Submitted:
17 February 2025
Posted:
18 February 2025
You are already at the latest version
Abstract
Background: Recent studies indicate that minimally invasive surgery is widely accepted as the optimal procedure for colorectal cancer. However, the ideal lo-cation of the specimen extraction site remains unclear. This study aimed to compare the conventional periumbilical midline incision with the Pfannenstiel incision for specimen extraction during minimally invasive surgery for rectal cancer. Methods: This retrospective cohort study included 76 patients who underwent minimally invasive surgery (double-stapling technique anastomosis) for rectal cancer between January 2022 and June 2023. Postoperative short- and mid-term outcomes were compared between the periumbilical midline incision and Pfannenstiel incision groups. Results: Patient backgrounds were comparable between the two groups. There were no significant differences in the surgical outcomes or short-term postoperative complications. The Pfannenstiel incision demonstrated advantages, including reduced postoperative pain at rest and during movement, and a lower incidence of incisional hernia (p = 0.038). Conclusions: Pfannenstiel incision is a safe and effective option associated with reduced postoperative pain and a lower risk of incisional hernia. Therefore, it can serve as a useful alternative for specimen extraction during minimally invasive rectal cancer surgery.
Keywords:
Pfannenstiel incision
; rectal cancer
; minimal invasive surgery
; incisional hernia
1. Introduction
Colorectal cancer is the second-most common cancer in Japan [1], and its morbidity and mortality rates are increasing globally [2]. Surgical treatment for resectable colorectal cancer has evolved from conventional laparotomy to minimally invasive surgery, aided by advancements in surgical devices and techniques [3,4]. Minimally invasive surgery is reported to be comparable or superior to conventional laparotomy in terms of blood loss, postoperative wound pain, surgical site infection (SSI), respiratory complications, and length of hospital stay [5,6,7,8].
Incisional hernia is a common complication following abdominal surgery, with an incidence rate of 13%–20% after midline laparotomy [9,10]. In addition, incisional hernia is associated with a decline in the quality of life and significant re-operation costs [11,12]. Although minimally invasive surgery is expected to reduce the incidence of incisional hernias because of smaller midline incisions, the incidence rate remains similar, with frequent symptoms such as pain and incarceration [13,14]. Patient-related risk factors for incisional hernia include advanced age, steroid use, diabetes, malnutrition, and obesity [15-19]. In addition, surgical factors such as closure method, SSI and specimen extraction sites have been reported [20,21]. The periumbilical midline incision remains the most commonly used incision for specimen extraction in minimally invasive surgery. On the other hand, there is increasing evidence to suggest that off-midline extraction incisions may avoid incisional hernia [14,20,22]. The Pfannenstiel incision is a transverse incision in the lower abdomen that is widely used in urological and gynecological open surgery [23]. Additionally, it has cosmetic advantages and is associated with less postoperative pain, a lower incidence of SSI, and a reduced risk of incisional hernia [24,25]. Recently, the usefulness of Pfannenstiel incision as a specimen extraction site for minimally invasive surgery has also been reported [26,27]. However, there is limited evidence regarding the safety and efficacy of Pfannenstiel incision as a specimen extraction site for minimally invasive rectal surgery.
Therefore, this study aimed to compare short-term outcomes and the incidence of incisional hernia between the conventional periumbilical midline incision (C) group and the Pfannenstiel incision (P) group to evaluate the optimal specimen extraction site for minimally invasive rectal cancer surgery.
2. Materials and Methods
2.1. Patients
This retrospective study was approved by our institutional review board (approval no.: 27-177[8062]). Data were collected from prospectively maintained databases from January 2022 to July 2023 for all consecutive patients who underwent minimally invasive surgery for rectal cancer at Jikei University School of Medicine. The exclusion criteria were abdominal perineal resection and simultaneous resection of distant metastases. Patients received intravenous acetaminophen (1,000 mg/dose, 15 mg/kg/dose for patients weighing less than 50 kg) every 6 h from POD 1 to 3, and epidural anesthesia was administered at the discretion of the anesthesiologist. Postoperative pain was evaluated using the numerical rating scale (NRS), graded from 0 to 10, where 0 = no pain and 10 = the worst imaginable pain.
