjuvant therapies, duration of operation, blood loss, length of stay, peritoneal rupture, and comorbidities, were prospectively collected from electronic clinical records. Postoperative follow-up, comprising CT reviews and physical examinations, was scheduled at 1, 3, 6, 12, 18, 24, and 36 months after surgery at our center. Aperture size was measured using the first postoperative CT image. The primary endpoint of this study was the occurrence of parastomal hernia (PSH). In alignment with the European Hernia Society (EHS) PSH classification, PSH was defined as an abnormal protrusion of abdominal cavity contents through the abdominal wall defect created during colostomy placement. [ 6 ] However, due to the study’s nature, the presence and subgroup of PSH were determined based on CT scans. The hernia defect size was measured as the largest hernia orifice on axial CT images. Two radiologists independently reviewed the CT scans. In cases of discrepancy, another experienced radiologist provided consensus. Additionally, when clinical symptoms were positive despite negative CT scans, it was also considered a PSH—abnormal protrusions near the stoma during standing Valsalva manoeuvre. Secondary Endpoints: The secondary endpoints included the occurrence of postoperative complications, specifically peristomal morbidity. These complications encompassed peristomal infection, incision or pelvic infection, stoma bleeding, prolapse, necrosis, dehiscence, and stricture. Postoperative complications were tracked for up to 90 days and classified according to the Clavien-Dindo classification. [ 26 ] Stoma Quality-of-Life Assessment: To evaluate stoma-related quality of life, we employed a validated stoma quality-of-life questionnaire (Stoma-QOL) developed by Prieto et al. [ 27 ] Participants completed this questionnaire at 1, 3, 6, 12, 18, and 24 months postoperatively. The Stoma-QOL comprises 20 questions across four domains: Sleep, Sexual activity, Relations with family and close friends, social relations outside family and close friends Surgical Technique Our initial design involves placing the mesh between the peritoneum and the sigmoid colon, which is pulled out through the extraperitoneal space. The colostomy site is typically positioned at the midclavicular line in the left lower quadrant and marked preoperatively. Importantly, it is usually not centered within the mesh area but slightly medial to the center. The development of the final technique has progressed through three phases In Open Surgery with Preperitoneal Mesh (Open-PP): A small incision is made on the posterior rectus sheath. The peritoneum is separated from the rectus sheath and transversus abdominis using blunt finger dissection and intermittent sharp division of connective tissue. Preperitoneal separation extends to the planned mesh area (10 cm * 12 cm). Dissection advances medially to reach the midline and laterally to meet the retroperitoneal space. The proximal colon is pulled through the dissected preperitoneal space. In Open Surgery with Retro-Muscular Mesh (Open-RM): The small incision on the posterior rectus sheath is extended to the upper and lower edges of the mesh area. Peritoneal separation is performed only laterally, not medially. The mesh is placed laterally before the peritoneum and medially before the posterior rectus sheath. In Laparoscopic Surgery with Retro-Muscular Mesh (Lap-RM): A circular incision is made, allowing space for accommodating the bowel. The anterior rectus sheath is incised for 2–3 cm. The rectus abdominis muscle is split and coagulated. Finger dissection separates the loose space behind the muscle. A 5 cm single-port device is inserted into the rectus sheath. Pneumoperitoneum pressure is set at 15 mmHg, and the camera is reversed for optimal viewing. Dissection of the extraperitoneal areolar tissue starts from the rectus sheath and advances first caudally, then laterally to reach the anterior superior iliac spine. The division of the posterior rectus sheath starts from below and lateral to the arcuate line and advances cranially along the semilunar line up to the level of the umbilicus. The posterior sheath near the linea alba is also divided for about 2 cm to facilitate easier stitching on the medial side. Then, the retromuscular space is expanded to the planned width. Seven sutures are tied to the corner and edge of the mesh and brought out of the skin at the marked points with the help of stitches or suture passer. The mesh is fixed to the planned position by tightening the sutures. The proximal colon is pulled out through the dissected retro-muscular space before the mesh. Then, the mesh is flattened with fingers to avoid folding. A laparoscopic mesh examination is performed to rule out torsion or folding. Statistics SPSS for Mac, version 26.0.0.2 (IBM Corp, Armonk, NY) was used for data analysis. Continuous data were shown as the median and range. Categorical variables were represented as percentages. The chi-squared test or fisher’s exact test was used for comparison of the categorical data and Student’s t-test or Mood's Median test was used for continuous data.. Statistical significance was defined as a p value less than 0.05. Results Operative Parameters In the cohort of 58 patients who underwent abdominoperineal resection (APR) or pelvic exenteration, mesh placement was not attempted in 7 patients due to factors such as obesity, swollen mesentery, and dense mesenteric adhesion. Additionally, in 8 patients, mesh placement was attempted but failed due to a large rupture of the peritoneum: three patients in the Open-PP group and five in the Open-RM group. Ultimately, successful mesh placement was achieved in 43 patients. These procedures were distributed as follows: Open-PP in 8 patients, Open-RM in 20 patients, and Lap-RM in 15 patients. All patients underwent surgery for malignant tumors of the rectum or anus. Among them, 32 patients underwent standard laparoscopic abdominoperineal resection, seven underwent partial pelvic exenteration, and four patients underwent laparoscopic total pelvic exenteration. Rupture of the peritoneum occurred in 6 out of 11 patients (3 failures and 3 repairs, 54.5%) in whom Open-PP mesh placement was attempted, in 11 out of 25 patients in the Open-RM group (5 failures, 6 repairs, 44%), and in 2 out of 15 patients in the Lap-RM group (no failure, 2 repairs, 13.3%). No other intraoperative complications were noted. Lap-RM mesh placement required a longer operation time for stoma formation, but the duration of the operation tended to decrease with increasing experience. The abdominal subcutaneous fat, rectus abdominis muscle thickness, and aperture size measured on the first postoperative CT were similar across the three groups. Postoperative Complications and Follow-Up Outcomes Postoperative complications within 90 days (as shown in Table 2 ) were recorded and classified according to the Clavien-Dindo classification. There was no significant difference in minor or major postoperative complications among the three groups. With the exception of two patients who were lost to follow-up (one refused follow-up, and one became paralyzed after a stroke), none of the 43 patients, with a median follow-up of 24 (ranging from 12 to 35) months, developed a parastomal hernia. In contrast, among the 15 patients who were either not considered for prophylactic mesh or experienced procedure failure, four patients developed a parastomal hernia (26.6%). Three complications were classified as CD IIIa (one due to mesh-related infection and two due to urinary leaks after pelvic exenteration). In the Lap-RM group, one patient suffered from a mesh-related infection, which was successfully controlled through interventional drainage, intermittent abscess irrigation, and intravenous antibiotics. Another patient developed adhesive small bowel obstruction during adjuvant chemotherapy and was managed conservatively. Additionally, one patient experienced pelvic bleeding postoperatively, which ceased after administering hemostatic drugs and infusing 3 units of red cell suspension. Five patients developed pelvic infections, and one patient had pneumonia, which improved with antibiotic treatment. Table 1 Patient characteristics Open-PP (n = 8) Open -RM (n = 20) Lap-RM (n = 15) p value Sex, n (%) 0.778 Male 5(62.5) 13(65) 8(53.3) Female 4(37.5) 7(35) 7(46.7) Age (years)* 62.5(45–81) 69.5(45–87) 62(34–86) 0.819 BMI (kg/m 2 )* 23.34(20.45–27.04) 21.09(15.57–27.68) 22.6(17.71–31.84) 0.202 Comorbidity, n (%) 0.105 DM 1(12.5) 3(15) 3(20) History of abdominal surgery 0 1(5) 0 COPD 1(12.5) 3(15) 1(7) Benign prostatic hypertrophy 0 3(15) 1(7) Surgical approach 0.306 LAPR 5(62.5) 16(80) 11(73.4) LERR 3(37.5) 2(10) 2(13.3) LTPE 2(10) 2(13.3) ASA score, n (%) 0.280 I/II/III 0/4/4 0/16/4 0/10/5 Tumor Stage, n (%) 0.369 0/I/II/III/IV 0/0/3/3/2 0/1/11/7/1 1/1/7/3/3 Tumor to anal verge (cm) 3.5(0.5-6) 2(0.5-5) 1(0.5-3) 0.057 Abdominal subcutaneous fat(mm) 2.38(0.60–4.41) 1.71(0.38–3.24) 2.13(0.85–3.90) 0.219 Rectus abdominis muscle thickness(mm) 1.02(0.48–1.39) 0.95(0.31–1.65) 1.11(0.77–1.54) 0.608 Aperture size 1.93(1.53–2.95) 1.77(0.98–2.65) 1.89(1.17–3.02) 0.216 Neoadjuvant therapy, n (%) 0.262 No 2(25) 8(40) 6(40) Yes 6(75) 12(60) 9(60) Adjuvant therapy, n (%) 0.335 No 4(50) 10(50) 11(78.5) Yes 4(50) 10(50) 4(21.5) Time for stoma formation (min)* 38(32–47) 29(23–41) 52(45–61) 0.031 operation time (min)* 200(180–300) 185(120–470) 180(140–240) 0.532 Hospital duration (day)* 6(5–12) 5(4–15) 6(5–20) 0.057 BMI body mass index; DM diabetes; COPD chronic obstructive pulmonary disease; ASA American Society of Anaesthesiologist; LAPR Laparoscopic abdominoperineal resection; LERR Laparoscopic extended radical rectectomy; LTPE laparoscopic total pelvic organ resection *Data was shown as Median. Time for stoma formation is recorded as time from the skin incision to the completion of colostomy. Table 2 postoperative complications and follow-up outcomes Clinical outcome at follow-up Open-PP (n = 8) Open -RM (n = 20) Lap-RM (n = 15) Missing Median follow-up(range) 32(30–35) 24(21–30) 16(12–20) Recurrence or metastasis, n (%) 2(25) 4(20) 0 2 Perioperative mortality, n (%) 0 0 0 - Complications according to Clavien-Dindo classification, n (%) 2 Grade I-II 4(50) 6(30) 4(26.6) - Grade IIIa 0 2(10) 2(13.3) - Grade IIIb-V 0 0 0 - Total number of complications 4 8 6 - Stoma-related complications, n (%) 2 Parastomal hernia 0 0 0 - Peristomal infection 0 0 0 - prolapse 0 0 0 - stricture 0 0 0 - Stoma bleeding 0 0 0 - necrosis 0 0 0 - dehiscence 0 0 0 - Fluid Collection 0 1(5) 2(13.3) - Skin dermatitis 1(12.5) 2(10) 1(6.7) - Mesh infection, n (%) 0 0 1(6.7) - Small bowel obstruction, n (%) 1(12.5) 0 0 - Pelvic and perineal infection, n (%) 1(12.5) 2(10) 2(13.3) - Pneumonia, n (%) 0 1(5) 0 - Others*, n (%) 1(12.5) 2(10) 0 - Readmission within 3 months, n (%) 2(25) 2(10) 2(13.3) - Reoperation within 3 months, n (%) 0 0 0 Others*: urinary tract infection, pelvic bleeding,and urethral fistula, etc. A total of 6 patients were re-admitted because of serious complications. Among them, two patients were diagnosed with a urinary leak, one with mesh-related infection, one adhesive bowel obstruction, and two pelvic infections. No patients required reoperation because of postoperative complications. Oncological outcomes During the follow-up period, three patients developed multiple lung metastases, two patients had peritoneal metastasis and carcinomatous lymphangitis, and one patient had liver metastasis and local recurrence. Four patients died due to local recurrence and metastasis. Quality of life The mean Stoma-QOL scores exhibited improvement over time. Specifically, the mean scores at months 1, 3, 6, 12, 18, and 24 were 39.59, 43.75, 49.87, 56.53, 68.51, and 71.63 respectively (Fig. 8). Discussion To the best of our knowledge, this represents the first description of retro-muscular mesh placement in the Sugarbaker configuration for preventing parastomal hernia (PSH) after end colostomy formation. Over time, various modifications of laparoscopic or open retro-muscular mesh placement in the Sugarbaker configuration have emerged and gradually become the preferred technique for parastomal hernia repair. Repairing a PSH using a retro-muscular Sugarbaker mesh offers the advantage of wide overlap, an intact mesh, and reduced risk of tension and folding compared to the intraabdominal counterpart. Laparoscopic placement of retro-muscular mesh for PSH repair has also been developed and reportedly results in a low recurrence rate. However, the use of a retro-muscular Sugarbaker mesh specifically for PSH prevention has not been previously reported. When the retromuscular Sugarbaker technique was used for PSH and incisional hernia repair, previously reported techniques employed an open or transabdominal laparoscopic approach for posterior component separation. [ 28 , 29 ] A wide posterior component separation is essential for tension-free suturing of the peritoneum. However, such extensive dissection can be overly traumatic for prophylactic mesh placement and may seem irrational. Drawing from our experience with the extraperitoneal route for colostomy, our initial plan was to achieve posterior component separation through finger dissection. Creating a preperitoneal tunnel for bowel passage is typically not challenging. However, expanding the preperitoneal space to accommodate the mesh carries substantial risks of peritoneal rupture. The primary reason for the high rupture rate is that the peritoneum adheres more to the posterior sheath than to the transversus abdominis. Although an inadvertent small hole can be promptly repaired by suturing, there is a chance it could develop into a larger tear during subsequent blunt separation. This explains why the earlier two phases (Open-PP and Open-RM) are associated with a significant rate of peritoneal rupture and procedural failure (54.5% and 42.3%). The last technique (lap-RM) avoids preperitoneal separation behind the rectus sheath by dividing the posterior sheath at its lateral edge, significantly reducing the risk of rupture. With a well-separated space, it is easy to close a small hole with a clip or suturing. Another noteworthy merit of this technique is that the abdominal aperture is covered and protected with the mesh and an intact posterior sheath, which very likely contributed to the low recurrence rate. The preliminary outcomes, with a median follow-up of 24 months (range: 12–35 months), appear quite satisfactory. The risk of mesh-related complications is similar to most reports on retro-muscular mesh placements. To mitigate infection risk, achieving effective hemostasis for any oozing and cauterizing the proximal stapled line are imperative steps. Among the 22 patients followed up for over two years, no clinical or radiologically confirmed parastomal hernia (PSH) was observed. In contrast, four patients among patients not considered for or who failed prophylactic mesh developed PSH. This result shows promise when compared to other studies, [ 4 ] which typically report a recurrence rate of 2.1–34.2% within two year. The intra-peritoneal Sugarbaker mesh, unlike the keyhole technique, provides comprehensive coverage of the abdominal wall aperture and has been shown to reduce PSH rates compared to either no mesh placement or keyhole mesh placement. [ 21 ] However, for PSH prevention, a Sugarbaker mesh is usually positioned within the peritoneal cavity. Despite the potential risks of intra-abdominal adhesion and intestinal erosion, an intraperitoneal Sugarbaker mesh is susceptible to medial pull due to lateralized bowel. Increased tension along its lateral edge can lead to mesh folding toward the center, resulting in defects and herniation. [ 30 , 31 ] With our technique, the intact peritoneum secures the sigmoid colon to the anterior abdominal wall, rendering medial tension on the mesh a non-issue. Furthermore, a retro-muscular mesh is less prone to shrinkage, folding, and twisting compared to an intraperitoneally placed mesh. While these theoretical merits are promising, their true benefits await confirmation through longer follow-up and validation by other surgeons’ practices. We have developed the novel technique for placing a retro-muscular mesh. There has been only one case of mesh-related infection caused by this technique. When the proximal colon is pulled out through the retro-muscular space dissected before the mesh, the tunnel may be contaminated. After that, we routinely