Modified Approach for Extraperitoneal Colostomy Creation in Laparoscopic Abdominoperineal Resection

Abstract

BACKGROUND: Parastomal hernia is a major long-term complication after abdominoperineal resection. Extraperitoneal colostomy has been proposed as an effective step for parastomal hernia prevention but it has not been widely used as it is technically-demanding and time-consuming. We proposed a modified approach for extraperitoneal colostomy creation by entering the extraperitoneal space through the arcuate line of the posterior rectus sheath. OBJECTIVE: To evaluate the safety, difficulty and efficacy for long-term parastomal hernia prevention of the modified approach for extraperitoneal colostomy creation compared with conventional transperitoneal colostomy approach. DESIGN: This was a retrospective evaluation of a surgical and video database. SETTINGS: This was a single-institution retrospective study. PATIENTS: Clinical data of 74 patients who underwent laparoscopic abdominoperineal resection surgery from January 2019 to January 2020 in the Department of General Surgery, Qilu Hospital of Shandong University were retrospectively reviewed. MAIN OUTCOME MEASURES: Baseline characteristics, time required for colostomy creation (from skin incision to colostomy maturation), perioperative complications, and long-term colostomy-related complications were compared. RESULTS: Baseline characteristics did not differ between the 2 approaches. The body mass index level ranged from 19.5 to 29.4 kg/m 2 for patients undergoing extraperitoneal approach. Time required for colostomy creation [22 (21-25) min for extraperitoneal vs. 23 (21-25) min for transperitoneal, p = 0.861] were comparable between the two approaches. The cumulative incidence of parastomal hernia was significantly greater with transperitoneal colostomy than extraperitoneal colostomy at 2 and 3 years postoperatively (16.2% vs. 0, p = 0.025, and 21.6% vs. 0, p = 0.005). The rest perioperative complications and long-term colostomy-related complications did not differ between the two approaches. LIMITATIONS: This study is limited by its retrospective design and small sample size. CONCLUSIONS: The modified approach for extraperitoneal colostomy creation is safe, technically simple and effective for long-term parastomal hernia prevention in patients with a body mass index of 19.5 - 29.4 kg/m 2.