Comparison of Paramedian Versus Midline Extraction Sites in Elective Laparoscopic Right Colectomy: A Propensity-Matched Study of Postoperative Ventral Hernia Development.

: Postoperative ventral hernia (POVH) remains a significant complication following laparoscopic colectomy despite minimally invasive approaches. Extraction site selection may influence POVH incidence, yet optimal location remains controversial. : This retrospective cohort study analyzed 550 patients undergoing elective laparoscopic right colectomy (2009-2024) at a single center. After exclusions for anastomotic leak and loss to follow-up, 266 patients were propensity-matched 1:1 comparing paramedian (n = 133) versus midline (n = 133) extraction sites. The primary outcome was POVH incidence at 36 months. Secondary outcomes included risk factor identification using multivariate logistic regression and Firth penalized methods. : POVH occurred in 3/133 (2.3%) paramedian versus 15/133 (11.3%) midline patients ( = 0.007). Multivariate analysis identified midline extraction (aOR 30.3, 95% CI: 3.34-969, < 0.001), chronic cough (aOR 25.6, 95% CI: 3.56-287, = 0.001), and constipation (aOR 10.1, 95% CI: 1.60-70.7, = 0.015) as independent POVH predictors. Patient comorbidities showed stronger associations than surgical factors in univariate analysis. The number needed to treat with paramedian extraction to prevent one POVH was 11.1. : Paramedian extraction sites significantly reduce POVH incidence compared to midline approaches in laparoscopic right colectomy. The identification of modifiable physiological risk factors, particularly conditions causing increased intra-abdominal pressure (chronic cough, constipation), suggests that comprehensive perioperative optimization targeting these specific factors may further reduce POVH risk.