placed drainage tubes in the surgical area and retained them until 2–3 days after surgery. In the initial phases of this series, we excluded patients with dense mesenteric adhesions and those with bulky and obese mesentery from mesh placement. Lysis of dense mesenteric adhesions is time-consuming and challenging when performed laparoscopically. However, obese mesentery is no longer considered a contraindication in the Lap-RM group. In the Lap-RM group, mesh placement can be completed in patients with a BMI up to 32. Limitations Our study has some limitations. First, considering the time acquired nature of the PSH, the follow-up of this study was short and longer follow-up is needed to confirm the benefits of preperitoneal Sugarbaker mesh in reducing PSH; the follow-up for Lap-RM is even shorter. We need multi-center, randomized trials with longer follow-up to confirm the study's findings and assess the long-term benefits and risks of this novel technique. Second, this technique requires more time than the intraperitoneal Sugarbaker and retro-muscular keyhole approaches. The impact of the longer operation time is still under evaluation. The procedure demands considerable skills in single-port laparoscopic surgery, although an additional port is also acceptable. Third, in the present series, we have not explored the possibility of using this technique with modifications for other types of stoma creation, such as loop colostomy or ileal conduit. Conclusions In conclusion, by combining the extraperitoneal route for colostomy with single-port laparoscopic posterior component separation, we have developed a novel technique for placing a retro-muscular mesh in a Sugarbaker configuration. This innovative approach offers several theoretical advantages, including complete coverage of the abdominal aperture by an intact mesh and posterior sheath, elimination of tension from lateralized bowel on intraperitoneal mesh, and the ability to use synthetic mesh. Preliminary outcomes indicate a significant reduction in PSH, although definitive benefits await longer follow-up, validation from other studies, and randomized clinical trials. Declarations Conflict of interest: The authors declare no conflict of interest. Ethics approval: The Institutional Review Committee of West China Hospital of Sichuan University approved this study. The requirement for informed consent was waived due to the retrospective nature of the study. Consent for patients : The authors will provide evidence of consent, if requested by the journal. Availability of data and material : The datasets during and/or analyzed during the current study are not publicly available due to the confidentiality of patient information but are available from the corresponding author on reasonable request. Funding This study was supported by the Department of Science and Technology of Sichuan Province (Award Number 2021YFS0025); the National Natural Science Foundation of China （82203474）;1·3·5 project for disciplines of excellence – Clinical Research Fund, West China Hospital, Sichuan University (2024HXFH012 to Qingbin Wu) The trial was registered with the Chinese Clinical Trial Registry (identifier: ChiCTR2200056134). Additionally, the study is registered on clinicaltrials.gov (NCT04177407). Acknowledgement Not applicable. Consent for publication Not applicable. References CARNE P W G, ROBERTSON G M, FRIZELLE F A. Parastomal hernia [J]. British Journal of Surgery, 2003, 90(7): 784–93. https://doi.org/10.1002/bjs.4220 CHAPMAN S J, WOOD B, DRAKE T M, et al. Systematic review and meta-analysis of prophylactic mesh during primary stoma formation to prevent parastomal hernia [J]. 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Annals of Surgery, 2009, 249(4): 583-7. https://doi.org/10.1097/SLA.0b013e31819ec809 FLESHMAN J W, BECK D E, HYMAN N, et al. A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies [J]. Diseases of the Colon & Rectum, 2014, 57(5): 623 – 31. https://doi.org/10.1097/DCR.0000000000000106 VIERIMAA M, KLINTRUP K, BIANCARI F, et al. Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy [J]. Diseases of the Colon & Rectum, 2015, 58(10): 943-9. https://doi.org/10.1097/DCR.0000000000000443 TAM K W, WEI P L, KUO L J, et al. Systematic review of the use of a mesh to prevent parastomal hernia [J]. World Journal of Surgery, 2010, 34(11): 2723. https://doi.org/10.1007/s00268-010-0739-2 SHABBIR J, CHAUDHARY B N, DAWSON R. A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation [J]. Colorectal Disease, 2011, 14(8): 931-6. https://doi.org/10.1111/j.1463-1318.2011.02835.x ANTONIOU S A, AGRESTA F, ALAMINO J M G, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias [J]. Hernia, 2018, 22(1): 183 – 98. https://doi.org/10.1007/s10029-017-1697-5 VERDAGUER-TREMOLOSA M, GARCIA-ALAMINO, J. M., RODRIGUES-GONçALVES, V., MARTíNEZ-LóPEZ, M. P., & LóPEZ-CANO, M. Prophylactic mesh does not prevent parastomal hernia in long-term: Meta-analysis and trial sequential analysis [J]. Surgery 2024, 175(2): 441–50. https://doi.org/10.1016/j.surg.2023.09.038 ODENSTEN C, STRIGRD K, RUTEGRD J, et al. Use of Prophylactic Mesh When Creating a Colostomy Does Not Prevent Parastomal Hernia [J]. Lippincott Williams & Wilkins Open Access, 2019, 269(3). https://doi.org/10.1097/SLA.0000000000002542 MCKECHNIE T, LEE J, LEE Y, et al. Prophylactic Mesh for Prevention of Parastomal Hernia Following End Colostomy: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials [J]. Journal of Gastrointestinal Surgery, 2022, 26(2): 486–502. https://doi.org/10.1007/s11605-021-05174-z LOPEZ-CANO M, ADELL-TRAPE M, VERDAGUER-TREMOLOSA M, et al. Parastomal hernia prevention with permanent mesh in end colostomy: failure with late follow-up of cohorts in three randomized trials [J]. Hernia:, 2023 .https://doi.org/10.1007/s10029-023-02781-4 FLEMING A M, PHILLIPS A L, DRAKE J A. Sugarbaker Versus Keyhole Repair for Parastomal Hernia: A Systematic Review and Meta-analysis of Comparative Studies [J]. Diseases of the Colon & Rectum, 2023, 66(11): 1517-8. https://doi.org/10.1007/s11605-022-05412-y LóPEZ-CANO M, SERRA-ARACIL X, MORA L, et al. Preventing Parastomal Hernia Using a Modified Sugarbaker Technique With Composite Mesh During Laparoscopic Abdominoperineal Resection A Randomized Controlled Trial [J]. Annals of Surgery, 2016, 264(6): 923–8 .https://doi.org/10.1097/SLA.0000000000001684 MARINEZ A C, GONZáLEZ E, HOLM K, et al. Stoma-related symptoms in patients operated for rectal cancer with abdominoperineal excision [J]. International Journal of Colorectal Disease, 2016, 31(3): 635 – 41. https://doi.org/10.1007/s00384-015-2491-4 MCCULLOCH P, COOK J A, ALTMAN D G, et al. IDEAL framework for surgical innovation 1: the idea and development stages [J]. Bmj, 2013, 346(jun18 3): f3012.https://doi.org/10.1136/bmj.f3012 AGHA R A, SOHRABI C, MATHEW G, et al. The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasE Series in Surgery (PROCESS) Guidelines [J]. International Journal of Surgery, 2020, 84: 231-5. https://doi.org/10.1016/j.ijsu.2020.11.005 KATAYAMA H, KUROKAWA Y, NAKAMURA K, et al. Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria [J]. Surgery Today, 2016, (6). https://doi.org/10.1007/s00595-015-1236-x PRIETO L, THORSEN H, JUUL K. Development and validation of a quality of life questionnaire for patients with colostomy or ileostomy [J]. Health and Quality of Life Outcomes, 2005, 3. https://doi.org/10.1186/1477-7525-3-62 BRANDSMA H T, HANSSON B M E, AUFENACKER T J, et al. Prophylactic mesh placement to prevent parastomal hernia, early results of a prospective multicentre randomized trial [J]. Hernia, 2015, 20(4): 535 – 41. https://doi.org/10.1007/s10029-015-1427-9 BRANDSMA H-T, HANSSON B M, AUFENACKER T J, et al. Prophylactic Mesh Placement During Formation of an End-colostomy: Long-term Randomized Controlled Trial on Effectiveness and Safety [J]. Annals of Surgery, 2023, 278(3): e440 -e6.https://doi.org/10.1097/SLA.0000000000005801 NVERLO S, GUNNARSSON U, STRIGRD K, et al. Quality of life after end colostomy without mesh and with prophylactic synthetic mesh in sublay position: one-year results of the STOMAMESH trial [J]. Int J Colorectal Dis, 2019, ( 9).https://doi.org/10.1007/s00384-019-03359-2 PRUDHOMME M, RULLIER E, LAKKIS Z, et al. End Colostomy With or Without Mesh to Prevent a Parastomal Hernia (GRECCAR 7) A Prospective, Randomized, Double Blinded, Multicentre Trial [J]. Annals of Surgery, 2021, 274(6): 928 – 34. https://doi.org/10.1097/SLA.0000000000004371 Additional Declarations No competing interests reported. Supplementary Files video2.mp4 Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Jun, 2025 Reviews received at journal 17 May, 2025 Reviewers agreed at journal 16 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers invited by journal 14 May, 2025 Editor assigned by journal 04 May, 2025 Submission checks completed at journal 17 Apr, 2025 First submitted to journal 16 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6465204","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456708840,"identity":"aaf14a6b-f3d9-4cf2-88d4-22f1c9e3b22e","order_by":0,"name":"Jianlin Xiao","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Jianlin","middleName":"","lastName":"Xiao","suffix":""},{"id":456708844,"identity":"d1a5bc17-a430-4d32-a145-426199d1613b","order_by":1,"name":"Wenjian Meng","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Wenjian","middleName":"","lastName":"Meng","suffix":""},{"id":456708845,"identity":"a70068a0-3d27-43a9-a0ae-50036317a7fb","order_by":2,"name":"Qingbin Wu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Qingbin","middleName":"","lastName":"Wu","suffix":""},{"id":456708848,"identity":"960fd485-f456-4a79-82d9-9521fb6530d8","order_by":3,"name":"Xuyang Yang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xuyang","middleName":"","lastName":"Yang","suffix":""},{"id":456708850,"identity":"7cd22128-c030-4e09-b0b5-79dc78b0508a","order_by":4,"name":"Mingtian Wei","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Mingtian","middleName":"","lastName":"Wei","suffix":""},{"id":456708854,"identity":"76026c8b-f8f2-40ff-aef2-3a6a280c9f23","order_by":5,"name":"Xiangbing Deng","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xiangbing","middleName":"","lastName":"Deng","suffix":""},{"id":456708855,"identity":"4661fa31-992a-43f2-a728-f55f2b5cd288","order_by":6,"name":"Ziqiang Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYNACAwYeIMn4AMJLIF4LswEJWiCATYIoLQbHzx5++aPAWoZ/dvu1yh81hxn42XMMGH7uwKPlTF6ahYRBOo/EnTNlt3mOHWaQ7HljwNh7BrcWswM5ZgYGBod5GG7kpN1mbDjMYHAjx4CZsQ2PlvNvzAwSgFrkgVoKfwK12BPUciPH+MEBoBaDG+nHGHhBtkgQ0GJ/440ZYwPQL4Y3cpileY4BPXXmWcHBXjxaJPtzjD/++GNtL3cj/eHHHzXWcvztyRsf/MSjhQESHcxAmgcck6A4ZTiAVwNQ+QeIFvYHBBSOglEwCkbBSAUAN9NRIhHStpoAAAAASUVORK5CYII=","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Ziqiang","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-04-16 16:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6465204/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6465204/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82898303,"identity":"3e88f5cb-fe32-49b7-8e73-328bb41ea181","added_by":"auto","created_at":"2025-05-16 13:09:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":86298,"visible":true,"origin":"","legend":"\u003cp\u003eThe cross-section diagram of abdominal wall structure during colostomy.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/587b0f3b8b8181f6bb0051d1.png"},{"id":82896769,"identity":"cbfd6d41-cd5b-4070-ac76-1be5ca0c80c4","added_by":"auto","created_at":"2025-05-16 13:01:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79218,"visible":true,"origin":"","legend":"\u003cp\u003eThe cross-section diagram of abdominal wall structure after evolution of the surgical technique.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/39c8d7406fc775233997979e.png"},{"id":82896771,"identity":"f568ec5f-a6c3-42ff-bf65-ab9c0cf433bf","added_by":"auto","created_at":"2025-05-16 13:01:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":121586,"visible":true,"origin":"","legend":"\u003cp\u003eC linea (pink line); D The incision of posterior sheath (blue line), the preperitoneal space (orange area), the anterior space of the posterior sheath (blue area)\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/a2552b5b24e8d290a0225007.png"},{"id":82898304,"identity":"de9a3c55-4829-4116-ae4e-d7ba9e2ed8f2","added_by":"auto","created_at":"2025-05-16 13:09:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":291637,"visible":true,"origin":"","legend":"\u003cp\u003etechnical modifications and postoperative complication\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/6da9154a54f264736834040c.png"},{"id":82896774,"identity":"fd23c3a4-a60a-436c-81c7-a7bc5e790bfa","added_by":"auto","created_at":"2025-05-16 13:01:37","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":186627,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patient selection\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/ad3206dda3e17a8c37562367.png"},{"id":82896772,"identity":"d9bd61fe-1b82-49c4-b22e-22cdd5366aa2","added_by":"auto","created_at":"2025-05-16 13:01:37","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":73149,"visible":true,"origin":"","legend":"\u003cp\u003eMean stoma QOL total assessment score over time\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/0c1df866d3eab72e222d038a.png"},{"id":82900934,"identity":"0bc7ae9b-8ee9-44ff-8a16-4a6b0e27afe3","added_by":"auto","created_at":"2025-05-16 13:25:37","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":112096,"visible":true,"origin":"","legend":"\u003cp\u003eA: peritoneal ischemia-like change in Open-PP; B: Avoiding peritoneal ischemia-like change in Lap-RM.\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/b98eec10221540c3d11bc23b.png"},{"id":82901594,"identity":"e532d411-f6cf-4df2-9b1b-49e2d7d78d13","added_by":"auto","created_at":"2025-05-16 13:33:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1853232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/1f54384a-72df-4a06-9136-2c687a98b7ba.pdf"},{"id":82896800,"identity":"8e4439ba-8487-403d-afa1-4548eda8f13c","added_by":"auto","created_at":"2025-05-16 13:01:44","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":98762757,"visible":true,"origin":"","legend":"","description":"","filename":"video2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6465204/v1/b79eaadad64d8a646c8f438c.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"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.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eParastomal hernia (PSH) is the most common long-term complication following permanent end colostomy.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e Systematic reviews have reported an incidence of up to 58% after long-term follow-up, as outlined in European guidelines.\u003csup\u003e[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e PSH can cause minor discomforts such as pouching difficulties, leakage, and skin irritation, as well as more severe conditions like bowel prolapse, obstruction, and strangulation, necessitating emergent surgical intervention.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e Over 25% of patients clinically diagnosed with PSH eventually require surgical repair.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e However, repairing PSH is a technically demanding procedure, often complicated by a significant recurrence rate and mesh-related infections.\u003csup\u003e[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e Consequently, prophylactic mesh placement offers a straightforward solution for PSH prevention.\u003c/p\u003e \u003cp\u003eCommonly used prophylactic techniques include the keyhole mesh in retro-muscular or retroperitoneal positions, the modified Sugarbaker technique, and a funnel-shaped mesh.\u003csup\u003e[\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e Previous meta-analyses have demonstrated the safety and efficacy of mesh reinforcement at the permanent colostomy site for PSH prevention.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e Prophylactic mesh placement has also been associated with reduced surgical repair needs despite existing PSH. Delayed occurrence of PSH has been observed. Accordingly, the European Hernia Association recommends using a synthetic, non-absorbable mesh prophylactically during elective permanent end colostomy construction.