Management Strategies for Diastasis Recti

Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System

Background

Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals.

Methods

The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects.

Results

For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed.

Conclusions

In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

Computational analysis of electrical stimulation to promote tissue healing for hernia repair at varying mesh placement planes

Development of a tear in the abdominal wall allowing for protrusion of intra-abdominal contents is known as a hernia. This can cause pain, discomfort, and may need surgical repair. Hernias can affect people of any age or demographic. In the USA, over 1 million hernia repair procedures are performed each year. During these surgeries, it is common for a mesh to be utilized to strengthen the repair. Different techniques allow for the mesh to be placed in different anatomical planes depending on hernia location and approach. The locations are onlay, inlay, and sublay, with sublay being split into retromuscular or preperitoneal with sublay being the most commonly used. The use of an electrically active hernia repair mesh is of interest to model as electrical stimulation has been shown to improve soft tissue healing which could reduce recurrence rates. Theoretical 3D COMSOL models were built to evaluate the varying electric fields of an electrically active hernia repair mesh at each of the different anatomical planes. Three voltages were chosen (10, 20, and 30 mV) for the study to simulate a low-level electrical signal and the electric field from a piezoelectric material at the tissue layers surrounding the mesh construct. Based on the model outputs, the optimal mesh placement location was the sublay-retromuscular as this location had the highest electric field values in the connective tissues and rectus abdominis muscle, which are the primary tissues of concern for the healing process and a successful repair.

Ventral ETEP Versus REPA, Comparison of Two Novel Minimally Invasive Techniques for Midline Defects

Introduction: This report aimed to compare ventral extended vision extraperitoneal (ETEP) and preaponeurotic repair (REPA) techniques in terms of surgical procedure, outcomes, and patient evolution. Methods: This was a retrospective study performed at a tertiary care academic center between 2017 and 2022. All consecutive patients operated on for midline hernias and rectus diastasis using REPA and ETEP were included. Follow-up visits were at 15 days, 30 days, and 6 months postoperative. Age, sex, BMI, American Surgical Anesthesiologic Classification (ASA), surgical time, need for conversion to open surgery, time of stay, seroma, hematoma, surgical site infection (SSI), recurrence, and re-interventions were assessed. Results: For the present study, 148 patients were included. From them, 62 patients received the REPA procedure and 86 were operated on using the ETEP technique. REPA average time was 105 minutes (interquartile range [IR] 80-130), and ETEP average time was 120 minutes (RIC 95-285) (p = 0.03). Ambulatory procedures were 32.3% (n = 20) REPA and 20.9% (n = 18) ETEP (p = 0.23). In REPA, the mean time for drain extraction was 11.92 days and 8 days in ETEP (p < 0.001). Seroma incidence was identified in 40.3% (n = 25) of the REPA cases and 5.8% (n = 5) of the ETEP procedures (p = 0.001). In a multivariate analysis for seroma incidence REPA technique was associated with a significant risk of its incidence [odds ratio (OR) 16, 67 95% confidence interval ((CI95) 4.67-59.52), p < 0.001]. Conclusion: REPA and ETEP are safe and reproducible. Both approaches reported short hospitalization times and almost no major complications. We found a longer surgical time in ETEP and a higher incidence of seroma in REPA.

Do Absorbable Sutures Work for Rectus Diastasis Repair in Abdominoplasty Patients?

Background

The standard treatment for rectus diastasis is rectus sheath plication during abdominoplasty. Lasting correction of diastasis is essential, but there is currently a debate as to whether absorbable or nonabsorbable rectus plication achieves a lower rate of recurrence.

Objectives

The goal of this study is to assess long-term patient outcomes and the recurrence of rectus diastasis after plication with long-lasting absorbable sutures.

Methods

A retrospective study of abdominoplasties performed by the senior author between 2018 and 2022 was performed. Only female patients with >6 months of follow-up were included. Plication of the rectus muscles was performed with a combination of interrupted, buried, figure of eight #0 polydioxanone suture and running #0 Maxon (Covidien, Mansfield, MA). Outcomes were assessed by physical examination at postoperative visits. A retrospective chart review was used to obtain demographic and perioperative information.

Results

Seventy-one patients underwent abdominoplasty with an average follow-up of 21.1 months. The average age was 43 years, and the average BMI was 27 kg/m2. Correction of rectus diastasis was performed using absorbable sutures in all patients with no recurrence of diastasis in any patient (0% diastasis recurrence rate). Complications included delayed wound healing (11%), seroma (8.5%), hematoma (2.8%), and deep vein thrombosis/pulmonary embolism (2.8%). No patients needed reoperation.

Conclusions

Abdominal wall plication using a double-layered, long-lasting absorbable suture closure is a safe, reliable, and effective method to address rectus diastasis during abdominoplasty. Our technique achieved no recurrence of diastasis in any patient and a low complication profile.

