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

Comparing the effects of suspension and isometric-isotonic training on postural stability, lumbopelvic control, and proprioception in women with diastasis recti abdominis: a randomized, single-blinded, controlled trial

BACKGROUND

Diastasis recti abdominis (DRA) affects a significant number of women in the postpartum period.

OBJECTIVE

This study compared the effectiveness of suspension training system (STS) with that of isometric-isotonic (ISoM-ISoT) exercises in the treatment of DRA and its secondary complications.

METHODS

Thirty-six women with DRA participated in this study. They were divided into the three groups of STS, ISoM-ISoT, and control. Inter-recti distance (IRD), proprioception, lumbopelvic control, postural stability, low back pain, and disability were assessed using a digital caliper, a goniometer, a lateral step-down test, a Biodex balance system, a visual analogue scale (VAS), and the Oswestry Disability Index (ODI), respectively. Two intervention groups underwent training for 8-week and the control group resumed their normal lives.

RESULTS

Positive effects were observed in the STS and ISoM-ISoT groups compared with the control group in: IRD (P = .001); lumbopelvic proprioception (P = .001); lumbopelvic control (P = .001); overall static balance (P = .010); overall dynamic balance (P = .012); low back pain (P = .001); and disability (P = .001). However, there was no significant difference between the training groups in: IRD (P = .12, MD = -2.76); lumbopelvic proprioception (P = .48, MD = -0.50); lumbopelvic control (P = .14, MD = 1.53); static balance (P = .62, MD = 0.07); dynamic balance (P = .27, MD = 0.33); pain (P = .25, MD = -0.52); and disability (P = .48, MD = -1.74). The results of the minimal clinically important difference (MCID) and minimal detectable change (MDC) suggested that the STS exercises outperformed ISoM-ISoT training regarding IRD, pain, disability, and proprioception, whereas ISoM-ISoT training had a better effect in lumbopelvic control and balance.

CONCLUSION

The results of our study showed that the STS had a positive effect on women with DRA and like the ISoM-ISoT exercises can be used to treat this dysfunction.

Comparative analysis of the efficacy and functionality of abdominoplasty versus minimally invasive techniques in the surgical treatment of diastasis rectus abdominis in postpartum women

INTRODUCTION

This review aims to describe the surgical options available for treatment of diastasis recti in postpartum women, as well as compare the effectiveness of these treatment options. Historically, diastasis recti has been repaired through open procedures, such as abdominoplasty. More recently, studies have explored other methods for the treatment of diastasis recti, including various minimally invasive surgical options.

METHODS

Twelve studies ranging from 2015 to 2022 were included in this analysis. Studies were identified using PubMed, EMBASE, and Cochrane Library. Studies that met the inclusion criteria were analyzed descriptively. Statistical comparison of surgical outcomes between studies was performed using Fisher's Exact Test in SPSS.

RESULTS

Minimally invasive approaches were categorized as laparoscopic preaponeurotic approaches, robotic approaches, and enhanced-view/extended totally extraperitoneal (eTEP) approaches. These techniques were compared to two open approaches: abdominoplasty and miniabdominoplasty. There were no significant differences in the rate of seromas, surgical site infections/complications, or hematomas between abdominoplasty and minimally invasive surgical techniques (p > 0.05). Among the minimally invasive techniques, no significant differences in readmission rates were reported (p > 0.05). Additionally, no significant differences in recurrence rates were seen following minimally invasive or abdominoplasty repairs, except for the increased recurrence rates seen with the r-TARRD robotic technique (p < 0.05).

CONCLUSION

Although current data on minimally invasive approaches is limited, our review reveals that both open and minimally invasive approaches are viable options for diastasis recti repair in postpartum women. Identifying the optimal approach for diastasis recti repair should rely on the patient's desired treatment outcome. If the patient indicates a desire for the removal of excess abdominal subcutaneous tissue, abdominoplasty may be a better surgical approach. Alternatively, if the patient puts a greater emphasis on shorter recovery time and smaller surgical incisions/scars, minimally invasive approaches may be a better surgical option.