\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e However, a recent meta-analysis, which included eight clinical trials with longer follow-ups, failed to conclusively prove the effectiveness of prophylactic mesh in reducing PSH or hernia repair rates.\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e Other recent reviews echo this sentiment, suggesting that routine mesh recommendation for prevention based on short-term outcomes may not be warranted.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIt is worth noting that most trials focused on PSH prevention have predominantly employed the keyhole mesh technique. In contrast, the Sugarbaker technique, although less commonly used for PSH prevention, shows promise due to its association with a reduced rate of PSH.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e The theoretical advantage lies in the comprehensive coverage of the colostomy with an intact mesh. However, two major concerns surround the Sugarbaker technique: the selection of optimal material and adhesion.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e This is because the mesh is typically placed in an intraperitoneal position.\u003c/p\u003e \u003cp\u003eIn this study, we present our efforts in developing a novel technique for preperitoneal or retro-muscular mesh placement within the Sugarbaker configuration. To achieve this, we combine posterior component separation with the extraperitoneal route for end sigmoid colostomy.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe novel technique was performed in our center. Inclusion criteria: eligible patients included those undergoing abdominoperineal resection who expressed a desire for parastomal hernia (PSH) prevention. Initial inclusion criteria encompassed patients requiring laparoscopic permanent colostomy for various diseases. Excluded were patients with non-curative resection, temporary colostomy, laparotomy, or emergency operations. Between November 2021 and October 2023, 58 patients meeting the inclusion criteria were enrolled in the study, and their characteristics and outcomes were documented in supplementary. This is a prospective single-arm study at the development phase and fulfills the requirement of IDEAL framework stage II.\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e Informed consent was obtained from each patient. The study has been reported in line with the PROCESS criteria.\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntraoperative Decision\u003c/h3\u003e\n\u003cp\u003eThe decision regarding mesh placement was left to the surgeon\u0026rsquo;s discretion. Typically, this procedure was not considered for patients with dense mesenteric adhesions, bulky mesentery, and a high risk of mesenteric vasculature tearing. Reasons for not attempting mesh placement and instances of procedure failure were prospectively recorded.\u003c/p\u003e\n\u003ch3\u003eBaseline Characteristics and Outcomes\u003c/h3\u003e\n\u003cp\u003eDemographic and perioperative data, including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, aperture size, rectus abdominis muscle thickness, abdominal subcutaneous fat, neoadjuvant therapies, duration of operation, blood loss, length of stay, peritoneal rupture, and comorbidities, were prospectively collected from electronic clinical records. Postoperative follow-up, comprising CT reviews and physical examinations, was scheduled at 1, 3, 6, 12, 18, 24, and 36 months after surgery at our center. Aperture size was measured using the first postoperative CT image.\u003c/p\u003e \u003cp\u003eThe primary endpoint of this study was the occurrence of parastomal hernia (PSH). In alignment with the European Hernia Society (EHS) PSH classification, PSH was defined as an abnormal protrusion of abdominal cavity contents through the abdominal wall defect created during colostomy placement.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e However, due to the study\u0026rsquo;s nature, the presence and subgroup of PSH were determined based on CT scans. The hernia defect size was measured as the largest hernia orifice on axial CT images. Two radiologists independently reviewed the CT scans. In cases of discrepancy, another experienced radiologist provided consensus. Additionally, when clinical symptoms were positive despite negative CT scans, it was also considered a PSH\u0026mdash;abnormal protrusions near the stoma during standing Valsalva manoeuvre.\u003c/p\u003e \u003cp\u003eSecondary Endpoints: The secondary endpoints included the occurrence of postoperative complications, specifically peristomal morbidity. These complications encompassed peristomal infection, incision or pelvic infection, stoma bleeding, prolapse, necrosis, dehiscence, and stricture. Postoperative complications were tracked for up to 90 days and classified according to the Clavien-Dindo classification.\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e Stoma Quality-of-Life Assessment: To evaluate stoma-related quality of life, we employed a validated stoma quality-of-life questionnaire (Stoma-QOL) developed by Prieto et al.\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e Participants completed this questionnaire at 1, 3, 6, 12, 18, and 24 months postoperatively. The Stoma-QOL comprises 20 questions across four domains: Sleep, Sexual activity, Relations with family and close friends, social relations outside family and close friends\u003c/p\u003e\n\u003ch3\u003eSurgical Technique\u003c/h3\u003e\n\u003cp\u003eOur initial design involves placing the mesh between the peritoneum and the sigmoid colon, which is pulled out through the extraperitoneal space. The colostomy site is typically positioned at the midclavicular line in the left lower quadrant and marked preoperatively. Importantly, it is usually not centered within the mesh area but slightly medial to the center.\u003c/p\u003e\n\u003ch3\u003eThe development of the final technique has progressed through three phases\u003c/h3\u003e\n\u003cp\u003eIn Open Surgery with Preperitoneal Mesh (Open-PP): A small incision is made on the posterior rectus sheath. The peritoneum is separated from the rectus sheath and transversus abdominis using blunt finger dissection and intermittent sharp division of connective tissue. Preperitoneal separation extends to the planned mesh area (10 cm * 12 cm). Dissection advances medially to reach the midline and laterally to meet the retroperitoneal space. The proximal colon is pulled through the dissected preperitoneal space.\u003c/p\u003e \u003cp\u003eIn Open Surgery with Retro-Muscular Mesh (Open-RM): The small incision on the posterior rectus sheath is extended to the upper and lower edges of the mesh area. Peritoneal separation is performed only laterally, not medially. The mesh is placed laterally before the peritoneum and medially before the posterior rectus sheath.\u003c/p\u003e \u003cp\u003eIn Laparoscopic Surgery with Retro-Muscular Mesh (Lap-RM): A circular incision is made, allowing space for accommodating the bowel. The anterior rectus sheath is incised for 2\u0026ndash;3 cm. The rectus abdominis muscle is split and coagulated. Finger dissection separates the loose space behind the muscle. A 5 cm single-port device is inserted into the rectus sheath. Pneumoperitoneum pressure is set at 15 mmHg, and the camera is reversed for optimal viewing. Dissection of the extraperitoneal areolar tissue starts from the rectus sheath and advances first caudally, then laterally to reach the anterior superior iliac spine. The division of the posterior rectus sheath starts from below and lateral to the arcuate line and advances cranially along the semilunar line up to the level of the umbilicus. The posterior sheath near the linea alba is also divided for about 2 cm to facilitate easier stitching on the medial side. Then, the retromuscular space is expanded to the planned width. Seven sutures are tied to the corner and edge of the mesh and brought out of the skin at the marked points with the help of stitches or suture passer. The mesh is fixed to the planned position by tightening the sutures. The proximal colon is pulled out through the dissected retro-muscular space before the mesh. Then, the mesh is flattened with fingers to avoid folding. A laparoscopic mesh examination is performed to rule out torsion or folding.