Patient characteristics, clinicopathological data, surgical factors, treatment out-comes, postoperative pain (measured using NRS at rest and upon movement from POD 1 to POD 7), and complications were retrospectively compared between the C and P groups.
2.2. Follow-Up
Postoperative follow-up included a medical interview, physical examination, tumor marker testing every three months, and computed tomography (CT) or magnetic resonance imaging (MRI) every six months. Incisional hernia was diagnosed on the basis of imaging findings indicating protrusion of visceral fat or part of the bowel above the level of the abdominal wall. When a hernia was suspected based on a medical interview and physical examination, CT or MRI was performed to confirm the diagnosis.
2.3. Statistical Analysis
The associations between each specimen extraction incision and clinicopathological characteristics were analyzed using Mann–Whitney U and Chi-Square (χ2) tests for continuous and categorical variables, respectively. Statistical significance was set at p < 0.05. All statistical analyses were performed using JMP® 13 (SAS Institute Inc. Cary, NC, USA).
3. Results
3.1. Characteristics of the Study Cohort
Of the 76 patients included in the study, 30 were included in the C group and 46 were included in the P group. The clinicopathological characteristics of the two groups are listed in Table 1. The characteristics of the patients in the C and P groups were comparable, except for the frequency of robotic surgeries. In particular, the two groups were similar in terms of preoperative nutritional status and diabetes.
3.2. Perioperative Outcomes
There were no significant differences between the two groups in terms of surgical procedures, frequency of temporary stoma creation, frequency and duration of epi-dural anesthesia. Overall, postoperative complications occurred in 10 patients (13.2%), among which 2 (2.6%) had major complications of Clavien–Dindo grade ≥ IIIa. No significant difference was observed between the two groups in terms of the incidence of overall postoperative or major complications. Notably, no SSI cases were reported in the P Group (Table 2).
3.3. Postoperative Pain
In terms of postoperative pain, the P group experienced less pain at rest on POD 1 (p = 0.032) and POD 7 (p = 0.019), upon movement on POD 6 (p = 0.038) and POD 7 (p = 0.009) (Table 3 and Table 4). Furthermore, after excluding cases with epidural anesthesia, postoperative pain was also better in the P group at rest in POD 3 (p = 0.020) and upon movement in POD 6 (p = 0.019) and POD 7 (p = 0.011) (Table 5 and Table 6).
3.4. Incisional Hernia
In both groups, the follow-up period was approximately two years, with no significant difference (p = 0.092). The P group had no incisional hernias, whereas the C group had an incidence rate of 15% (p = 0.038). In addition, the duration from surgery to the diagnosis of incisional hernia was approximately 10 months.
4. Discussion
Conventionally, open surgery has been the standard treatment for resectable colorectal cancer. In recent years, minimally invasive surgery for colorectal cancer has become widely accepted, offering several advantages over open surgery [3-8]. Minimally invasive surgery for colorectal cancer requires a specimen extraction incision, and conventionally a periumbilical midline incision that extends from the camera port in the navel has been used [28]. However, the optimal site for the specimen extraction incision for colorectal surgery remains unclear. Furthermore, some studies have indicated that the risk of postoperative complications such as incisional hernia and SSI is influenced by the specimen extraction site [14,20,22,28].
