Surgical treatment of diastasis recti: the importance of an overall view of the problem

Hernia (2020)Cite this article

Abstract

Purpose

Diastasis recti (DR) is characterized by an alteration of the linea alba with increased inter-recti distance (IRD). It is more frequent in females, and when symptomatic or associated with midline hernia it needs to be surgically repaired. This retrospective study aims to demonstrate how an overall approach to DR leads to good results in terms of functional and morphological outcomes and quality of life (QoL).

Methods

From January 2018 to December 2019, 94 patients were operated for DR > 50 mm, with or without midline hernias. Three different surgical approaches were used: complete laparoabdominoplasty, laparominiabdominoplasty and minimally invasive (endoscopic) technique. QoL was assessed with the EuraHS-QoL tool.

Results

All patients were female except two males. We performed 26 endoscopic treatments (27.7%), 39 laparoabdominoplasties (41.5%) and 29 laparominiabdominoplasties (umbilical float procedure) (30.9%). The total median operative time was 160 min. No intraoperative complications were registered. In three (4.2%) cases, major surgical complications occurred, all after open operations. In 13 open surgery cases, vacuum-assisted closure (VAC) therapy was used to repair the cutaneous ischemic defect. No recurrence was registered to date. Minimally invasive surgery showed fewer complications and lower hospital stay than the open approach. The QoL was significantly improved.

Conclusion

Our experience shows the importance of an overall view of the functional and cosmetic impairment created by DR. The surgeon should obtain an optimal repair of the function, by open or minimally invasive surgery, also considering the morphological aspects, which are very important for the patients in terms of QoL.

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References

  1. 1.

    Brauman D (2008) Diastasis recti: clinical anatomy. Plast Reconstr Surg 122:1564–1569. https://doi.org/10.1097/PRS.0b013e3181882493

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Palanivelu C, Rangarajan M, Jategaonkar PA et al (2009) Laparoscopic repair of diastasis recti using the “Venetian blinds” technique of plication with prosthetic reinforcement: a retrospective study. Hernia 13:287–292. https://doi.org/10.1007/s10029-008-0464-z

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Bellido Luque J, Bellido Luque A, Valdivia J et al (2015) Totally endoscopic surgery on diastasis recti associated with midline hernias. The advantages of a minimally invasive approach. Prospective cohort study. Hernia 19:493–501. https://doi.org/10.1007/s10029-014-1300-2

    Article  PubMed  Google Scholar 

  4. 4.

    Mommers EHH, Ponten JEH, Al Omar AK et al (2017) The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc 31:4934–4949. https://doi.org/10.1007/s00464-017-5607-9

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Brooks DC, Rosen M, Chen W (2018) Overview of abdominal wall hernias in adults. https://www.uptodate.com/contents/overview-of-abdominal-wall-hernias-in-adults. Accessed 7 May 2020

  6. 6.

    Reinpold W, Köckerling F, Bittner R et al (2019) Classification of rectus diastasis—a proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front Surg. https://doi.org/10.3389/fsurg.2019.00001

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Beer GM, Schuster A, Seifert B et al (2009) The normal width of the linea alba in nulliparous women. Clin Anat 22:706–711. https://doi.org/10.1002/ca.20836

    Article  PubMed  Google Scholar 

  8. 8.

    Ranney B (1990) Diastasis recti and umbilical hernia causes, recognition and repair. S Dak J Med 43:5–8

    CAS  Google Scholar 

  9. 9.

    Sperstad JB, Tennfjord MK, Hilde G et al (2016) Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 50:1092–1096. https://doi.org/10.1136/bjsports-2016-096065

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Lockwood T (1998) Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg 101:1685–1691. https://doi.org/10.1097/00006534-199805000-00042

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Seeras K, Qasawa RN, Prakash S (2020) Anatomy, abdomen and pelvis, anterolateral abdominal wall. StatPearls Publishing, Treasure Island

    Google Scholar 

  12. 12.