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eSPSS for Mac, version 26.0.0.2 (IBM Corp, Armonk, NY) was used for data analysis. Continuous data were shown as the median and range. Categorical variables were represented as percentages. The chi-squared test or fisher\u0026rsquo;s exact test was used for comparison of the categorical data and Student\u0026rsquo;s t-test or Mood's Median test was used for continuous data.. Statistical significance was defined as a p value less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOperative Parameters\u003c/h2\u003e \u003cp\u003eIn the cohort of 58 patients who underwent abdominoperineal resection (APR) or pelvic exenteration, mesh placement was not attempted in 7 patients due to factors such as obesity, swollen mesentery, and dense mesenteric adhesion. Additionally, in 8 patients, mesh placement was attempted but failed due to a large rupture of the peritoneum: three patients in the Open-PP group and five in the Open-RM group. Ultimately, successful mesh placement was achieved in 43 patients. These procedures were distributed as follows: Open-PP in 8 patients, Open-RM in 20 patients, and Lap-RM in 15 patients. All patients underwent surgery for malignant tumors of the rectum or anus. Among them, 32 patients underwent standard laparoscopic abdominoperineal resection, seven underwent partial pelvic exenteration, and four patients underwent laparoscopic total pelvic exenteration. Rupture of the peritoneum occurred in 6 out of 11 patients (3 failures and 3 repairs, 54.5%) in whom Open-PP mesh placement was attempted, in 11 out of 25 patients in the Open-RM group (5 failures, 6 repairs, 44%), and in 2 out of 15 patients in the Lap-RM group (no failure, 2 repairs, 13.3%). No other intraoperative complications were noted. Lap-RM mesh placement required a longer operation time for stoma formation, but the duration of the operation tended to decrease with increasing experience. The abdominal subcutaneous fat, rectus abdominis muscle thickness, and aperture size measured on the first postoperative CT were similar across the three groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Complications and Follow-Up Outcomes\u003c/h2\u003e \u003cp\u003ePostoperative complications within 90 days (as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) were recorded and classified according to the Clavien-Dindo classification. There was no significant difference in minor or major postoperative complications among the three groups. With the exception of two patients who were lost to follow-up (one refused follow-up, and one became paralyzed after a stroke), none of the 43 patients, with a median follow-up of 24 (ranging from 12 to 35) months, developed a parastomal hernia. In contrast, among the 15 patients who were either not considered for prophylactic mesh or experienced procedure failure, four patients developed a parastomal hernia (26.6%). Three complications were classified as CD IIIa (one due to mesh-related infection and two due to urinary leaks after pelvic exenteration). In the Lap-RM group, one patient suffered from a mesh-related infection, which was successfully controlled through interventional drainage, intermittent abscess irrigation, and intravenous antibiotics. Another patient developed adhesive small bowel obstruction during adjuvant chemotherapy and was managed conservatively. Additionally, one patient experienced pelvic bleeding postoperatively, which ceased after administering hemostatic drugs and infusing 3 units of red cell suspension. Five patients developed pelvic infections, and one patient had pneumonia, which improved with antibiotic treatment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen-PP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen -RM\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLap-RM\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.5(45\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.5(45\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62(34\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.34(20.45\u0026ndash;27.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.09(15.57\u0026ndash;27.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.6(17.71\u0026ndash;31.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of abdominal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign prostatic hypertrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAPR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLERR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLTPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA score, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI/II/III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/4/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/16/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/10/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0/I/II/III/IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/0/3/3/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/1/11/7/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1/1/7/3/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor to anal verge (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5(0.5-6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(0.5-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(0.5-3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal subcutaneous fat(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.38(0.60\u0026ndash;4.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71(0.38\u0026ndash;3.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.13(0.85\u0026ndash;3.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectus abdominis muscle thickness(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02(0.48\u0026ndash;1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.95(0.31\u0026ndash;1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.11(0.77\u0026ndash;1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAperture size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.93(1.53\u0026ndash;2.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.77(0.98\u0026ndash;2.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.89(1.17\u0026ndash;3.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant therapy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant therapy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(78.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime for stoma formation (min)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(32\u0026ndash;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(23\u0026ndash;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52(45\u0026ndash;61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eoperation time (min)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200(180\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185(120\u0026ndash;470)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e180(140\u0026ndash;240)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital duration (day)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(5\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(4\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eBMI\u003c/em\u003e body mass index; \u003cem\u003eDM\u003c/em\u003e diabetes; \u003cem\u003eCOPD\u003c/em\u003e chronic obstructive pulmonary disease; \u003cem\u003eASA\u003c/em\u003e American Society of Anaesthesiologist; \u003cem\u003eLAPR\u003c/em\u003e Laparoscopic abdominoperineal resection; \u003cem\u003eLERR\u003c/em\u003e Laparoscopic extended radical rectectomy; \u003cem\u003eLTPE\u003c/em\u003e laparoscopic total pelvic organ resection\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Data was shown as Median.