The Pfannenstiel incision, introduced by the German gynecologist Pfannenstiel, is a transverse lower abdominal incision [23]. It has been commonly used in gynecological and urological surgeries because it provides easy access to deep pelvic organs [29-31]. This incision offers several benefits, including excellent cosmetic results by following Langer's line, reduced postoperative pain, and lower incidence of SSI and incisional hernia [24,25]. The incidence of incisional hernia after open surgery is reported to be low at 0.5%–2.1% [24,32] with Pfannenstiel incision compared to 11%–20% [9,10,33] with midline incision. Furthermore, a meta-analysis comparing specimen extraction sites in minimally invasive surgery reported that the risk of incisional hernia was significantly higher with a midline incision than with a non- midline incision [14,20,22,26,27]. The lower incidence of SSI and incisional hernia associated with Pfannenstiel incisions may be attributed to (1) the lack of a continuous abdominal wall layer at the incision site and (2) avoidance of cutting the linea alba, which has the lowest blood flow in the abdominal wall [24,25]. Most cases of hernia occur within two years after surgery, although some occur later, emphasizing the importance of the follow-up period [33]. The follow-up period for both groups in this study was approximately two years. The incidence of incisional hernia was significantly lower in the P group, and no hernia cases were reported in this group.
Postoperative pain is associated with early mobilization, reduced respiratory complications, and a shorter hospital stay [34,35]. Several reports have compared postoperative pain between Pfannenstiel and midline incisions in open abdominal or laparoscopic surgery; however, the results remain inconsistent [26,27,30,36]. In addition, there are few studies on postoperative pain at specimen extraction sites after minimally invasive colorectal cancer surgery. In this study, the P group showed better postoperative pain outcomes at rest on POD 1 and 7, and upon movement on POD 6 and 7. There was no significant difference between the two groups in terms of the use of epidural anesthesia, and the duration of epidural anesthesia use extended to POD 5 in both groups. When cases involving epidural anesthesia were excluded, the P group also showed better results at rest on POD 3 and POD 7, and upon movement on POD 6 and POD 7, suggesting that the Pfannenstiel incision was superior to the midline incision in terms of reducing postoperative pain.
This study had several limitations. First, this was a single-center study with a limited number of patients. Second, as this was a retrospective study, the patient back-ground and data collection could not be completely controlled. Although there were no significant differences in clinicopathological characteristics between the two groups, except for robotic surgery use, selection bias could not be ruled out. Finally, the choice of the incision type was left to the surgeon’s discretion. A prospective study with a larger sample size is needed to compare the benefits of the specimen extraction site in minimally invasive rectal surgery using periumbilical midline incision and Pfannenstiel incision.
5. Conclusions
Pfannenstiel incision is preferable to conventional periumbilical midline incision for minimally invasive rectal cancer surgery because it results in a lower incidence of incisional hernia and reduced postoperative pain.
Author Contributions
Conceptualization, Y.T. (Yasuhiro Takeda) and K.E.; methodology, Y.T. (Yasuhiro Takeda), K.G. and T.K.; software, Y.T. (Yasuhiro Takeda), T.A., T.N. and Y.T. (Yasuhiro Takano); validation, Y.T. (Yasuhiro Takeda), T.K. and M.O.; formal analysis, Y.T. (Yasuhiro Takeda) and M.K.; investigation, Y.T. (Yasuhiro Takeda), K.G. and T.K.; resources, Y.T. (Yasuhiro Takeda) and M.K.; data curation, Y.T. (Yasuhiro Takeda), K.G., T.K., M.O. and Y.T. (Yasuhiro Takano); writing—original draft preparation, Y.T. (Yasuhiro Takeda), T.A., T.N. and M.O.; writing—review and editing, Y.T. (Yasuhiro Takeda) and K.E.; visualization, Y.T. (Yasuhiro Takeda) and M.K.; supervision, Y.T. (Yasuhiro Takeda) and K.E.; project administration, Y.T. (Yasuhiro Takeda) and K.E.; funding acquisition, Y.T. (Yasuhiro Takeda) and K.E. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
This retrospective study protocol was approved by the Ethics Committee of the Jikei University School of Medicine (approval no: 30–249 9270) and adhered to the principles of the Declaration of Helsinki.
Informed Consent Statement
Patient consent was waived due to retrospective design.
Data Availability Statement
The data presented in this study are available from the corresponding author upon reasonable requests. The data are not publicly available since they are covered by institutional privacy policies.
Acknowledgments
We thank Editage (www.editage.com) for their English language editing services.