Level of Evidence 3

Validation of a synthetic simulation model of endoscopic rectus sheath plication

PURPOSE

Literature reviews outline minimally invasive approaches for abdominal diastasis in patients without skin excess. However, few surgeons are trained in endoscopic rectus sheath plication, and no simulated training programs exist for this method. This study aimed to develop and validate a synthetic simulation model for the training of skills in this approach under the Messick validity framework.

METHODS

A cross-sectional study was carried out to assess the participants' previous level of laparoscopic/endoscopic skills by a questionnaire. Participants performed an endoscopic plication on the model and their performance was evaluated by one blinded observer using the global rating scale OSATS and a procedure specific checklist (PSC) scale. A 5-level Likert survey was applied to 5 experts and 4 plastic surgeons to assess Face and Content validity.

RESULTS

Fifteen non-experts and 5 experts in abdominal wall endoscopic surgery were recruited. A median OSATS score [25 (range 24-25) vs 14 (range 5-22); p < 0.05 of maximum 25 points] and a median PSC score [11 (range 10-11) vs 8 (range 3-10); p < 0.05 of maximum 11 points] was significantly higher for experts compared with nonexperts. All experts agreed or strongly agreed that the model simulates a real scenario of endoscopic plication of the rectus sheath.

CONCLUSION

Our simulation model met all validation criteria outlined in the Messick framework, demonstrating its ability to differentiate between experts and non-experts based on their baseline endoscopic surgical skills. This model stands as a valuable tool for evaluating skills in endoscopic rectus sheath plication.

Frequency of Medical Claims for Diastasis Recti Abdominis Among U.S. Active Duty Service Women, 2016 to 2019

Background

Diastasis recti abdominis (DRA) is a condition in pregnant and postpartum women. Proposed risk factors include age, sex, multiparity, cesarean delivery, diabetes, gestational weight gain, and high birth weight. This study aims to estimate the prevalence of DRA using medical claims data among U.S. active duty service women (ADSW) and determine associated risk factors.

Materials and Methods

We conducted a cross-sectional study of ADSW aged 18 years and older in the U.S. Army, Air Force, Navy, and Marine Corps during fiscal years (FYs) 2016 to 2019. Utilizing claims data, we identified ADSW with a diagnosis of DRA during the study period. Risk factors, including age, race, socioeconomic status, branch of service, military occupation, delivery type, and parity, were evaluated through descriptive statistics, chi-square tests, and logistic regression analysis.

Results

A total of 340,748 ADSW were identified during FYs 2016 to 2019, of whom 2,768 (0.81%) had a medical claim for DRA. Of those with deliveries during the study period, 1.41% were multiparous and 84.53% had a cesarean delivery. Increased risk of DRA was found in ages 30 to 39 years, Black women, ranks representing a higher socioeconomic status, and women with overweight and obese body mass indices.

Conclusions

Although the prevalence of DRA, defined as a medical claim for DRA, in the study population is low, subpopulations may be disproportionately affected by the condition. Further research could potentially detail the impact of DRA on the functional impairment and operational readiness of ADSW in the U.S. military and any possible means of prevention.

Clinical significance of diastasis recti: Literature review and awareness amongst health care professionals

BACKGROUND

A variety of physical complaints have been related to chronic diastasis recti (DR), including back pain, pelvic pain, and urinary incontinence. However, its clinical significance is still subject of debate, leaving many patients to feel unheard when experiencing symptoms. This study aims to assess current knowledge on DR, its potential treatments, and the awareness of this condition amongst involved health care professionals.

METHODS

A literature review was performed to analyze current available knowledge on DR and its treatment. Then, a survey was conducted to investigate the awareness on DR amongst general practitioners, midwives, gynecologists, general surgeons, and plastic surgeons.

RESULTS

Over 500 health care professionals completed our survey, including 46 general practitioners, 39 midwives, 249 gynecologists, 33 general surgeons, and 74 plastic surgeons. Although the majority of respondents (>78% in all groups) reported to encounter DR in daily practice, opinions differed markedly on most significant symptoms, associated physical complaints, best first referral for treatment, and best treatment modality.

CONCLUSION

Current literature is not unanimous on the relation between DR and physical complaints and on its most suitable treatment. This incongruity is corroborated by the variety of responses from involved health care professionals in our survey. More clinical data are needed to provide clarity on this issue.

Endoscopic treatment of diastasis recti: Training method and literature review

INTRODUCTION

Endoscopic treatment of diastasis rectus abdominis offers the possibility of correcting the condition without complete abdominoplasty. The purpose of this study was to develop a training method on fresh cadavers models based on a literature review on this surgery.

MATERIAL AND METHODS

The endoscopic procedure considered involved the insertion of a 10mm suprapubic trocar and of 5mm trocars in each iliac fossae. The muscle suture is done using running barbed suture. The surgery was performed on eight fresh cadavers to estimate the learning curve for this intervention, which was estimated with the CUSUM method. A systematic literature review in the PubMed database was performed, and 20 articles that met the inclusion criteria were analyzed.

