Combined Incisions in Retroperitoneal Sarcoma Surgery: Safe Access Without Added Morbidity in a Single Center Retrospective Analysis

INTRODUCTION: Incisional hernia is a prevalent long-term complication after open abdominal surgery, with reported rates exceeding 20%-30%. Despite extensive research on abdominal wall failure, evidence regarding incisional hernia after retroperitoneal sarcoma resections is scarce. Retroperitoneal sarcoma frequently requires wide exposure, and combined incisions are often used, yet their effect on incisional hernia risk is unknown. Our aim was to determine the incisional hernia rate in these surgeries and to determine its association with incision type. METHODS: We conducted a retrospective cohort study of 134 patients who underwent primary RPS resection between 2004 and 2025 at a tertiary referral center. Patients were grouped according to incision type: single midline or combined incisions. Clinicopathologic variables were collected from a prospectively maintained institutional database. Incisional hernia was identified by cross-sectional imaging. RESULTS: Incisional hernia occurred in 33.5% of patients, with no significant difference between simple and combined incision groups (32.7% vs. 37.0%, p = 0.883). Time to hernia development was similar (log-rank p = 0.829). Tumor size was the only independent predictor of incisional hernia in a logistic regression model: larger tumors were associated with reduced hernia risk (OR 0.68, 95% CI 0.47-0.98, p = 0.042). Incision type and other known risk factors were not associated with incisional hernia. CONCLUSION: Combined incisions were not associated with a higher risk of incisional hernia, indicating that the additional exposure required for complex retroperitoneal sarcoma resections does not compromise long-term abdominal wall integrity. These findings support prioritizing optimal oncologic exposure when selecting incision type, without concern for increased hernia risk.