Conflicts of Interest
The authors declare no conflicts of interest.eclare conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| CT | Computed tomography |
| MRI | Magnetic resonance imaging |
| NRS | Numerical rating scale |
| SSI | Surgical site infection |
References
- Hashiguchi, Y.; Muro, K.; Saito, Y.; Ito, Y.; Ajioka, Y.; Hamaguchi, T.; Hasegawa, K.; Hotta, K.; Ishida, H.; Ishiguro, M.; et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020, 25, 1–42. [Google Scholar] [CrossRef] [PubMed]
- Siegel, R.L.; Miller, K.D.; Goding Sauer, A.; Fedewa, S.A.; Butterly, L.F.; Anderson, J.C.; Cercek, A.; Smith, R.A.; Jemal, A. Colorectal cancer statistics, 2020. CA Cancer J Clin 2020, 70, 145–164. [Google Scholar] [CrossRef] [PubMed]
- Jayne, D.G.; Thorpe, H.C.; Copeland, J.; Quirke, P.; Brown, J.M.; Guillou, P.J. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 2010, 97, 1638–1645. [Google Scholar] [CrossRef] [PubMed]
- Bonjer, H.J.; Deijen, C.L.; Abis, G.A.; Cuesta, M.A.; van der Pas, M.H.; de Lange-de Klerk, E.S.; Lacy, A.M.; Bemelman, W.A.; Andersson, J.; Angenete, E.; et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015, 372, 1324–1332. [Google Scholar] [CrossRef]
- Kiran, R.P.; El-Gazzaz, G.H.; Vogel, J.D.; Remzi, F.H. Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg 2010, 211, 232–238. [Google Scholar] [CrossRef]
- Yamamoto, S.; Inomata, M.; Katayama, H.; Mizusawa, J.; Etoh, T.; Konishi, F.; Sugihara, K.; Watanabe, M.; Moriya, Y.; Kitano, S. Short-term surgical outcomes from a randomized controlled trial to evaluate laparoscopic and open D3 dissection for stage II/III colon cancer: Japan Clinical Oncology Group Study JCOG 0404. Ann Surg 2014, 260, 23–30. [Google Scholar] [CrossRef]
- Fujii, S.; Akagi, T.; Inomata, M.; Katayama, H.; Mizusawa, J.; Ota, M.; Saito, S.; Kinugasa, Y.; Yamaguchi, S.; Sato, T.; et al. Transitional impact of short- and long-term outcomes of a randomized controlled trial to evaluate laparoscopic versus open surgery for colorectal cancer from Japan Clinical Oncology Group Study JCOG0404. Ann Gastroenterol Surg 2019, 3, 301–309. [Google Scholar] [CrossRef]
- Udayasiri, D.K.; Skandarajah, A.; Hayes, I.P. Laparoscopic Compared With Open Resection for Colorectal Cancer and Long-term Incidence of Adhesional Intestinal Obstruction and Incisional Hernia: A Systematic Review and Meta-analysis. Dis Colon Rectum 2020, 63, 101–112. [Google Scholar] [CrossRef]
- Mudge, M.; Hughes, L.E. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985, 72, 70–71. [Google Scholar] [CrossRef]
- Sugerman, H.J.; Kellum, J.M., Jr.; Reines, H.D.; DeMaria, E.J.; Newsome, H.H.; Lowry, J.W. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996, 171, 80–84. [Google Scholar] [CrossRef]
- Krpata, D.M.; Schmotzer, B.J.; Flocke, S.; Jin, J.; Blatnik, J.A.; Ermlich, B.; Novitsky, Y.W.; Rosen, M.J. Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function. J Am Coll Surg 2012, 215, 635–642. [Google Scholar] [CrossRef] [PubMed]