RESULTS

The learning curve threshold was reached after 6 operations and can be separated into two phases. The most common complication of this surgery is seroma, it is encountered in 3 to 27% of cases according to the studies. Diastasis recurrence is rare, occurring in less than 2% of cases. In comparison, open surgical treatment of diastasis recti is associated with a higher risk of hematoma, skin necrosis and longer operating times. Recurrence rates are similarly low after open and endoscopic repair. Mesh reinforcement is indicated in cases of diastasis wider than 5cm, diastasis recurrence, severe musculoaponeurotic laxity, or hernia larger than 1cm.

CONCLUSION

The data in the literature indicate that laparoscopic surgery is an efficient and safe approach to correct diastasis of the rectus muscles and can be offered by plastic surgeons to selected patients.

Laparoscopic transversus abdominis plane block is useful in pain relief after laparoscopic stapled repair of diastasis recti and ventral hernia

Background

There is still no consensus on perioperative pain control techniques in patients undergoing laparoscopic surgery; protocols of conventional therapy can be improved by the use of perioperative anaesthesiologic techniques, such as epidural or loco-regional analgesic administration as transversus abdominis plane (TAP) block. The aim of this evaluation was to investigate the role of laparoscopic-assisted TAP block during repair of diastasis recti associated with primary midline hernias in term of post-operative pain relief.

Materials

and

Methods

This was a retrospective evaluation of a prospectively maintained database including patients undergoing laparoscopic repair of diastasis recti associated with primary ventral hernia. Patients were divided into two groups: Group A patients (n = 34) received laparoscopic-assisted bilateral TAP-block of 7.5 mg/ml ropivacaine for each side and Group B patients (n = 29) received conventional post-operative therapy. All patients received 24 h infusion of 20 mg morphine; pain was checked at 6, 24 and 48 h after surgery by numeric rating scale (NRS) score. A rescue analgesia by was given if NRS score was >4 or on patient request.

Results

No differences in operative time, complications and post-operative stay, no complications related to TAP-block technique were found. Post-operative pain scores (determined by NRS) were found to be significantly different between groups. Group A patients showed a significant reduction in NRS score at 6, 24 and 48 h (P < 0.005) and in the number of patients requiring further analgesic drugs administration (P < 0.005) compared to Group B patients.

Conclusions

Laparoscopic-guided TAP-block can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic repair of diastasis recti and ventral hernias. The non-randomised nature of the study and the lack of a consistent series of patients require further evaluations.

A Novel Robotic Approach for the Repair of Abdominal Wall Hernias With Concomitant Diastasis Recti: Outcomes and Long-term Follow-up

BACKGROUND

Diastasis recti (DR) is defined as the separation of the rectus muscles as a result of the linea alba thinning and stretching. The purpose of this study was to evaluate the long-term outcomes of a new technique, robotic rectus abdominis medialization (rRAM), for DR repair with a concomitant ventral hernia.

METHODS

Patients who underwent rRAM for repair of DR and a concomitant ventral hernia were identified between January 2015 and December 2020. The results are from a single surgeon at a single institution.

RESULTS

A total of 40 patients were identified, 29 of which were female. The mean age was 43 years, the mean body mass index was 27 kg/m 2 , and the mean inter-rectus distance was 6 cm based on available preoperative imaging. The median postoperative length of stay was 1 day, and the median follow-up time was 1 month. Within 30 postoperative days, 3 patients were re-admitted and 5 developed complications, of which 1 required operative re-intervention for seroma. Beyond 30 days, 3 patients required operative re-intervention most commonly for persistent pain from suture material. On the basis of computed tomography scans performed at a mean of 30 months after the date of service, the mean postoperative inter-rectus distance was 1 cm; 1 patient had DR recurrence, and 1 patient developed a new incisional hernia without DR recurrence. There was no hernia recurrence.

CONCLUSIONS

rRAM is a safe and effective technique for DR repair with a concomitant ventral hernia. Further studies are needed to determine how outcomes from this robotic approach compare with those from different robotic, laparoscopic, and open techniques.

Minimally invasive bilayer suturing technique for the repair of concomitant ventral hernias and diastasis recti

BACKGROUND

According to EHS guidelines, mesh repair is recommended in case of concomitant diastasis recti (DR) and ventral hernia more than 1 cm in diameter. Since in this situation, the higher risk of hernia recurrence may be attributed to the weakness of aponeurotic layers, in our current practice, for hernias up to 3 cm, we use a bilayer suture technique. The study aimed at describing our surgical technique and evaluating the results of our current practice.

METHODS

The technique combines suturing repair of the hernia orifice and diastasis correction by suture, and includes an open step through periumbilical incision and an endoscopic step. The study is an observational report on 77 cases of concomitant ventral hernias and DR.