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eTime for stoma formation is recorded as time from the skin incision to the completion of colostomy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003epostoperative complications and follow-up outcomes Clinical outcome at follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen-PP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen -RM\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eLap-RM\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian follow-up(range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32(30\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(21\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(12\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence or metastasis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioperative mortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications according to Clavien-Dindo classification, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade I-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade IIIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade IIIb-V\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStoma-related complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParastomal hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeristomal infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eprolapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStoma bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enecrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluid Collection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMesh infection, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall bowel obstruction, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic and perineal infection, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers*, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission within 3 months, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation within 3 months, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eOthers*: urinary tract infection, pelvic bleeding,and urethral fistula, etc.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 6 patients were re-admitted because of serious complications. Among them, two patients were diagnosed with a urinary leak, one with mesh-related infection, one adhesive bowel obstruction, and two pelvic infections. No patients required reoperation because of postoperative complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOncological outcomes\u003c/h2\u003e \u003cp\u003eDuring the follow-up period, three patients developed multiple lung metastases, two patients had peritoneal metastasis and carcinomatous lymphangitis, and one patient had liver metastasis and local recurrence. Four patients died due to local recurrence and metastasis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life\u003c/h2\u003e \u003cp\u003eThe mean Stoma-QOL scores exhibited improvement over time. Specifically, the mean scores at months 1, 3, 6, 12, 18, and 24 were 39.59, 43.75, 49.87, 56.53, 68.51, and 71.63 respectively (Fig.\u0026nbsp;8).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this represents the first description of retro-muscular mesh placement in the Sugarbaker configuration for preventing parastomal hernia (PSH) after end colostomy formation. Over time, various modifications of laparoscopic or open retro-muscular mesh placement in the Sugarbaker configuration have emerged and gradually become the preferred technique for parastomal hernia repair. Repairing a PSH using a retro-muscular Sugarbaker mesh offers the advantage of wide overlap, an intact mesh, and reduced risk of tension and folding compared to the intraabdominal counterpart. Laparoscopic placement of retro-muscular mesh for PSH repair has also been developed and reportedly results in a low recurrence rate. However, the use of a retro-muscular Sugarbaker mesh specifically for PSH prevention has not been previously reported.\u003c/p\u003e \u003cp\u003eWhen the retromuscular Sugarbaker technique was used for PSH and incisional hernia repair, previously reported techniques employed an open or transabdominal laparoscopic approach for posterior component separation.\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e A wide posterior component separation is essential for tension-free suturing of the peritoneum. However, such extensive dissection can be overly traumatic for prophylactic mesh placement and may seem irrational. Drawing from our experience with the extraperitoneal route for colostomy, our initial plan was to achieve posterior component separation through finger dissection. Creating a preperitoneal tunnel for bowel passage is typically not challenging. However, expanding the preperitoneal space to accommodate the mesh carries substantial risks of peritoneal rupture. The primary reason for the high rupture rate is that the peritoneum adheres more to the posterior sheath than to the transversus abdominis. Although an inadvertent small hole can be promptly repaired by suturing, there is a chance it could develop into a larger tear during subsequent blunt separation. This explains why the earlier two phases (Open-PP and Open-RM) are associated with a significant rate of peritoneal rupture and procedural failure (54.5% and 42.3%). The last technique (lap-RM) avoids preperitoneal separation behind the rectus sheath by dividing the posterior sheath at its lateral edge, significantly reducing the risk of rupture. With a well-separated space, it is easy to close a small hole with a clip or suturing. Another noteworthy merit of this technique is that the abdominal aperture is covered and protected with the mesh and an intact posterior sheath, which very likely contributed to the low recurrence rate.\u003c/p\u003e \u003cp\u003eThe preliminary outcomes, with a median follow-up of 24 months (range: 12\u0026ndash;35 months), appear quite satisfactory. The risk of mesh-related complications is similar to most reports on retro-muscular mesh placements. To mitigate infection risk, achieving effective hemostasis for any oozing and cauterizing the proximal stapled line are imperative steps. Among the 22 patients followed up for over two years, no clinical or radiologically confirmed parastomal hernia (PSH) was observed. In contrast, four patients among patients not considered for or who failed prophylactic mesh developed PSH. This result shows promise when compared to other studies,\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e which typically report a recurrence rate of 2.1\u0026ndash;34.2% within two year.\u003c/p\u003e \u003cp\u003eThe intra-peritoneal Sugarbaker mesh, unlike the keyhole technique, provides comprehensive coverage of the abdominal wall aperture and has been shown to reduce PSH rates compared to either no mesh placement or keyhole mesh placement.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e However, for PSH prevention, a Sugarbaker mesh is usually positioned within the peritoneal cavity. Despite the potential risks of intra-abdominal adhesion and intestinal erosion, an intraperitoneal Sugarbaker mesh is susceptible to medial pull due to lateralized bowel. Increased tension along its lateral edge can lead to mesh folding toward the center, resulting in defects and herniation.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e With our technique, the intact peritoneum secures the sigmoid colon to the anterior abdominal wall, rendering medial tension on the mesh a non-issue. Furthermore, a retro-muscular mesh is less prone to shrinkage, folding, and twisting compared to an intraperitoneally placed mesh. While these theoretical merits are promising, their true benefits await confirmation through longer follow-up and validation by other surgeons\u0026rsquo; practices.\u003c/p\u003e \u003cp\u003eWe have developed the novel technique for placing a retro-muscular mesh. There has been only one case of mesh-related infection caused by this technique. When the proximal colon is pulled out through the retro-muscular space dissected before the mesh, the tunnel may be contaminated. After that, we routinely placed drainage tubes in the surgical area and retained them until 2\u0026ndash;3 days after surgery.\u003c/p\u003e \u003cp\u003eIn the initial phases of this series, we excluded patients with dense mesenteric adhesions and those with bulky and obese mesentery from mesh placement. Lysis of dense mesenteric adhesions is time-consuming and challenging when performed laparoscopically. However, obese mesentery is no longer considered a contraindication in the Lap-RM group. In the Lap-RM group, mesh placement can be completed in patients with a BMI up to 32.