- Reynolds, D.; Davenport, D.L.; Korosec, R.L.; Roth, J.S. Financial implications of ventral hernia repair: a hospital cost analysis. J Gastrointest Surg discussion p.166-157. 2013, 17, 159–166. [Google Scholar] [CrossRef] [PubMed]
- Lee, L.; Mappin-Kasirer, B.; Sender Liberman, A.; Stein, B.; Charlebois, P.; Vassiliou, M.; Fried, G.M.; Feldman, L.S. High incidence of symptomatic incisional hernia after midline extraction in laparoscopic colon resection. Surg Endosc 2012, 26, 3180–3185. [Google Scholar] [CrossRef] [PubMed]
- Lee, L.; Abou-Khalil, M.; Liberman, S.; Boutros, M.; Fried, G.M.; Feldman, L.S. Incidence of incisional hernia in the specimen extraction site for laparoscopic colorectal surgery: systematic review and meta-analysis. Surg Endosc 2017, 31, 5083–5093. [Google Scholar] [CrossRef] [PubMed]
- Franchi, M.; Ghezzi, F.; Buttarelli, M.; Tateo, S.; Balestreri, D.; Bolis, P. Incisional hernia in gynecologic oncology patients: a 10-year study. Obstet Gynecol 2001, 97, 696–700. [Google Scholar] [CrossRef] [PubMed]
- Togo, S.; Nagano, Y.; Masumoto, C.; Takakura, H.; Matsuo, K.; Takeda, K.; Tanaka, K.; Endo, I.; Shimada, H. Outcome of and risk factors for incisional hernia after partial hepatectomy. J Gastrointest Surg 2008, 12, 1115–1120. [Google Scholar] [CrossRef]
- Goodenough, C.J.; Ko, T.C.; Kao, L.S.; Nguyen, M.T.; Holihan, J.L.; Alawadi, Z.; Nguyen, D.H.; Flores, J.R.; Arita, N.T.; Roth, J.S.; et al. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project). J Am Coll Surg 2015, 220, 405–413. [Google Scholar] [CrossRef]
- Walming, S.; Angenete, E.; Block, M.; Bock, D.; Gessler, B.; Haglind, E. Retrospective review of risk factors for surgical wound dehiscence and incisional hernia. BMC Surg 2017, 17, 19. [Google Scholar] [CrossRef]
- Lee, J.S.; Kim, J.M.; Kim, K.S.; Choi, G.S.; Joh, J.W.; Lee, S.K. Predictors of incisional hernia in adult liver transplant recipients. Hernia 2019, 23, 61–65. [Google Scholar] [CrossRef]
- Benlice, C.; Stocchi, L.; Costedio, M.M.; Gorgun, E.; Kessler, H. Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection. Dis Colon Rectum 2016, 59, 743–750. [Google Scholar] [CrossRef]
- Deerenberg, E.B.; Henriksen, N.A.; Antoniou, G.A.; Antoniou, S.A.; Bramer, W.M.; Fischer, J.P.; Fortelny, R.H.; Gök, H.; Harris, H.W.; Hope, W.; et al. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg 2022, 109, 1239–1250. [Google Scholar] [CrossRef] [PubMed]
- den Hartog, F.P.J.; van Egmond, S.; Poelman, M.M.; Menon, A.G.; Kleinrensink, G.J.; Lange, J.F.; Tanis, P.J.; Deerenberg, E.B. The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis. Colorectal Dis 2023, 25, 586–599. [Google Scholar] [CrossRef] [PubMed]
- Classic pages in obstetrics and gynecology. Hermann Johann Pfannenstiel. Uber die Vortheile des suprasymphysären Fascienquerschnitts für die gynäkologischen Köliotomien, zugleich ein Beitrag zu der Indikationsstellung der Operationswege. Sammlung Klinischer Vorträge, Gynäkologie (Leipzig), vol.97 pp. 1735-1756, 1900. Am J Obstet Gynecol 1974, 118, 427.