RESULTS

The median diameter of the hernia orifice was 1.5 cm (0.8-3). The median inter-rectus distance was 60 mm (30-120) at rest and 38 mm (10-85) at leg raise at tape measurement and 43 mm (25-92) and 35 mm (25-85) at CT scan respectively. Postoperative complications involved 22 seromas (28.6%), 1 hematoma (1.3%) and 1 early diastasis recurrence (1.3%). At mid-term evaluation, with 19 (12-33) months follow-up, 75 (97.4%) patients were evaluated. There were no hernia recurrences and 2 (2.6%) diastasis recurrences. The patients rated the result of their operation as excellent or good in 92% and 80% of the cases at global and esthetic evaluations, respectively. The result was rated bad at esthetic evaluation in 20% of the cases because the skin appearance was flawed, due to discrepancy between the unchanged cutaneous layer and the narrowed musculoaponeurotic layer.

CONCLUSION

The technique provides effective repair of concomitant diastasis and ventral hernias up to 3 cm. Nevertheless, patients should be informed that the skin appearance can be flawed, because of the discrepancy between the unchanged cutaneous layer and the narrowed musculoaponeurotic layer.

Back Pain According to Roland-Morris Low Back Pain Scale After Abdominoplasty With Plication: A Prospective Case Series

INTRODUCTION

Chronic back pain is a physically debilitating condition that affects more than 80% of adults in the United States. A recent case series highlighted how abdominoplasty with plication can offer an alternative surgical approach for treating chronic back pain. These results have been corroborated by a large prospective series. However, this study excluded male and nulliparous subjects, who may also benefit from this surgery. Our group aims to investigate the effect of abdominoplasty on back pain in a more diverse patient population.

METHODS

Subjects older than 18 years undergoing abdominoplasty with plication were recruited. An initial survey called the Roland-Morris Disability Questionnaire (RMQ) was administered at the preoperative visit. This questionnaire inquiries about and grades the patient's history of back pain and surgery. Demographic, medical, and social history was also obtained. A follow-up survey and RMQ was then given 6 months after surgery.

RESULTS

Thirty subjects were enrolled. Subjects had a mean age of 43.4 ± 14.3 years. Twenty-eight subjects were female and 26 were postpartum. Twenty-one subjects reported initial back pain on the RMQ scale. Of these, 19 reported a decrease in RMQ score after surgery, including male and nulliparous subjects. A significant decrease in mean RMQ score was demonstrated 6 months after surgery (2.94-0.44, P < 0.001). Further subgroup analysis of female subjects demonstrated significantly decreased final RMQ score in parous women, vaginal or cesarean section delivery, and absence of twin gestation.

CONCLUSIONS

Abdominoplasty with plication significantly decreases self-reported back pain 6 months after surgery. These results support that abdominoplasty is not purely a cosmetic procedure but can also be applied therapeutically to improve functional symptoms of back pain.

Retrospective Analysis of Predictive Factors for Complications in Abdominoplasty in Massive Weight Loss Patients

INTRODUCTION

Ex-obese patients present with redundancy of abdominal skin and soft tissue due to massive weight loss (MWL). The plastic surgeon can restore the body shape through body contouring procedures. Hence the need to adequately direct patients to body contouring by identifying suitable candidates exists. Our work aims to retrospectively analyze the abdominoplasty complications in our case series to identify associated risk factors and evaluate the effect of combined procedures on abdominoplasty outcomes.

MATERIALS AND METHODS

We retrospectively investigated predictive factors of abdominoplasty procedure complications on 213 MWL patients who received abdominoplasty with and without rectus sheath plication, abdominal liposuction, and other body contouring procedures. We identified risk and protective factors with univariate and multivariate regression analysis. Furthermore, we assessed the impact of additional procedures on the complication rates.

RESULTS

The overall complication rate was 49.8% (26.8% minor complications; 23% major complications). The delayed wound healing rate was 27.7%, and the revision surgery rate was 25.8% (14.7% early revision; 14.2% late revision). These results were compared with literature reports. Several negative predictors emerged as non-modifiable (advanced age, diabetes mellitus, surgical mode of weight loss) or modifiable (preoperative obesity and body mass index (BMI); active smoking; preoperative anemia; use of fibrin glue or quilting sutures). Performing rectus sheath plication improved most of the outcomes. Liposuction of hypochondriac regions and flanks led to increased safety and reduced the risk of surgical dehiscence and delayed wound healing, in contrast to epimesogastric liposuction. The other combined body contouring procedures did not worsen the outcomes, except for poor scarring.

CONCLUSION

Our findings encourage us to continue associating rectus sheath plication, liposuction, and other body contouring surgeries with abdominoplasty. We emphasize the importance of proper patient selection, particularly with regard to anemia, before body contouring surgery in the interests of offering safe surgery and satisfactory results. Further studies are needed to investigate how the optimal BMI cut-off and abstinence from smoking (in terms of time) before surgery reduce postoperative complications.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/journal/00266 .

Preaponeurotic endoscopic repair (REPA) indication in men could be controversial

PURPOSE

To evaluate the outcomes of REPA and establish if any differences in complications and evolution are present between males and females.

METHODS

A retrospective study including consecutive patients operated by REPA approach between November 2017 and April 2019 was conducted. Demographic data, operative times, postoperative complications, and hospital stay were analyzed. The EuraHS-QoL score was used to assess postoperative pain, daily activity constraints, and aesthetic discomfort. The results were compared between sexes. Statistical analysis was performed using SPSS 19.