A deep learning-based approach for rectus abdominis segmentation and distance measurement in ultrasonography

Introduction: Diastasis recti abdominis (DRA) is a common condition in postpartum women. Measuring the distance between separated rectus abdominis (RA) in ultrasound images is a reliable method for the diagnosis of this disease. In clinical practice, the RA distance in multiple ultrasound images of a patient is measured by experienced sonographers, which is time-consuming, labor-intensive, and highly dependent on experience of operators. Therefore, an objective and fully automatic technique is highly desired to improve the DRA diagnostic efficiency. This study aimed to demonstrate the deep learning-based methods on the performance of RA segmentation and distance measurement in ultrasound images. Methods: A total of 675 RA ultrasound images were collected from 94 postpartum women, and were split into training (448 images), validation (86 images), and test (141 images) datasets. Three segmentation models including U-Net, UNet++ and Res-UNet were evaluated on their performance of RA segmentation and distance measurement. Results: Res-UNet model outperformed the other two models with the highest Dice score (85.93% ± 0.26%), the highest MIoU score (76.00% ± 0.39%) and the lowest Hausdorff distance (21.80 ± 0.76 mm). The average physical distance between RAs measured from the segmentation masks generated by Res-UNet and that measured by experienced sonographers was only 3.44 ± 0.16 mm. In addition, these two measurements were highly correlated with each other (r = 0.944), with no systematic difference. Conclusion: Deep learning model Res-UNet has good reliability in RA segmentation and distance measurement in ultrasound images, with great potential in the clinical diagnosis of DRA.

An Algorithmic Approach for the MIS Repair of Ventral Midline Hernias Associated With Diastasis of the Rectus Abdominis Muscle

Purpose: We present our algorithmic approach for symptomatic ventral hernias with Diastasis of the Rectus Abdominis Muscle (DRAM). Methods: Retrospective analysis of patients with symptomatic ventral hernias and DRAM undergoing hernia repair and plication of DRAM from July 2018-March 2021 was conducted. Based on our algorithm, patients were selected for an Endoscopic Onlay Repair (ENDOR) or a Robotic Extended Totally Extraperitoneal Ventral Repair (R-eTEP). Results: We performed a R-eTEP in fifty-seven patients and an ENDOR in twenty-four patients. In the R-eTEP group, thirty-seven (65%) patients were female, the mean age was 54.8 (±10.6), and the mean BMI was 32 (±4.8). Fifty patients (87.7%) had multiple defects, of which 19 (38%) were recurrent hernias and 31 (62%) were incisional hernias. The mean operative time was 200 (±62.4) minutes, with two cases requiring a hybrid approach. The median length of stay was 1 day (0-12), and the median follow-up was 103 days. Twenty-four patients underwent an ENDOR, 19 females (79.2%), the mean age was 45.7 years (±11.7) and the mean BMI was 28 (±3.6). 13 patients had isolated umbilical or epigastric hernias. The mean operative time was 146.2 min (±51.1). Fibrin sealant and suture was the predominant method for mesh fixation, and most cases were performed in an ambulatory setting. Four patients developed post-operative seromas; one requiring drainage due to infection. The Median follow-up was 48.5 days (10-523), with two reported hernia recurrences. Conclusion: An algorithmic approach for adequate patient selection was shown to be safe for treating ventral hernias with DRAM.

Efficacy and Challenges in the Treatment of Diastasis Recti Abdominis—A Scoping Review on the Current Trends and Future Perspectives

Diastasis recti abdominis (DRA) is more prevalent in women during pregnancy and postpartum. However, there is a lack of awareness regarding this condition among women. The prevalence of DRA is high in late pregnancy and reduces during postpartum. The purpose of this study is to provide an overview of the treatment strategies for DRA and to discuss the significance of the technology towards better diagnosis and treatment. This work investigated 77 research articles published in the recognized research databases. The study aims to analyze the diagnostic and treatment procedures and the role of technology within them. The management strategy for DRA can either be conservative or surgical. Exercise therapy has been shown to improve functional impairments. These exercises focus on recruiting the abdominal muscles. Electromyography and Ultrasound imaging have been employed as useful tools in assessing the abdominal muscles effectively. This study has examined the treatment methods for DRA to obtain a better understanding of the existing methods. Further investigation and experimentation into therapeutic exercises is strongly recommended to identify the best set of exercises for a faster resolution. Further studies regarding the role of technology to assess therapeutic exercises would be worthwhile.