- Luijendijk, R.W.; Jeekel, J.; Storm, R.K.; Schutte, P.J.; Hop, W.C.; Drogendijk, A.C.; Huikeshoven, F.J. The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg 1997, 225, 365–369. [Google Scholar] [CrossRef] [PubMed]
- Drosdeck, J.; Harzman, A.; Suzo, A.; Arnold, M.; Abdel-Rasoul, M.; Husain, S. Multivariate analysis of risk factors for surgical site infection after laparoscopic colorectal surgery. Surg Endosc 2013, 27, 4574–4580. [Google Scholar] [CrossRef]
- Amer, T.; Biju, R.D.; Hutton, R.; Alsawi, M.; Aboumarzouk, O.; Hasan, R.; Clark, R.; Little, B. Laparoscopic nephrectomy - Pfannenstiel or expanded port site specimen extraction: a systematic review and meta-analysis. Cent European J Urol 2015, 68, 322–329. [Google Scholar] [CrossRef]
- Takagi, K.; Umeda, Y.; Yoshida, R.; Fuji, T.; Yasui, K.; Kimura, J.; Hata, N.; Yagi, T.; Fujiwara, T. Role of the Pfannenstiel Incision in Robotic Hepato-Pancreato-Biliary Surgery. J Clin Med 2023, 12. [Google Scholar] [CrossRef]
- Sajid, M.S.; Bhatti, M.I.; Sains, P.; Baig, M.K. Specimen retrieval approaches in patients undergoing laparoscopic colorectal resections: a literature-based review of published studies. Gastroenterol Rep (Oxf) 2014, 2, 251–261. [Google Scholar] [CrossRef]
- Biswas, K.K. Why not Pfannenstiel's incision? Obstet Gynecol 1973, 41, 303–307. [Google Scholar]
- van Coeverden de Groot, H.A.; Jeeva, M.A.; Gunston, K.D. Morbidity after total abdominal hysterectomy. S Afr Med J 1983, 63, 515–516. [Google Scholar]
- Grantcharov, T.P.; Rosenberg, J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 2001, 167, 260–267. [Google Scholar] [CrossRef]
- Griffiths, D.A. A reappraisal of the Pfannenstiel incision. Br J Urol 1976, 48, 469–474. [Google Scholar] [CrossRef] [PubMed]
- Lee, L.; Mata, J.; Droeser, R.A.; Kaneva, P.; Liberman, S.; Charlebois, P.; Stein, B.; Fried, G.M.; Feldman, L.S. Incisional Hernia After Midline Versus Transverse Specimen Extraction Incision: A Randomized Trial in Patients Undergoing Laparoscopic Colectomy. Ann Surg 2018, 268, 41–47. [Google Scholar] [CrossRef] [PubMed]
- García-Valdecasas, J.C.; Almenara, R.; Cabrer, C.; de Lacy, A.M.; Sust, M.; Taurá, P.; Fuster, J.; Grande, L.; Pera, M.; Sentis, J.; et al. Subcostal incision versus midline laparotomy in gallstone surgery: a prospective and randomized trial. Br J Surg 1988, 75, 473–475. [Google Scholar] [CrossRef]
- Lindgren, P.G.; Nordgren, S.R.; Oresland, T.; Hultén, L. Midline or transverse abdominal incision for right-sided colon cancer-a randomized trial. Colorectal Dis 2001, 3, 46–50. [Google Scholar] [CrossRef] [PubMed]
- Habib, A.S.; Wahl, K.; Gu, J.; Gan, T.J. Comparison of postoperative pain outcomes after vertical or Pfannenstiel incision for major gynecologic surgery. Curr Med Res Opin 2009, 25, 1529–1534. [Google Scholar] [CrossRef]
Table 1.
Clinicopathological characteristics.
