Prophylactic full-thickness suturing of the rectus abdominis muscle reduces parastomal hernia after enterostomy: a 5-year retrospective cohort study

Background Parastomal hernia (PSH) is one of the most common long-term complications after enterostomy. Prophylactic mesh can reduce PSH risk but is limited by mesh-related adverse events and high costs. This study aimed to evaluate the efficacy and safety of prophylactic full-thickness rectus abdominis suturing for PSH prevention without implant materials. Methods This single-center retrospective cohort study enrolled 244 patients undergoing enterostomy from January 2020 to December 2024. Patients were allocated alternately by calendar-month: 94 patients received full-thickness rectus-suture reinforcement (reinforcement group), and 150 underwent conventional stoma creation (conventional group). The primary endpoint was CT-confirmed PSH incidence within 2-year follow-up. Secondary endpoints included hernia-sac diameter, time-to-PSH-onset and stoma-related complications. Univariable and multivariable logistic regression, Firth penalized regression, 1:1 propensity-score-matching (PSM), Kaplan–Meier survival analysis and interrupted time-series (ITS) segmented regression were performed. Results The reinforcement group showed significantly lower 2-year PSH incidence (9.6% vs. 27.3%, P < 0.001). Suture reinforcement was an independent protective factor against PSH (adjusted OR = 0.29, 95% CI: 0.13–0.65, P = 0.002), and Firth-penalized logistic regression confirmed the stability of this finding (OR = 0.31, 95% CI: 0.14–0.68, P = 0.003). After PSM, the inter-group difference remained significant (14.9% vs. 31.9%, P = 0.006), and multivariable regression in the matched cohort still identified suture reinforcement as an independent protective factor (adjusted OR = 0.35, 95% CI: 0.17–0.72, P = 0.004). Patients in the reinforcement group had smaller hernia-sac diameter (2.9 cm vs. 7.3 cm, P < 0.001) and delayed PSH onset (12.2 months vs. 6.7 months, P = 0.001). ITS analysis supported the robustness of observational findings. Early postoperative complication rates were comparable between groups. Conclusions Prophylactic full-thickness rectus-abdominis suturing is associated with reduced PSH incidence, delayed hernia onset and milder hernia severity. This implant-free, low-cost technique is safe and simple. Prospective randomized trials are needed to further validate its clinical value.