• Cigdem Benlice, Luca Stocchi, Meagan M Costedio, Emre Gorgun, and Hermann Kessler.
• Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
• Dis. Colon Rectum. 2016 Aug 1; 59 (8): 743-50.

BackgroundThe impact of the specific incision used for specimen extraction during laparoscopic colorectal surgery on incisional hernia rates relative to other contributing factors remains unclear.ObjectiveThis study aimed to assess the relationship between extraction-site location and incisional hernia after laparoscopic colorectal surgery.DesignThis was a retrospective cohort study (January 2000 through December 2011).SettingsThe study was conducted at a high-volume, specialized colorectal surgery department.PatientsAll of the patients undergoing elective laparoscopic colorectal resection were identified from our prospectively maintained institutional database.Main Outcome MeasuresExtraction-site and port-site incisional hernias clinically detected by physician or detected on CT scan were collected. Converted cases, defined as the use of a midline incision to perform the operation, were kept in the intent-to-treat analysis. Specific extraction-site groups were compared, and other relevant factors associated with incisional hernia rates were also evaluated with univariate and multivariate analyses.ResultsA total of 2148 patients (54.0% with abdominal and 46.0% with pelvic operations) with a mean age of 51.7 ± 18.2 years (52% women) were reviewed. Used extraction sites were infraumbilical midline (23.7%), stoma site/right or left lower quadrant (15%), periumbilical midline (22.5%), and Pfannenstiel (29.6%) and midline converted (9.2%). Overall crude extraction site incisional hernia rate during a mean follow-up of 5.9 ± 3.0 years was 7.2% (n = 155). Extraction-site incisional hernia crude rates were highest after periumbilical midline (12.6%) and a midline incision used for conversion to open surgery (12.0%). Independent factors associated with extraction-site incisional hernia were any extraction sites compared with Pfannenstiel (periumbilical midline HR = 12.7; midline converted HR = 13.1; stoma site HR = 28.4; p < 0.001 for each), increased BMI (HR = 1.23; p = 0.002), synchronous port-site hernias (HR = 3.66; p < 0.001), and postoperative superficial surgical-site infection (HR = 2.11; p < 0.001).LimitationsThis study was limited by its retrospective nature, incisional hernia diagnoses based on clinical examination, and heterogeneous surgical population.ConclusionsPreferential extraction sites to minimize incisional hernia rates should be Pfannenstiel or incisions off the midline. Midline incisions should be avoided when possible.

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