| Variable | All (n = 76) | Conventional (n = 46) | Pfannenstiel (n = 30) | P value | |
|---|---|---|---|---|---|
| Gender, male, n (%) | 47 (61.8) | 27 (58.7) | 20 (66.7) | 0.630 | |
| Age, years, median (range) | 62 (54-72) | 65 (52-72) | 60 (55-73) | 0.894 | |
| BMI, kg/m2, median (range) | 22.6 (20.8-25.2) | 22.3 (20.5-25.1) | 22.6 (20.9–25.6) | 0.422 | |
| Albumin mg/mL, median (range) | 4.3 (3.9-4.5) | 4.3 (3.7-4.5) | 4.2 (4.1-4.4) | 0.840 | |
| ASA-score, n (%) | 0.719 | ||||
| 1 | 12 (15.8) | 6 (13.0) | 6 (20.0) | ||
| 2 | 56 (73.7) | 35 (76.1) | 21 (70.0) | ||
| 3 | 8 (10.5) | 5 (10.9) | 3 (10.0) | ||
| CCI, 2, n (%) | 17 (22.4) | 11 (23.9) | 6 (20.0) | 0.783 | |
| Age-adjusted CCI , 4, n (%) | 35 (46.1) | 22 (47.8) | 13 (43.3) | 0.815 | |
| History of abdominal surgery, Yes, n (%)* | 7 (9.2) | 6 (13.0) | 1 (3.3) | 0.153 | |
| Diabetes, Yes (%) | 17 (22.4) | 11 (23.9) | 6 (20.0) | 0.783 | |
| Neoadjuvant chemoradiotherapy, Yes, n (%) | 5 (6.9) | 1 (2.2) | 4 (13.8) | 0.076 | |
| LAR, Yes, n (%) | 36 (47.4) | 18 (39.1) | 18 (60.0) | 0.101 | |
| Robotic surgery, Yes, n (%) | 26 (34.2) | 11 (23.9) | 15 (50.0) | 0.026 | |
| Abbreviations: BMI, body mass index; ASA-PS, American society of Anaesthesiologists - Physical Status; | |||||
| CCI, charlson comorbidity index * Patients except for appendectomy and cesarean section | |||||
Table 2.
Short-term outcomes.
| Variable | All (n = 76) | Conventional (n = 46) | Pfannenstiel (n = 30) | P value | |
|---|---|---|---|---|---|
| Operating time, ≥ 360 min, n (%) | 36 (47.4) | 18 (39.1) | 18 (60.0) | 0.101 | |
| Estimated blood loss, ≥ 50 ml, n (%) | 14 (18.4) | 6 (13.0) | 8 (26.7) | 0.225 | |
| Epidural anesthesia, yes (%) | 36 (47.4) | 20 (43.5) | 16 (53.3) | 0.483 | |
| Duration of epidural anesthesia, day* | 3.8 ± 1.2 | 3.8 ± 1.4 | 3.9 ± 0.8 | 0.592 | |
| Patholofgical TNM stage | 0.811 | ||||
| I-II | 46 (60.5) | 27 (58.7) | 19 (63.3) | ||
| III | 30 (39.5) | 19 (41.3) | 11 (36.7) | ||
| Adjuvant chemotherapy, Yes, n (%) | 29 (38.2) | 21 (45.7) | 8 (26.7) | 0.147 | |
| Surgical site infection, (%) | 3 (4.0) | 3 (6.5) | 0 (0) | 0.154 | |
| Postoperative complications, all (%) | 10 (13.2) | 8 (17.4) | 2 (6.7) | 0.299 | |
| Postoperative complication, ≥ II (%) | 6 (7.9) | 5 (10.9) | 1 (3.3) | 0.234 | |
| Postoperative complication, ≥ IIIa (%) | 2 (2.6) | 1 (2.2) | 1 (3.3) | 0.758 | |
| Mortality | 0 | 0 | 0 | 1.000 | |
| Postoperative hospital stay, days (range) | 14 (8-19) | 13 (8-25) | 14 (8-17) | 0.533 | |
| Incisional hernia, Yes, n (%) | 7 (9.2) | 7 (15.2) | 0 (0) | 0.038 | |
| * Mean ±SD, | |||||
Table 3.
