Sugarbaker Mesh Lowers Parastomal Hernia After APR

Key Takeaways

• Adults undergoing elective laparoscopic abdominoperineal resection with permanent end colostomy for lower rectal cancer had lower cumulative radiologic parastomal hernia incidence with prophylactic Sugarbaker mesh than with no mesh over up to 4 years.
• Kaplan–Meier analysis showed a significant between-group difference in radiologic parastomal hernia incidence (log-rank p = 0.00018), with a reported 4-year absolute risk reduction of 47.0% and an approximate number needed to treat of 2.1.

In a single-center ambispective study from Vietnam, long-term separation in radiologic parastomal hernia risk was observed after prophylactic Sugarbaker mesh placement during elective laparoscopic abdominoperineal resection, with a reported 4-year absolute risk reduction of 47.0% and an approximate number needed to treat of 2.1. 84 patients underwent laparoscopic APR with permanent end colostomy for lower rectal cancer, and the lower hernia incidence in the mesh group persisted over follow-up extending to 4 years.

The ambispective study combined a retrospective historical cohort (2018–2021) with a prospectively followed period after mesh introduction (2021–2025); from 2021 onward, patients who declined mesh were also included in the non-mesh group. Among 101 patients assessed, 84 were included in the final analysis (40 mesh, 44 non-mesh) after excluding 3 mesh patients with follow-up under 12 months and 14 non-mesh patients lost to follow-up; all analyzed patients were adults undergoing elective laparoscopic APR with permanent end colostomy for lower rectal cancer, and protocol exclusion criteria also included emergency surgery, conversion to open surgery, prior mesh at the stoma site, mesh intolerance, and refusal to participate. The primary endpoint was cumulative incidence of radiologically diagnosed parastomal hernia, assessed by CT at 12 months and annually thereafter using the European Hernia Society CT definition.

The prophylactic approach used a trans-rectus end colostomy with intraperitoneal composite mesh, at least 5 cm of overlap, bowel lateralization, and double-crown fixation with absorbable tacks. Mesh placement added 15.4 ± 1.5 minutes, while overall operative time was 180.0 ± 48.3 minutes with mesh versus 173.5 ± 43.9 minutes without mesh (p = 0.8). Time to restoration of stoma function was 2.0 ± 0.5 versus 2.1 ± 0.5 days (p = 0.7), and early postoperative complications were reported as low and similar between groups, with no mesh infection, enteric fistula, or mesh removal reported during follow-up.

Mean follow-up was longer in the historical non-mesh cohort than in the mesh cohort, at 36.8 ± 15.4 months versus 29.4 ± 12.6 months (p = 0.018), reflecting the study’s nonrandomized design and staged adoption of prophylactic mesh. The comparison was described as exploratory, and no multivariable analysis was performed because of the limited sample size, leaving residual confounding possible in this historical comparison. The study also did not compare alternative mesh materials or other prophylactic techniques and was not powered for oncologic outcomes, so the observed association applies to this cohort and follow-up structure.

Clinician Questions

Does prophylactic Sugarbaker mesh reduce parastomal hernia after laparoscopic abdominoperineal resection for low rectal cancer?

In an 84-patient ambispective cohort of elective laparoscopic abdominoperineal resection with permanent end colostomy for lower rectal cancer, prophylactic Sugarbaker mesh was associated with lower cumulative radiologic parastomal hernia incidence than no mesh over up to 4 years, with a Kaplan–Meier log-rank p = 0.00018, a 4-year absolute risk reduction of 47.0%, and an approximate number needed to treat of 2.1 in this nonrandomized historical comparison.

How much operative time did prophylactic Sugarbaker mesh add during laparoscopic APR?

During laparoscopic abdominoperineal resection, prophylactic Sugarbaker mesh placement added a mean 15.4 ± 1.5 minutes, while total operative time was similar between groups at 180.0 ± 48.3 minutes with mesh versus 173.5 ± 43.9 minutes without mesh (p = 0.8).

Were mesh-related complications reported after prophylactic Sugarbaker mesh at permanent end colostomy creation?

No mesh-related complications were observed during follow-up after prophylactic Sugarbaker mesh at permanent end colostomy creation, including mesh infection, enteric fistula, or mesh removal, and reported rates of intraoperative bleeding, postoperative bleeding, surgical site infection, urinary retention, and mechanical bowel obstruction were low and similar between groups.

How was parastomal hernia assessed in this laparoscopic APR cohort?

The primary outcome in this laparoscopic abdominoperineal resection cohort was cumulative incidence of radiologically diagnosed parastomal hernia, assessed with abdominopelvic CT at 12 months after surgery and annually thereafter, using the European Hernia Society CT definition of protrusion of abdominal cavity contents through the abdominal wall at the stoma site.