Comment on: Effect of transverse versus midline periumbilical incision on incisional hernia and short-term outcomes after laparoscopic colon cancer surgery: multicentre, open-label, randomized clinical trial 

Correspondence to: Marie Burgard (email: marie.burgard@web.de)

BJS Open, https://doi.org/10.1093/bjsopen/zraf062, published 03 June 2025

We read with great interest the recently published article by Lee et al. 1 and would like to commend the authors on conducting a robust multicentre study addressing a clinically significant and practical issue in minimally invasive colorectal surgery. Their contribution provides valuable evidence suggesting that off-midline extraction sites — specifically, periumbilical transverse incisions — are associated with a lower risk of radiologically confirmed incisional hernia at one year, compared with midline incisions.

The study adds to the growing body of evidence favouring off-midline extraction sites to reduce postoperative hernia risk. However, we believe several important aspects merit further discussion.

First, the analysis would have been strengthened by consideration of key baseline anatomical variables, including the presence of umbilical hernia, diastasis recti and prior umbilical access and/or hernia repair at this site. These factors are highly relevant to hernia risk and should ideally be incorporated into future studies to enhance both predictive accuracy and clinical applicability. Nevertheless, it may be reasonably assumed that these potential confounders were equally distributed between groups owing to randomization.

Second, the authors reported the overall incidence of incisional hernia. A more granular analysis, specifically distinguishing hernias at the extraction site, would have been welcome. The number, size and placement of laparoscopic ports — including those on the linea alba — may themselves act as confounding variables and should be accounted for in such analyses.

Third, while the study notes that transverse midline incisions may be preferable to vertical ones, it is important to recognize that both approaches compromise the integrity of the linea alba in the weak periumbilical area. The long-term implications of such incisions warrant careful consideration and are recommended against in the European Hernia Society guidelines on laparotomy closure to prevent incisional hernia. In addition to an increased risk of incisional hernia periumbilical incisions are associated with an increased risk of surgical site infections and can lead to poor cosmetic outcomes. In this regard, we favour the Pfannenstiel incision for specimen extraction. In our experience, this approach offers a more cosmetically acceptable result and, notably, we observed a 0% incidence of incisional hernia in our centre compared with 30.9% when employing a midline extraction2. Furthermore, a prior systematic review and meta-analysis supports this, showing the lowest incidence of incisional hernia with Pfannenstiel extraction sites3.

Finally, these observations should encourage a wider adoption of intracorporeal anastomosis — facilitated and optimized by robotic platforms — which avoids the need for midline specimen extraction and allows for smaller, lower-risk extraction sites, such as a Pfannenstiel incision.