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur study has some limitations. First, considering the time acquired nature of the PSH, the follow-up of this study was short and longer follow-up is needed to confirm the benefits of preperitoneal Sugarbaker mesh in reducing PSH; the follow-up for Lap-RM is even shorter. We need multi-center, randomized trials with longer follow-up to confirm the study's findings and assess the long-term benefits and risks of this novel technique. Second, this technique requires more time than the intraperitoneal Sugarbaker and retro-muscular keyhole approaches. The impact of the longer operation time is still under evaluation. The procedure demands considerable skills in single-port laparoscopic surgery, although an additional port is also acceptable. Third, in the present series, we have not explored the possibility of using this technique with modifications for other types of stoma creation, such as loop colostomy or ileal conduit.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, by combining the extraperitoneal route for colostomy with single-port laparoscopic posterior component separation, we have developed a novel technique for placing a retro-muscular mesh in a Sugarbaker configuration. This innovative approach offers several theoretical advantages, including complete coverage of the abdominal aperture by an intact mesh and posterior sheath, elimination of tension from lateralized bowel on intraperitoneal mesh, and the ability to use synthetic mesh. Preliminary outcomes indicate a significant reduction in PSH, although definitive benefits await longer follow-up, validation from other studies, and randomized clinical trials.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThe Institutional Review Committee of West China Hospital of Sichuan University approved this study. The requirement for informed consent was waived due to the retrospective nature of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for patients\u003c/strong\u003e: The authors will provide evidence of consent, if requested by the journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e: The datasets during and/or analyzed during the current study are not publicly available due to the confidentiality of patient information but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Department of Science and Technology of Sichuan Province (Award Number 2021YFS0025); the National Natural Science Foundation of China （82203474）;1\u0026middot;3\u0026middot;5 project for disciplines of excellence \u0026ndash; Clinical Research Fund, West China Hospital, Sichuan University (2024HXFH012 to Qingbin Wu)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe trial was registered with the Chinese Clinical Trial Registry (identifier: ChiCTR2200056134).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, the study is registered on clinicaltrials.gov (NCT04177407).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCARNE P W G, ROBERTSON G M, FRIZELLE F A. Parastomal hernia [J]. British Journal of Surgery, 2003, 90(7): 784\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/bjs.4220\u003c/span\u003e\u003cspan address=\"10.1002/bjs.4220\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCHAPMAN S J, WOOD B, DRAKE T M, et al. Systematic review and meta-analysis of prophylactic mesh during primary stoma formation to prevent parastomal hernia [J]. Diseases of the Colon \u0026amp; Rectum, 2016, 36(1).\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/DCR.0000000000000670\u003c/span\u003e\u003cspan address=\"10.1097/DCR.0000000000000670\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCROSS A J, BUCHWALD P L, FRIZELLE F A, et al. 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Surgery Today, 2016, (6).\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00595-015-1236-x\u003c/span\u003e\u003cspan address=\"10.1007/s00595-015-1236-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePRIETO L, THORSEN H, JUUL K. Development and validation of a quality of life questionnaire for patients with colostomy or ileostomy [J]. Health and Quality of Life Outcomes, 2005, 3.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1477-7525-3-62\u003c/span\u003e\u003cspan address=\"10.1186/1477-7525-3-62\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBRANDSMA H T, HANSSON B M E, AUFENACKER T J, et al. 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Annals of Surgery, 2023, 278(3): e440\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e-e6.https://doi.org/10.1097/SLA.0000000000005801\u003c/span\u003e\u003cspan address=\"-e6.10.1097/SLA.0000000000005801\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNVERLO S, GUNNARSSON U, STRIGRD K, et al. Quality of life after end colostomy without mesh and with prophylactic synthetic mesh in sublay position: one-year results of the STOMAMESH trial [J]. Int J Colorectal Dis, 2019, (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e9).https://doi.org/10.1007/s00384-019-03359-2\u003c/span\u003e\u003cspan address=\"9).10.1007/s00384-019-03359-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePRUDHOMME M, RULLIER E, LAKKIS Z, et al. End Colostomy With or Without Mesh to Prevent a Parastomal Hernia (GRECCAR 7) \u0026lt;\u0026thinsp;i\u0026thinsp;\u0026gt;\u0026thinsp;A Prospective, Randomized, Double Blinded, Multicentre Trial [J]. Annals of Surgery, 2021, 274(6): 928\u0026thinsp;\u0026ndash;\u0026thinsp;34.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/SLA.0000000000004371\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0000000000004371\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Laparoscopic abdominoperineal resection, Parastomal hernia, Permanent colostomy, Mesh, case series","lastPublishedDoi":"10.21203/rs.3.rs-6465204/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6465204/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eParastomal 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 in techniques and mesh selection are necessary.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis 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 underwent three phases of refinement: Initially, posterior component separation was performed using finger dissection. The mesh was then placed either in a preperitoneal position (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 perioperative and postoperative complications and outcomes were prospectively recorded and reported following the IDEAL frameworks (I-IIa stage).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA 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 compared to those in the Lap-RM group (54.5%, 44% vs. 13.3%). None of the patients who received mesh placement developed parastomal hernia during a median follow-up of 24 (12\u0026ndash;35) months. However, 15 patients who were not considered for or failed this procedure had a recurrence rate of 26.6%. Additionally, one patient experienced a mesh-related infection.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eProphylactic 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.\u003c/p\u003e","manuscriptTitle":"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.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 13:01:32","doi":"10.21203/rs.3.rs-6465204/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-30T21:27:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-17T12:59:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286291217874795504956649265610987738444","date":"2025-05-16T05:16:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122094380709766234510546363939913923814","date":"2025-05-14T04:53:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-14T04:35:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-04T18:48:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-17T04:38:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2025-04-16T15:57:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f6138123-67a9-4182-9a5a-4a85f9b900c8","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-02T21:38:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 13:01:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6465204","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6465204","identity":"rs-6465204","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}