RESULTS

Fifty-four patients were included and 53.7% were male. Patients had a mean age of 50.7 years and a mean BMI of 28.7. The average RAD (Rectus Abdominis Diastasis) size was 2.6 cm (range of 2-5 cm). Seroma was significantly more frequent in males, with an incidence of 55.2 and 24% for females (p = 0.02). Three cases required reintervention (5.5% of total cases), which corresponded to a cystic seroma, an abdominal wall hematoma, and a hernia recurrence. The three cases were males and a p value of 0.04 was obtained when comparing reintervention rates between males and females. No cases of surgical wound infection nor cutaneous necrosis were recorded. No conversions were needed. The mean postoperative pain was 2.25, the mean daily activity constraints score was 2.63, and the degree of aesthetic discomfort was 1.23 with no significant differences between groups.

CONCLUSION

The correction of small midline defect associated with minor RAD using REPA seems feasible and reproducible. REPA had achieved good results in females, but in males, the outcomes were poorer.

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.

Post-Partum Diastasis Recti Abdominis Treatment Using the Extended-View Totally Extraperitoneal Approach, Rives-Stoppa Technique, and Transversus Abdominis Release Procedure

Introduction

Diastasis recti abdominis usually occurs during pregnancy and delivery in young women with no surgical history, and can induce a severely negative body image, urogynecological symptoms, and musculoskeletal pain. However, the optimal surgical procedure for diastasis recti abdominis is undetermined, and minimally invasive surgery has not been adopted. Additionally, open repair causes scarring that is unlikely to improve negative body image and may even worsen it. We present a case of diastasis recti abdominis surgically treated using an extended-view totally extraperitoneal approach, Rives-Stoppa technique, and transversus abdominis release procedure.

Case Description

The patient was a 29-year-old woman who delivered transvaginally two weeks before presenting with bulging of the abdominal wall. Computed tomography revealed separation of the rectus. A three-month course of conservative therapy comprising exercises to strengthen the transversus abdominis was ineffective, and the patient had newly developed abdominal pain. Therefore, we performed surgical repair using the Rives-Stoppa technique and transversus abdominis release via the extended-view totally extraperitoneal approach. The postoperative course was uneventful, with no recurrence. This procedure may be superior to other methods in terms of cosmetic appearance, preventing infection, bowel adhesion, and recurrence.

Discussion

In the case study, the Rives-Stoppa technique and transversus abdominis release via the extended-view totally extraperitoneal approach achieved a good therapeutic outcome for diastasis recti abdominis.

Experience with Abdominoplasty at National Orthopedic Hospital, Enugu, South-East, Nigeria

Background

Abdominoplasty is a body contouring surgical procedure designed to improve the contour of the lower trunk. It is one the most commonly performed cosmetic procedures in developed countries. In developing nations such as ours, it constitutes a small percentage of aesthetic procedures performed. In our hospital, a number of cases have been done in the past 12 years. However, some studies from developed countries suggest that cosmetic surgeries in developing countries in associated with higher risk of complications. The aim of this study was to evaluate the outcome of abdominoplasties performed in a specialist hospital of a developing country.

Patients and Methods

The study was a 12-year retrospective study. The folders of all the patients that had abdominoplasty were retrieved and reviewed. Data was subjected to statistical analysis using PSPP4Windows®17 computer software version 1.4.1, 2019. The results are presented in prose, tables, charts, and figures.

Results

A total of 30 women aged between 26 and 59 years had abdominoplasty. All were multiparous. About 76% of the patients had previous abdominal surgeries and 74% of this were caesarean section. No mortality was recorded but some patients had minor complications. The most common was respiratory distress which resolved on supportive treatment. Outcome was satisfactory in 95.5% and good in 4.5% of patients.

Conclusion

Abdominoplasty in our environment is safe in trained hands.

A Proposed Classification and Treatment Algorithm for Rectus Diastasis: A Prospective Study

Background

This study presents a classification system and treatment method to correct Rectus diastasis (RD) during abdominoplasty.

Materials and methods

One hundred and sixty seven patients undergoing abdominoplasty were enrolled between April 2014 and January 2018. Forty-three patients did not present with RD and were excluded from the analysis. Mean age was 40.32 years, mean BMI was 23.84, and minimum follow-up was 24 months. A four-type (A: mild 2–3cm, B: moderate 3–5cm, C: severe 5–7cm, and D: very severe 7–9cm) classification system is described. A different treatment method is performed in each category using continuous and interrupted absorbable sutures. Postoperatively patients filled up a questionnaire that involved the level of pain, the postoperative day they performed specific indoor/outdoor activities, and the evaluation of the aesthetic result.