    Todros S, de Cesare N, Concheri G et al (2020) Numerical modelling of abdominal wall mechanics: the role of muscular contraction and intra-abdominal pressure. J Mech Behav Biomed Mater 103:103578. https://doi.org/10.1016/j.jmbbm.2019.103578

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Janis JE, Nahabedian MY, Heniford BT (2018) Introduction to “current concepts in abdominal wall reconstruction”. Plast Reconstr Surg 142:7S–8S. https://doi.org/10.1097/PRS.0000000000004832

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Olsson A, Kiwanuka O, Wilhelmsson S et al (2019) Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. BJS Open 3:750–758. https://doi.org/10.1002/bjs5.50213

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Köhler G, Luketina R-R, Emmanuel K (2015) Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus diastasis is a significant risk factor for recurrence. World J Surg 39:121–126. https://doi.org/10.1007/s00268-014-2765-y

    Article  PubMed  Google Scholar 

  16. 16.

    Nahabedian MY (2018) Management strategies for diastasis recti. Semin Plast Surg 32:147–153. https://doi.org/10.1055/s-0038-1661380

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Bittner R, Bain K, Bansal VK et al (2019) Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): part B. Surg Endosc 33:3511–3549. https://doi.org/10.1007/s00464-019-06908-6

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Campanelli G (2020) Making complex abdominal wall hernia surgery easy. Is there a way? Hernia. https://doi.org/10.1007/s10029-020-02148-z

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Baumann DP, Butler CE (2019) Diastasis recti and primary midline ventral hernia: the plastic surgery approach. Hernia 23:1017–1018. https://doi.org/10.1007/s10029-019-02055-y

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Ferrara F, Fiori F, Gentile D, et al (2018) Treatment of diastasis recti abdominis with open and video-assisted approaches. In: Oral presentation at United Congress of Italian Surgical Societies. Rome, Italy

  21. 21.

    Fiori F, Ferrara F, Gentile D et al (2019) Totally endoscopic sublay anterior repair for ventral and incisional hernias. J Laparoendosc Adv Surg Tech. https://doi.org/10.1089/lap.2018.0807

    Article  Google Scholar 

  22. 22.

    Matarasso A, Matarasso DM, Matarasso EJ (2014) Abdominoplasty: classic principles and technique. Clin Plast Surg 41:655–672. https://doi.org/10.1016/j.cps.2014.07.005

    Article  PubMed  Google Scholar 

  23. 23.

    Wan D, Hubbard BA, Byrd HS (2019) Achieving aesthetic results in the umbilical float mini-abdominoplasty: patient selection and surgical technique. Plast Reconstr Surg 143:722–732. https://doi.org/10.1097/PRS.0000000000005387

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Muysoms F, Campanelli G, Champault GG et al (2012) EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall Hernia repair. Hernia 16:239–250. https://doi.org/10.1007/s10029-012-0912-7

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Hills NF, Graham RB, McLean L (2018) Comparison of trunk muscle function between women with and without diastasis recti abdominis at 1 year postpartum. Phys Ther 98:891–901. https://doi.org/10.1093/ptj/pzy083

    Article  PubMed  Google Scholar 

  27. 27.

    Spitznagle TM, Leong FC, Van Dillen LR (2007) Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J 18:321–328. https://doi.org/10.1007/s00192-006-0143-5

    Article  Google Scholar 

  28. 28.

    Parker MA, Millar LA, Dugan SA (2009) Diastasis rectus abdominis and lumbo-pelvic pain and dysfunction-are they related? J Womens Health Phys Thera 33:15–22. https://doi.org/10.1097/01274882-200933020-00003

    Article  Google Scholar 

  29. 29.

    Logan JM, Broughton G (2008) Plastic surgery: understanding abdominoplasty and liposuction. AORN J 88:603–604. https://doi.org/10.1016/j.aorn.2008.07.018

    Article  Google Scholar 

  30. 30.

