Parastomal hernias remain a formidable challenge with high recurrence rates and limited long-term success across techniques. The eTEP Pauli repair merges the principles of retromuscular repair and the Sugarbaker method within an extraperitoneal space, avoiding stoma relocation and reducing intraperitoneal complications. This chapter outlines indications, contraindications, port placement strategies, and stepwise execution of the repair, including transversus abdominis release around the stoma. The approach allows simultaneous midline hernia repair, improved mesh placement, and lower recurrence. Though technically demanding, the eTEP Pauli repair offers a promising, anatomically sound solution for complex PSH in well-selected patients.