Post-partum abdominal wall insufficiency syndrome (PPAWIS): lessons learned from a single surgeon's experience based on 200 cases

Background

Post-partum abdominal wall insufficiency (PPAWI) with rectus diastasis is present in over 30% of women after pregnancy. Little is known about how PPAWI affects the social, sexual life and self-esteem of patients. This study was designed to evaluate the safety of onlay mesh combined with abdominoplasty and its impact on the well-being of the patients.

Method

Two hundred patients with PPAWI underwent surgery with onlay mesh and abdominoplasty. The safety of the procedure was assessed by postoperative complications, time of hospitalization and time of drainage. Before the operation and 6 months later, a questionnaire asking about the patient’s sexual and social life and the presence of back pain was completed. The final cosmetic effect was assessed separately.

Results

The onlay procedure with abdominoplasty was found to be safe and fast. The mean operation time was 82 min, and the drainage time was 2.1 days. In this group < 2% postoperative complications were noted. There were no recurrences within the 6 month. Significant improvements in social and sexual life and the level of self-esteem were noted. Back pain was relieved or minimalized in all patients. The final cosmetic effect was insufficient for 2 patients (1%).

Conclusion

PPAWI can be treated safely with onlay mesh and abdominoplasty. The patients’ symptoms were strongly correlated with the morphological status of the front abdominal wall and improved after the procedure. Describing the psychological and social consequences of PPAWI should lead the surgical societies to propose a definition of a new disease called PPAWIS (post-partum abdominal wall insufficiency syndrome).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01757-y.

Experiences of women undergoing abdominoplasty in the public sector: a qualitative study

Introduction: This study was designed to improve understanding of the experiences of women un-dergoing abdominoplasty in a public hospital setting, including their experience of processes of care, surgical treatment and outcomes of surgery. Methods: This was a prospective, qualitative study, with one-to-one interviews with women, tran-scription of interviews and development of themes. Results: Twenty interviews were carried out with 16 women, with four women being interviewed before and after surgery and the remaining 12 being interviewed one time only. Messages emerging from the interviews included gratitude for treatment in the public sector, uncertainty associated with waiting times and surgeon allocation, and varied satisfaction with outcomes. This article also explores the evidence for the association between physical symptoms and rectus diastasis (separa-tion of the rectus abdominis muscles) as well as mental health improvement. Conclusion: Women undergoing abdominoplasty in the public sector are not a homogenous group, either in their motivations for surgery or their reported outcomes. This qualitative study found evidence for improvement in physical symptoms and psychological wellbeing in women undergoing abdominoplasty, which supports existing quantitative studies, but also highlights a need for clear information for public sector patients, especially relating to scars, and for liaison psy-chiatry. Criteria-based assessment contributes an additional burden for these patients.

Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study

Aim

The prevalence and definition of diastasis recti abdominis (DRA) is under debate. This retrospective cross-sectional study evaluated the interrectal distance and the prevalence of DRA in computed tomography (CT) in an asymptomatic population.

Materials and methods

Patients undergoing CT scans for suspected appendicitis or kidney stones from 01/2016 to 12/2018 were screened retrospectively to participate. A study population with equal distribution according to gender and age (18–90 years) was generated (n = 329 patients) and the interrectal distance was measured at six reference points.

Results

DRA (defined as > 2 cm at 3 cm above the umbilicus) was present in 57% of the population. The 80th percentile of the interrectal distance was 10 mm at the xiphoid (median 3 mm, 95% confidence interval (CI) 0–19 mm), 27 mm halfway from xiphoid to umbilicus (median 17 mm, 95% CI 0–39 mm), 34 mm at 3 cm above the umbilicus (median 22 mm, 95% CI 0–50 mm), 32 mm at the umbilicus (median 25 mm, 95% CI 0–45 mm), 25 mm at 2 cm below the umbilicus (median 14 mm, 95% CI 0–39 mm), and 4 mm halfway from umbilicus to pubic symphysis (median 0 mm, 95% CI 0–19 mm). In the multivariate analysis, higher age (p = 0.001), increased body mass index (p < 0.001), and parity (p < 0.037) were independent risk factors for DRA, while split xiphoid, tobacco abuse, and umbilical hernia were not.

