Modified preperitoneal endoscopic pauli (Pe-Pauli) approach for concomitant repair of parastomal and midline hernias.

Parastomal hernia repair remains a complex surgical challenge due to high recurrence rates and significant technical demands. The modified Sugarbaker technique, particularly Pauli's retromuscular adaptation, has demonstrated promising outcomes. Concurrently, the PeTEP approach enables extensive preperitoneal dissection while preserving the integrity of the abdominal wall. We present the first reported case of atotally endoscopic preperitoneal repair combining both techniques (Pe-Pauli) for the simultaneous treatment of parastomal and midline hernias. A 73-year-oldwoman with a prior Hartmann procedure and failed reconstruction presented with symptomatic parastomal and midline incisional hernias. Through a cranial endoscopic approach, trocars were placed for PeTEP, along with an additional lateral access for parastomal repair. To preserve peritonealintegrity, the Red Cross Step technique was employed, facilitating safe dissection through the transversalis fascia and the musculoaponeurotic edge of the transversus abdominis muscle. The hernia contents were reduced, the defects were closed with barbed sutures, and a 20 × 30 cm Synecor® mesh was positioned in the preperitoneal space. A second polypropylene mesh was placed to reinforce the midline. The procedure lasted 325 minutes, with an uneventful recovery and no recurrence at 6-monthfollow-up. The Pe-Pauli approach allows for anatomical extra peritoneal reconstruction of complex hernias in a single-stage procedure. Although technically demanding, it may improve outcomes in selected patients. Further studies are required to validate its long-term safety and efficacy.