“Pauli”-tical science: early single-center experience with the technique of the minimally invasive retromuscular parastomal hernia repair

Background Parastomal hernias cause significant morbidity and are frequent after stoma creation, with reported incidences reaching up to 50%. With current repair methods, recurrence and mesh-related complications remain high. The Pauli Parastomal Hernia Repair (PPHR), developed as a modification of the Sugarbaker approach, utilizes a posterior component separation technique to lateralize the bowel within the retromuscular space to offset the bowel and minimize mesh-related complications. Small series on outcomes show promise, but data are overall lacking for minimally invasive (MIS) modifications of this approach. We report our series of robotic approaches to PPHR. Methods This study is a retrospective case series of patients undergoing elective robotic PPHR (rPPHR) from 2022 to 2024 at a single-institution tertiary referral center by two fellowship-trained abdominal wall surgeons. Patient and hernia characteristics, operative details, and post-operative outcomes were abstracted from the electronic health records. Hernia recurrence (defined as CT evidence or physical exam findings) and 30-day morbidity, including stoma and mesh-related complications, were reported and analyzed. Results During this time period, 26 patients underwent elective robotic PPHR. Twenty patients (77%) had a concomitant midline component, and 13 (50%) had a previous hernia repair with 6 (46%) having previous mesh placement. The average parastomal hernia size was 24 ± 17 cm 2 . Stoma types varied with 11 (42%) end colostomies, 10 (38%) end ileostomies, and 5 (19%) ileal conduits. There were no intra-operative complications. The 30-day morbidity was 23%, which included one surgical site infection (SSI), one seroma, one ileus, and one mechanical obstruction at the stoma. With a median follow-up of 15.4 months, there was a 1-year recurrence rate of 4% and 2-year recurrence rate of 8%. One repair required reoperation for postoperative pouching difficulty without a recurrence present. Conclusion The rPPHR technique for parastomal hernia repair is a technically challenging procedure with promising early outcomes and deserves continued study of longer-term outcomes.