Conclusion

The prevalence of DRA is much higher than commonly estimated (57%). The IRD 3 cm above the umbilicus may be considered normal up to 34 mm. To avoid over-treatment, the definition of DRA should be revised.

Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review

BACKGROUND

A subcutaneous endoscopic onlay repair for ventral hernia with an anterior plication of diastasis recti (DR) has been published under different names in different countries. The aim of this systematic review is to assess the safety and feasibility of different named techniques with the same surgical concept.

METHODS

The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score system was used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study designs, risk of bias, publication bias, heterogeneity, and statistical analysis.

RESULTS

The systematic literature search found 2548 articles, 317 of which were duplicates and excluded from analysis. The titles and abstracts from the remaining 2231 articles were assessed. After careful evaluation, 2125 articles were determined to be unrelated to our study and subsequently excluded. The full text of the remaining 106 articles was thoroughly assessed. Case reports, editorials, letters to the editor, and general reviews were then excluded. A total of 13 articles were ultimately included for this review, describing a similar subcutaneous endoscopic approach for repair of concomitant ventral hernias and rectus diastasis defined under nine different named techniques on 716 patients. The number of patients in those studies varied from 10 to 201. The mean operative time varied from 68.5 to 195 min. The most common complication was seroma, followed by pain requiring intervention, hematoma, and surgical site infection.

CONCLUSIONS

There are a few technique variations described in different studies, but with no significant differences in outcomes. We, therefore, propose to unify these procedures under one term, ENDoscopic Onlay Repair (ENDOR). This technique has shown to be effective and safe, with seroma being the most common complication.

Clinical assessment of pelvic floor and abdominal muscles 3 months post partum: an inter-rater reliability study

OBJECTIVES

Evaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum.

DESIGN

A multicentre inter-rater reliability study.

SETTING

Three primary care rehabilitation centres in Sweden.

PARTICIPANTS

A total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order.

OUTCOME MEASURES

Inter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging).

RESULTS

Vaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres.

CONCLUSIONS

Vaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging.

TRIAL REGISTRATION NUMBER

NCT03703804.

Closing the gap: evidence-based surgical treatment of rectus diastasis associated with abdominal wall hernias

PURPOSE

Rectus diastasis (RD) associated with abdominal hernias present a surgical challenge associated with a paucity in treatment guidelines. The objective of this systematic review is to review surgical techniques and assess complication and recurrence rates of RD in patients with concurrent abdominal hernias.

METHODS

PubMed and EMBASE databases were systematically searched, and data extraction was performed on articles which met the inclusion criteria. Pooled analyses of complication and recurrence rates were performed to compare open vs. minimally invasive surgery. Student t tests were performed to compare differences in continuous outcomes.

RESULTS

Twenty-eight studies were included in this review. RD can be surgically repaired by both open and laparoscopic approaches using both non-absorbable and absorbable sutures. The majority of the techniques reported included mesh insertion either above the aponeurosis, retromuscular, preperitoneal, or intraperitoneal. Open techniques, compared to laparoscopic approaches, were associated with a significantly higher rate of skin dehiscence (6.79% vs. 2.86%; p = 0.003) and hematoma formation (4.73% vs. 1.09%; p < 0.001) and a significantly lower rate of post-operative seroma formation (2.47% vs. 8.29%; p < 0.001). No significant difference in RD recurrence rates were observed between open and laparoscopic repair (0.22 vs. 0.63%, p = 0.17).

CONCLUSION

Both open and laparoscopic surgery are safe and effective methods that can be used to repair RD in patients with RD and concurrent abdominal hernias as evident by the low recurrence and complication rates and almost negligible major complications post repair.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.

METHODS

A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.

RESULTS

In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.

