Abdominal Rectus Divarication (Diastasis) with or without Hernia

Common after Pregnancy and requires Surgery

What is Abdominal Rectus Divarication

This condition is also called Divarication of Recti or Abdominal Rectus Diastasis. This occurs when the Linea Alba widens, the abdominal cavity bulges, generating an unnatural separation between the abdominal muscles known as abdominal rectus diastasis. Linea alba is a tough midline structure below our abdominal wall skin. This results in a large bulge in the abdominal wall on sitting and walking.

What is the cause of Divarication of Recti?

Pregnancy is the most frequent cause in women. This disease can also appear in the upper abdomen of heavier males or in obese people. Despite the fact that many patients have the illness, the effectiveness of physiotherapy is not very useful and thus surgery remains the mainstay of treatment.

 What are the signs and symptoms?

• The signs and symptoms include abdominal pain and discomfort, musculoskeletal and urogynaecology issues, negative body image, and reduced quality of life.
• There may be an associated hernia with this condition. Hernias usually associated are epigastric or umbilical hernias.
• Umbilical or epigastric hernias, discomfort when touching the abdominal wall, unsteadiness on one’s feet, and a sense of losing one’s functional “core” can all be connected with divarication of recti.
• Some patients who have severe rectus divarication experience back pain, which may be caused by this loss of core stability.
• Even in people who are extremely thin, pregnancy-induced rectus divarication can significantly alter the contour of the abdominal wall.
• Males’ rectus divarication differs from that of females, manifesting as a midline protrusion between the xiphoid and the umbilicus.

This review’s objective was to provide a summary of available therapies for abdominal rectus diastasis alone or with hernia

Treatment Options available for Divarication of Recti

 Patients who suffer from Divarication of Recti or associated hernias will benefit from a repair in the form of a surgery. Surgery seeks to reinforce the abdominal wall and restore a healthy anatomy. The midline defect is closed and strengthened as the rectus abdominis muscles are brought together during surgery. During this treatment, hernias are also fixed. Surgical mesh is employed in the restoration process in all the cases. At times some form of physiotherapy is advised before surgery as a treatment option. Physiotherapy has proved to be not a definitive treatment for Divarication of the Recti; however it helps in restoring the tone of the recti muscles. There are various surgical techniques, including open, minimally invasive (laparoscopic) and Robotic procedures. The recurrence rate is to be at least 10-15%, regardless of the procedure utilized.

Open Surgery

This procedure comprises plication (re-approximation) of the defect through a midline incision. The patient is kept in the hospital for at least few days and will require pain medication for one to two weeks. A drain may be used to ward off collection of fluid after surgery. It can take up to 4-6 weeks to resume all of your regular daily activities.

Laparoscopic Surgery

There are two methods and each one has its specific indications. Surgeons chose the procedure depending upon many patients factors.

One technique involves making three tiny incisions on the belly and plication, or tightening, the abdominal wall from the inside. The insertion of an intra-abdominal mesh, which is secured in place by tiny tacks, is then used to enhance this tightening. If there is a hernia in addition to the diastasis, this approach is typically favoured. The recovery process following surgery is the same as it is for open surgery, however a mesh is typically employed and is placed inside the abdominal cavity.

The other technique involves making space above and beneath the muscles of the abdominal wall; this procedure is used more extensively. This procedure uses three tiny incisions made below the umbilicus and avoids “entering” the abdominal cavity. Although it is normally safer, the use of a mesh is necessary, especially when a hernia is also present. A drain is left in place under the skin after surgery to prevent or regulate seroma production; this drain may remain there for a week or more.

Robotic Surgery

For certain conditions, robot aided surgery offers new opportunities for minimally invasive treatment. This is a new method and slowly being adapted for this condition.  However, compared to laparoscopic or open repair, the operating time for robot assisted repair is much greater.

Recurrence

Any such repair carries a number of hazards, chief among them the return of the defect. However the benefits are way much higher and surgery should always be preferred.

Repair of Divarication of Recti in patients with lax abdominal wall

In some patients with divarication of recti, manly women, there is immense laxity of the abdominal wall. In these patients abdominoplasty is offered as a part of the procedure. Thus after the divarication and hernia are repaired, mesh is inserted, the lax extra part of the lower abdominal wall is removed. The lower end is sutured in the bikini line and a new umbilicus is created at the intended spot. This of course is done as an open procedure, but there is no midline incision. The recovery is almost similar to the above procedures, though the incision can have issues like infection or small dehiscence or dermal loss of skin. These issues are easily manageable and the patient has a better looking abdominal wall.

Conclusion

Patients with abdominal rectus diastasis who also have symptoms should be referred for surgery. The choice of surgical technique should be based on the quantity of extra skin, whether abdominoplasty is required, whether a hernia is present, and any general relative contraindications to laparoscopic surgery, such as repeated prior laparotomies or peritonitis. Both surgical procedures have minimal rates of complications and recurrence. Robotic assisted surgery is being used with encouraging outcomes, and it may soon be used as a therapeutic option.

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