Standardization of the Extent and Timing of Rectus Diastasis Repair in Abdominoplasty Cases with TOF Neuromuscular Monitoring: A Clinical Study

Abstract

Despite the close focus on the anterior abdominal wall and the classification, maneuvers and materials related to the rectus abdominis and its fascia, there is no established standard concerning the extent of plication. The anterior abdominal wall is a musculoaponeurotic structure and a dynamic motor system with innervation and tonus. Therefore, the timing of the plication is as important as the suture technique and material, since the muscle relaxant will lose its effect in varying time periods. The aims of our study were to determine the change in the amount of plication between groups with and without muscle relaxants before plication and whether the amount of this change can be standardized using train-of-four (TOF) monitoring. In 2022 and 2023, 12 women aged between 25 and 48 years with a body mass index between 24 and 38 years were included in the study. Neuromuscular blockade was monitored by train-of-four (TOF) monitoring in all patients. Maximum plication areas at above-zero TOF value and zero TOF value were calculated and compared with each other. The reduction in the area of group 1, which represents the phase without muscle relaxant, and group 2, which represents the phase with neuromuscular blockade, were compared using the t-test. When assessed for above-zero TOF, the area between plication lines (a, a′) was always smaller than the area between the plication lines (b, b′) when the TOF value was zero. The t test comparison of group 1, which includes (a, a′) values, and group 2, which includes (b, b′) values, resulted in a value of p = 0.000. All cases, the plication value obtained with above-zero TOF value was lower than the plication value when the TOF value was zero. This difference was also confirmed statistically on a group basis. This suggests that neuromuscular measurements should be taken during the plication phase in the routine flow of surgery. Muscle relaxants are not routinely administered to patients undergoing abdominoplasty or rectus diastasis repair who are already under sufficient analgesia, unless there is a pressure alert on the anesthesia device. The surgeon cannot always determine the degree of muscle laxity accurately by palpation. TOF monitoring is a cost-effective quantitative method that can be easily and quickly performed, accurately determining the timing of muscle-fascia plication of the rectus abdominis. Through this approach, the anterior abdominal wall can be plicated with maximum tightness and maximum aesthetic gain can be obtained.

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