    Emanuelsson P, Gunnarsson U, Dahlstrand U et al (2016) Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: a randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures. Surgery 160:1367–1375. https://doi.org/10.1016/j.surg.2016.05.035

    Article  PubMed  Google Scholar 

  31. 31.

    Cheesborough JE, Dumanian GA (2015) Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs. Plast Reconstr Surg 135:268–276. https://doi.org/10.1097/PRS.0000000000000840

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Kulacoglu H (2018) Umbilical hernia repair and pregnancy: before, during, after…. Front Surg 5:1–7. https://doi.org/10.3389/fsurg.2018.00001

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Reynvoet E, Deschepper E, Rogiers X et al (2014) Laparoscopic ventral hernia repair: is there an optimal mesh fixation technique? A systematic review. Langenbeck’s Arch Surg 399:55–63. https://doi.org/10.1007/s00423-013-1126-x

    Article  Google Scholar 

  34. 34.

    Canziani M, Frattini F, Cavalli M et al (2009) Sutureless mesh fibrin glue incisional hernia repair. Hernia 13:625–629. https://doi.org/10.1007/s10029-009-0555-5

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Baumann DP, Butler CE (2012) Bioprosthetic mesh in abdominal wall reconstruction. Semin Plast Surg 26:18–24. https://doi.org/10.1055/s-0032-1302461

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Bittner R, Bain K, Bansal VK et al (2019) Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))—part A. Surg Endosc 33:3069–3139. https://doi.org/10.1007/s00464-019-06907-7

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Lak KL, Goldblatt MI (2018) Mesh selection in abdominal wall reconstruction. Plast Reconstr Surg 142:99S–106S. https://doi.org/10.1097/PRS.0000000000004862

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Campanelli G (2020) Synthetic, biologic or biosynthetic? That is the question! Hernia 24:1. https://doi.org/10.1007/s10029-020-02128-3

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Reinpold W, Schröder M, Berger C et al (2019) Mini- or less-open sublay operation (MILOS). Ann Surg 269:748–755. https://doi.org/10.1097/SLA.0000000000002661

    Article  PubMed  Google Scholar 

  40. 40.

    Emanuelsson P, Gunnarsson U, Strigård K, Stark B (2014) Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up. J Plast Reconstr Aesthet Surg 67:1082–1088. https://doi.org/10.1016/j.bjps.2014.04.015

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Campanelli G (2019) Primary ventral hernia: where are we at? Hernia 23:829. https://doi.org/10.1007/s10029-019-02058-9

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Juárez Muas DM (2019) Preaponeurotic endoscopic repair (REPA) of diastasis recti associated or not to midline hernias. Surg Endosc 33:1777–1782. https://doi.org/10.1007/s00464-018-6450-3

    Article  PubMed  Google Scholar 

  43. 43.

    Claus CMP, Malcher F, Cavazzola LT et al (2018) Subcutaneous onlay laparoscopic approach (Scola) for ventral hernia and rectus abdominis diastasis repair: technical description and initial results. Arq Bras Cir Dig 31:e1399. https://doi.org/10.1590/0102-672020180001e1399

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Timmermans L, De Goede B, Van Dijk SM et al (2014) Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery. Am J Surg 207:980–988. https://doi.org/10.1016/j.amjsurg.2013.08.030

    Article  PubMed  Google Scholar 

  45. 45.

    Huguier V, Faure J-L, Doucet C et al (2012) Couplage cœlioscopie-abdominoplastie dans dix cas d’important diastasis des grands droits. Ann Chir Plast Esthétique 57:350–355. https://doi.org/10.1016/j.anplas.2011.08.011

    CAS  Article  Google Scholar 

  46. 46.