Postoperative Numerical Rating Scale (NRS）at rest.
| Postoperative day | Conventional (N = 46) |
Pfannenstiel (N = 30) |
P value |
|---|---|---|---|
| POD1 | 1.7 ± 1.4 | 1.0 ± 1.1 | 0.032 |
| POD2 | 1.4 ± 1.4 | 0.9 ± 1.0 | 0.090 |
| POD3 | 1.3 ± 1.9 | 0.6 ± 0.8 | 0.110 |
| POD4 | 0.9 ± 1.2 | 0.6 ± 1.0 | 0.250 |
| POD5 | 0.6 ± 1.0 | 0.5 ± 1.1 | 0.683 |
| POD6 | 0.4 ± 0.8 | 0.3 ± 0.7 | 0.610 |
| POD7 | 0.4 ± 0.6 | 0.1 ± 0.3 | 0.019 |
| * Mean ±SD |
Table 4.
Postoperative Numerical Rating Scale (NRS）upon movement.
| Postoperative day | Conventional (N = 46) |
Pfannenstiel (N = 30) |
P value |
|---|---|---|---|
| POD1 | 3.9 ± 1.5 | 3.4 ± 2.3 | 0.342 |
| POD2 | 4.0 ± 1.6 | 3.5 ± 2.2 | 0.296 |
| POD3 | 3.5 ± 2.0 | 2.6 ± 1.4 | 0.087 |
| POD4 | 2.5 ± 1.7 | 2.1 ± 1.6 | 0.194 |
| POD5 | 2.3 ± 1.8 | 2.0 ± 1.7 | 0.414 |
| POD6 | 1.9 ± 1.3 | 1.2 ± 1.3 | 0.038 |
| POD7 | 1.4 ± 1.3 | 0.7 ± 1.2 | 0.009 |
| * Mean ±SD |
Table 5.
Postoperative Numerical Rating Scale (NRS）at rest, excluding patients with epidural anesthesia.
Table 5.
Postoperative Numerical Rating Scale (NRS）at rest, excluding patients with epidural anesthesia.
| Postoperative day | Conventional (N = 26) |
Pfannenstiel (N = 14) |
P value |
|---|---|---|---|
| POD1 | 1.7 ± 1.5 | 0.9 ± 1.2 | 0.053 |
| POD2 | 1.6 ± 1.5 | 0.7 ± 0.9 | 0.069 |
| POD3 | 1.4 ± 2.0 | 0.3 ± 0.6 | 0.020 |
| POD4 | 0.9 ± 1.1 | 0.5 ± 1.2 | 0.107 |
| POD5 | 0.6 ± 0.8 | 0.5 ± 1.2 | 0.231 |
| POD6 | 0.6 ± 0.8 | 0.4 ± 0.9 | 0.442 |
| POD7 | 0.5 ± 0.7 | 0.1 ± 0.3 | 0.042 |
| * Mean ±SD |
Table 6.
Postoperative Numerical Rating Scale (NRS）upon movement, excluding patients with epidural anesthesia.
Table 6.
Postoperative Numerical Rating Scale (NRS）upon movement, excluding patients with epidural anesthesia.
| Postoperative day | Conventional (N = 26) |
Pfannenstiel (N = 14) |
P value |
|---|---|---|---|
| POD1 | 3.7 ± 1.5 | 3.5 ± 2.1 | 0.885 |
| POD2 | 3.9 ± 1.5 | 3.4 ± 1.9 | 0.497 |
| POD3 | 3.5 ± 2.2 | 2.4 ± 1.2 | 0.077 |
| POD4 | 2.4 ± 1.1 | 1.9 ± 1.6 | 0.121 |
| POD5 | 2.2 ± 1.5 | 2.0 ± 1.9 | 0.577 |
| POD6 | 1.9 ± 1.2 | 0.9 ± 1.3 | 0.019 |
| POD7 | 1.5 ± 1.2 | 0.5 ± 0.9 | 0.011 |
| * Mean ±SD |
Table 7.
Incisional hernia.
| Variable | Conventional (N = 46) |
Pfannenstiel (N = 30) |
P value |
|---|---|---|---|
| Follow up time, months* | 24.5 ± 7.9 | 23.3 ± 3.8 | 0.092 |
| Incisional hernia, n (%) | 7 (15.2) | 0 (0.0) | 0.038 |
| Time to hernia occurrence, months* | 10.2 ± 2.3 | N/A | |
| * Mean ±SD |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