Results

No statistically significant differences were observed between the four RD types regarding pain, complications, and return to specific activities. All types of RD had the same low rate complication profile. The seroma rate was 0.81%. The infection rate was 0.81%, and the thromboembolism and the pneumonic embolism rate was 0%. After 2–6 years of follow-up no clinical recurrence of rectus diastasis was observed. All reoperations (14.52%) were performed due to scar deformities. Mean pain score levels were very low (<1.5) and within a week most patients returned to specific indoor and outdoor activities. Most patients were extremely satisfied with the results.

Conclusions

In this article, we present an updated classification system and treatment protocol to provide surgeons a safe and standardized method that produces high-quality aesthetic results.

Level of evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02739-w.

Biplanar Lipoabdominoplasty: Introducing the Subscarpal Lipo Aponeurotic System

Preservation of Scarpa’s fascia in abdominoplasty has been previously presented. Herein we introduce the subscarpal lipo aponeurotic system (SLAS) and the technique of preserving the SLAS and its tightening in lipoabdominoplasty.

Effect of Exercise on Inter-Recti Distance and Associated Low Back Pain Among Post-Partum Females: A Randomized Controlled Trial

Objective: This study aimed to emphasize facilitation training and strengthening of abdominal and core muscles in improving the inter-recti distance (IRD) and associated low back pain (LBP) among young postpartum females. Materials and methods: A single-blinded randomized controlled trial, among forty young postpartum females, was conducted at a community health center. The females were divided into two equal groups through the envelope method where Group A received abdominal crunch training protocol whereas group B received double straight leg raise (DSLR) exercise protocol for 6 weeks and pre and post IRD and Oswestry disability index (ODI) scores were recorded. Results: Group A showed improvement in IRD with a mean difference of 1.95±0.4 whereas in group B it was found to be 2.85±0.35 when assessed through finger palpation method. The mean difference of IRD, when measured through digital nylon caliper method in abdominal crunch and DSLR exercise group was 4.06±0.74 and 1.2±0.49 respectively. Moreover, ODI scores of group A were 2.70±1.05 whereas, group B scores were found to be 1.1±0.06 showing that LBP reduced in participants who performed abdominal crunch exercise. Conclusion: This study reveals that 6 weeks of exercise protocol was observed to be effective in the management of DRA. Thus, abdominal crunch exercise seemed to produce promising results in a reduction of IRD and associated LBP.

Prevalence and Risk Factors of Hernia in Patients With Rectus Abdominis Diastasis: A 10-Year Multicenter Retrospective Study

Objectives: Hernias are very common in patients with rectus abdominis diastasis (RAD). This study aimed to identify and compare the risk factors and patterns of hernia between men and women with RAD. Method: We included patients with RAD from six hospitals within the Partners Healthcare System in Massachusetts, USA between 2009 and 2018. Univariate and multivariable binary logistic regression analyses were used to identify risk factors associated with hernia. Results: Of the 1,294 RAD cases, 866 (67%) were women. The risk of RAD in women was 1.9 times greater than that of men. There were 240 men (56.1%) and 310 women (35.8%) having one or more hernia (P < 0.001). Of the 550 hernia cases, 278 men and 175 women had umbilical hernia (28.1 vs. 38.3%, P = 0.085). The distribution of hernia type differed between the two groups (P < 0.0001). Multivariate analysis identified that alcohol use [odd ratio (OR) 1.74 (1.17-2.59); P = 0.006] and depressive disorder [OR 1.90 (1.209-2.998); P = 0.005] were risk factors of coexisting hernia for men with RAD; age [OR 1.51 (1.33-1.72); P = 0.000] and smoking/tobacco use [OR 1.66 (1.13-2.44); P = 0.010] were risk factors of hernia for women. Conclusion: The prevalence and risk factors of hernia in women with RAD significantly differed from that in men with RAD. Umbilical hernia is an important type of hernia. Alcohol use and depressive disorder in men, and age and smoking in women were risk factors of hernias in patients with RAD.

Diastasis recti repair with onlay mesh

INTRODUCTION

Diastasis recti represents a midline contour abnormality of the anterior abdominal wall that is secondary to attenuation of the linea alba. Severe diastasis recti is defined as attenuation of the linea alba as well as the linea semilunaris. Treatment options are variable and include conditioning exercises and surgical repair with or without mesh. This manuscript will review the indications and technique of onlay mesh for correction of severe diastasis recti.

METHODS

Abdominoplasty with diastasis repair has been performed in 63 women from January 2010 to January 2020. Of these, 4 had repair for severe diastasis that included plication and onlay mesh. The mesh was polypropylene in 3 patients and silk in 1 patient. Indications for onlay mesh included severe diastasis as a means of further reinforcing the strength of the anterior rectus sheath.

RESULTS

Of the 4 patients, all tolerated the operation well without morbidity. Natural contour was established in all. There were no infections, seromas, delayed healing or mesh removals. All drains were removed by 7 days.

CONCLUSION

The use of an onlay mesh has demonstrated success and should be considered in select patients for the surgical management of severe diastasis.

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.