    Neaman KC, Hansen JE (2007) Analysis of complications from abdominoplasty. Ann Plast Surg 58:292–298. https://doi.org/10.1097/01.sap.0000239806.43438.54

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Momeni A, Heier M, Bannasch H, Stark GB (2009) Complications in abdominoplasty: a risk factor analysis. J Plast Reconstr Aesthet Surg 62:1250–1254. https://doi.org/10.1016/j.bjps.2008.03.043

    Article  PubMed  Google Scholar 

  48. 48.

    Vastine VL, Morgan RF, Williams GS et al (1999) Wound complications of abdominoplasty in obese patients. Ann Plast Surg 42:34–39. https://doi.org/10.1097/00000637-199901000-00006

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Neaman KC, Armstrong SD, Baca ME et al (2013) Outcomes of traditional cosmetic abdominoplasty in a community setting. Plast Reconstr Surg 131:403e–410e. https://doi.org/10.1097/PRS.0b013e31827c6fc3

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Costa-Ferreira A, Marco R, Vásconez L, Amarante J (2016) Abdominoplasty with scarpa fascia preservation. Ann Plast Surg 76:S264–S274. https://doi.org/10.1097/SAP.0000000000000851

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Winocour J, Gupta V, Ramirez JR et al (2015) Abdominoplasty: risk factors, complication rates, and safety of combined procedures. Plast Reconstr Surg 136:597e–606e. https://doi.org/10.1097/PRS.0000000000001700

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Mayr M, Holm C, Höfter E et al (2004) Effects of aesthetic abdominoplasty on abdominal wall perfusion: a quantitative evaluation. Plast Reconstr Surg 114:1586–1594. https://doi.org/10.1097/01.PRS.0000138757.33998.EE

    Article  PubMed  Google Scholar 

  53. 53.

    Brito M, Meireles R (2020) Abdominoplasty and patient safety: the impact of body mass index and bariatric surgery on complications profile. Aesthet Plast Surg. https://doi.org/10.1007/s00266-020-01725-y

    Article  Google Scholar 

  54. 54.

    Batac J, Hamade M, Hamade H, Glickman L (2019) Abdominoplasty in the obese patient. Plast Reconstr Surg 143:721e–726e. https://doi.org/10.1097/PRS.0000000000005413

    CAS  Article  PubMed  Google Scholar 

  55. 55.

    Arthurs ZM, Cuadrado D, Sohn V et al (2007) Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg 193:567–570. https://doi.org/10.1016/j.amjsurg.2007.01.006

    Article  PubMed  Google Scholar 

  56. 56.

    Greco JA, Castaldo ET, Nanney LB et al (2008) The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast Surg 61:235–242. https://doi.org/10.1097/SAP.0b013e318166d351

    CAS  Article  PubMed  Google Scholar 

  57. 57.

    Zuelzer HB, Ratliff CR, Drake DB (2010) Complications of abdominal contouring surgery in obese patients. Ann Plast Surg. https://doi.org/10.1097/SAP.0b013e3181cf9f9e

    Article  PubMed  Google Scholar 

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  1. Unit of General Surgery, Department of Surgery, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Via Pio II n.3, 20153, Milan, Italy

    Federico Fiori, Francesco Ferrara, Davide Gobatti, Daniele Gentile & Marco Stella

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  1. Federico Fiori
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  2. Francesco Ferrara
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  3. Davide Gobatti
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  4. Daniele Gentile
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  5. Marco Stella
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Contributions

FF and FF: design, conception and writing; FF: data analysis; DG and DG: data acquisition; MS: supervision.

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Correspondence to Francesco Ferrara.

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The procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Formal informed consent was obtained from all patients.

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All patients provided informed consent. 

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Fiori, F., Ferrara, F., Gobatti, D. et al. Surgical treatment of diastasis recti: the importance of an overall view of the problem. Hernia (2020). https://doi.org/10.1007/s10029-020-02252-0

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Keywords

  • Diastasis recti
  • Surgery
  • Minimally invasive
  • Abdominal wall
  • Hernia