CONCLUSION

Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Essential anatomical landmarks in placement of an adequate size mesh for a successful ventral hernia repair

Safe and effective hernia repair requires a surgeon to have the appropriate knowledge necessary to learn details of the surgical technique. Long-term results of treatment, even with the use of synthetic implants, have shown that recurrences were still a significant clinical problem concerning up to every fourth patient. Therefore, it was pointed out that the mere presence of synthetic material is not a solitary circumstance sufficient for a successful repair. A key finding in recurrence prevention has been to focus surgeons&apos; attention on the relationship between the size of the hernia orifice and the mesh surface. An optimal ratio of these values has not been established yet, however, it is considered that the mesh surface area should be at least sixteen times larger than the area of the abdominal wall defect. In cases of medium and large hernias, in order to place an extensive mesh sheet in the appropriate anatomical space of the abdominal wall, an extensive dissection needs to be performed, including several different compartments. Therefore, a surgeon undertaking a hernia repair needs to know perfectly the anatomy and function of all the myofascial structures involved. Performing an incorrect dissection of a mistaken structure may lead to catastrophic abdominal deformities. Depriving the patient of the natural support of the abdominal wall provided by the muscles may lead to total or partial destabilization of the trunk and lead to disability. In this paper a detailed description of anatomical structures and its practical use has been presented.

Impact of Rectus Diastasis Repair on Abdominal Strength and Function: A Systematic Review

Rectus diastasis plication performed during abdominoplasty aims to narrow the widened linea alba and return the rectus muscle bellies to their anatomic position. It is unclear whether plication improves abdominal strength and function.

This systematic review summarizes the effect of rectus plication on abdominal strength, function, and postoperative complications.

A comprehensive search of CINAHL, Embase, Medline and Web of Science was performed. Screening and data extraction were performed in duplicate. Data were extracted from the included articles, and outcomes were analyzed categorically.

A total of 497 patients from seven articles were included. Mean age was 44.5 years (range 20.5-72) and 94.4% were female. Three articles reported abdominal strength measurements, with two showing significant improvement. Four articles used the SF-36 survey, all demonstrating improvement in physical function subscale postoperatively. An additional six instruments were used to assess functional outcomes, of which four demonstrated significant improvement. The overall complication rate was 17.0%.

Rectus plication is commonly performed during abdominoplasty to improve abdominal form and function. While the literature to date is encouraging with respect to functional outcomes, improvements in abdominal strength are less consistent. Heterogeneity in patient population, outcome measures, and comparison groups limit the strength of our conclusions. Future research should include a large comparative study as well as a protocol for standardizing outcomes in this population.

Laparoscopic enhanced-view totally extraperitoneal Rives-Stoppa repair (eTEP-RS) for ventral and incisional hernias - early operative outcomes and technical remarks on a novel retromuscular approach

Introduction

Incisional hernias can complicate up to one in four laparotomy procedures, and successful repair remains a significant clinical challenge for surgeons. Recently, the surgical technique of ventral hernia repair (eTEP-RS) has been introduced.

Aim

To present early results in treating patients with ventral hernia using the eTEP-RS technique and to discuss key technical aspects affecting the safety and efficiency of repair.

Material and methods

A prospective study of early outcomes was conducted for all ventral hernia patients (hernia orifice between 4 and 8 cm) who underwent eTEP-RS between March 2019 and July 2020.

Results

As of July 2020, we performed a total of 11 eTEP-RS procedures. The mean duration of the surgery was 204 min (158 to 295). The average size of the treated defect in the transverse dimension was 5.8 cm, and the defect area was 38.5 cm². The average size of the mesh used was 486 cm² (280 to 590). After an average follow-up of 7 months (1–17) there was no recurrence or major complication. Based on our initial experiences we present a detailed description of the main aspects of the surgical technique itself, as well as the essential nuances, to enable evaluation of the technique and future popularization.

Conclusions

The eTEP-RS technique is a safe alternative to open ventral hernia repair and allows for the placement of a large piece of mesh in accordance with current recommendations. Excellent knowledge of the detailed anatomy of the abdominal wall is essential for safe and effective hernia repair.