Evaluation of functional outcomes following rectus diastasis repair-an up-to-date literature review

INTRODUCTION

Over the last decade rectus diastasis has gained attention as a condition that may benefit from surgery. Numerous surgical techniques have been presented but scientifically proper studies reporting functional outcome are few and evidence is incomplete. The aim of this up-to-date review is to analyse the outcomes of rectus diastasis repair in recently published papers, focusing on functional changes following surgery.

METHOD

A comprehensive search in PubMed and Web of Science was performed. Suitable papers were selected using titles and abstracts with terms suggesting surgical treatment of rectus diastasis. All abstracts were scrutinised, and irrelevant studies excluded in four stages. Reports providing original data, including outcome assessment following surgery, were included.

RESULT

Ten papers with a total of 780 patients were found to fulfil the search criteria. Study design, surgical procedure, follow-up time, functional outcome and assessment instruments were compiled. All included studies reported improvements in a variety of functional aspects regardless of surgical method. The outcomes assessed include core stability, back pain, abdominal pain, posture, urinary incontinence, abdominal muscle strength and quality of life.

CONCLUSION

The results of this review show that surgical repair of rectus diastasis is a safe and effective treatment that improves functional disability. However, the absence of standardized instruments for assessing outcome makes it impossible to compare studies. Since indications for surgery are relative and related to core function, valid instruments for assessing indication and outcome are needed to ensure benefit of the procedure.

Muscle elasticity is different in individuals with diastasis recti abdominis than healthy volunteers

Objective

To determine the value of shear wave elastography (SWE) in assessing abdominal wall muscles, including rectus abdominis (RA), external oblique muscle (EO), internal oblique muscle, and transversus abdominis (TrA) in patients with diastasis recti abdominis (DRA) and healthy controls.

Methods

From October 2018 to December 2019, 36 postpartum DRA patients and 24 nulliparous healthy women were identified. Inter-rectus distance (IRD) measurements were taken by B-mode ultrasound. Shear wave speed (SWS) values were acquired by one operator at ten specific locations. Clinical and ultrasound variables, including demographics, IRD, muscle thickness, and muscle SWS, were compared between the two groups using Student’s t test or Fisher's exact test. Pearson correlation analyses were conducted for the variables of IRD, muscle thickness, and SWS in the 36 DRA patients.

Results

The maximum diameter of recti abdominus separation was located at the umbilicus in DRA patients (4.59 ± 1.14 cm). The SWS value was significantly lower in the RA (p = 0.003) and higher in the TrA muscle (p < 0.001) in DRA patients compared with the age-matched controls. However, SWS in both muscles (RA and TrA) showed a statistically positive correlation with IRD (p < 0.05). In addition, the SWS value in EO statistically decreased in DRA patients compared with the healthy controls (1.65 ± 0.15 vs. 1.79 ± 0.14, p = 0.001).

Conclusions

The application of SWE to abdominal wall muscles in DRA patients is feasible. The correlation between SWS value and IRD in RA should be interpreted with caution.

Abdominal Plication for Better Cosmetic Outcomes During Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

Deep inferior epigastric perforator flap (DIEP) for breast reconstruction is a widely accepted technique for breast reconstruction. Secondary benefit of this technique is abdominal contour improvement. Because of direct access, abdominal plication can be performed at the time of abdominal closure. Our goal was to investigate if this addition affected the complications.

METHODS

A retrospective chart review was performed on all DIEP flap reconstructions performed by a single surgeon at a cancer center, from March 2011 through February 2020. Presence of abdominal plication, age, and body mass index were compared with reoperation due to abdominal wound or hernia, procedure length in minutes, and length of stay. The association between the dependent and independent variables for the unadjusted and adjusted analysis was performed using the binary logistic regression analysis.

RESULTS

Three hundred fifty-eight DIEP flaps performed on 233 patients for breast reconstruction were analyzed. Flap loss was 1.7%. Abdominal plication was performed in 178 flaps (49.7%) and not performed in 180 flaps (50.3%). Thirty-nine percent were immediate; 61% were delayed. The results did not show a statistically significant association between abdominal plication and the need to reoperate (P = 0.3). Results from the adjusted analysis (age, body mass index) also did not show a significant association between the plication, need to reoperate, procedure duration, or hospital stay (P = 0.4).

CONCLUSIONS

Abdominal plication can improve cosmetic outcomes without increasing the duration of surgery, hospital stay, or reoperation rates due to abdominal complications. Therefore, it can be a valuable addition in DIEP flap breast reconstructions.

A new minimally invasive technique for the repair of diastasis recti: a pilot study

Background

Diastasis recti is an abdominal wall defect that occurs frequently in women during pregnancy. Patients with diastasis can experience lower back pain, uro-gynecological symptoms, and discomfort at the level of the defect. Diastasis recti is diagnosed when the inter-rectus distance is > 2 cm. Several techniques, including both minimally invasive and open access surgical treatment, are available. Abdominoplasty with plication of the anterior rectus sheath is the most commonly used, with the major limitation of requiring a wide skin incision. The new technique we propose is a modification of Costa’s technique that combines Rives–Stoppa principles and minimally invasive access using a surgical stapler to plicate the posterior sheaths of the recti abdominis.

Methods

It is a fully laparoscopic technique. The pneumoperitoneum is induced from a sovrapubic trocar, placed using an open access technique. The posterior rectus sheath is dissected from the rectus muscle using a blunt dissector to create a virtual cavity. The posterior sheets of the recti muscles are plicated using an endo-stapler. A mesh is then placed in the retromuscular space on top of the posterior sheet without any fixation. Using a clinical questionnaire, we analyzed the outcomes in 74 patients who underwent minimally invasive repair for diastasis of the rectus abdominis sheath.

Results

Seventy-four patients (9 men and 65 women) were treated using this technique. Follow-up was started two months after surgery. All procedures were conducted successfully. There were no major complications or readmissions. No postoperative infections were reported. There were two recurrences after six months. There was a significant reduction in symptoms.

Conclusions

This new method is feasible and has achieved promising results, even though a longer follow-up is needed to objectively assess this technique.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08393-2.

Treatment of rectus diastasis: should the midline always be reinforced with mesh? A systematic review

BACKGROUND

Two main trends are described for the treatment of diastasis recti: plication versus midline mesh reinforcement. Indications for these procedures have not been clearly described. This study reviewed the outcomes in the treatment of rectus diastasis with plication versus mesh by the assessment of durability, complications, and patient-reported outcomes.

MATERIALS AND METHODS

A systematic review of literature on the treatment of diastasis recti was performed searching through PubMed, Embase, Web of Science, and Cochrane databases. This resulted in 53 eligible articles and predefined inclusion criteria led to the selection of 24 articles. Primary outcomes included recurrence and perioperative complications and secondary outcomes were defined as patient satisfaction, chronic pain, and quality of life.

RESULTS

A total of 931 patients were surgically treated for rectus divarication (age range: 18 - 70 years). The most frequently noted comorbidity was obesity and 10.6 percent were smokers. Recurrence was reported in 5 percent of the patients. The most frequent complication was seroma (7 percent), followed by abdominal hypoesthesia (6 percent), and surgical site infection (2 percent). Chronic pain was reported in 4 percent of the patients. Satisfaction was assessed subjectively in the majority of patients and was generally rated as high. Follow-up period ranged from 3 weeks to 20 years.

CONCLUSIONS

Durability, safety, and high patient satisfaction support surgical correction of rectus diastasis and could not favor a treatment method. Inter-rectus distance could not be identified as the indicator for technique, which emphasizes that other factors might add to the entity of abdominal wall protrusion more than previously thought.

Nonsurgical Treatment of Postpartum Lower Abdominal Skin and Soft-Tissue Laxity Using Microfocused Ultrasound With Visualization

BACKGROUND

Microfocused ultrasound with visualization (MFU-V) is a well-established treatment modality for skin tightening. There is a paucity of evidence for its use in body treatments, such as the lower abdomen.

OBJECTIVE

To investigate the effectiveness and safety of MFU-V in treating lower abdominal skin and soft-tissue laxity in postpartum women.

METHODS

The lower abdomen of 20 female patients between 6 and 24 months postpartum are treated with MFU-V using 1.5-, 3.0-, and 4.5-mm transducers. Data are prospectively collected and analyzed at 3 and 6 months using subject-reported and investigator-reported outcome measures. One additional patient underwent planned abdominoplasty 6 weeks after MFU-V treatment with tissue assessed intraoperatively and histologically.

RESULTS

There was a mean improvement of 1.0 and 1.3 grades at 6 months using the investigator-reported and patient-reported skin laxity scale, respectively (p < .001). Patient-reported outcomes and satisfaction survey showed consistent improvement at 6 months. Histological examination of pretreated tissue showed increased total collagen, increased number and thickness of fibrous septae, and no change in fat cells within pretreated tissue compared with the control. No significant adverse events were recorded.

CONCLUSION

MFU-V is an effective and safe treatment modality for lower abdominal skin laxity in postpartum patients.

Management of Diastasis of the Rectus Abdominis Muscles: Recommendations for Swedish National Guidelines

Background:

Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike.

Methods:

The consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience.

Results:

The proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient’s symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior.

Discussion:

The level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.

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

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.

Hernia umbilical: un problema no resuelto

La cirugía de la hernia umbilical ha sido considerada tradicionalmente como sencilla y de fácil ejecución. El cambio conceptual de la hernia umbilical y los avances en su tratamiento han modificado su abordaje, estableciéndose escenarios de complejidad variable (obesidad, embarazo, cirróticos, distasis de los rectos, etc.) que demandan un conocimiento más profundo del tema por parte de la comunidad médica. El impacto económico en el sistema de salud, debido a su alta prevalencia como patología quirúrgica, implica un uso racional de recursos, así como la necesidad de una nueva categorización dentro de la cirugía de la pared abdominal. Es necesario establecer modificaciones en los procesos diagnósticos y terapéuticos en una entidad que ha sido relegada a los niveles básicos del ejercicio quirúrgico habitual.