The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options

Abstract

BackgroundDiastasis of the rectus abdominis muscles (DRAM) is characterised by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This causes the midline to “bulge” when intra-abdominal pressure is increased. Plastic surgery treatment for DRAM has been thoroughly evaluated, though general surgical treatments and the efficacy of physiotherapy remain elusive. The aim of this systematic literature review is to evaluate both general surgical and physiotherapeutic treatment options for restoring DRAM in terms of postoperative complications, patient satisfaction, and recurrence rates.MethodMEDLINE®, Embase, PubMed, PubMed Central®, The cochrane central registry of controlled trials (CENTRAL), Google Scholar, and the Physiotherapy Evidence Database (PEDro) were searched using the following terms: ‘rectus diastasis’, ‘diastasis recti’, ‘midline’, and ‘abdominal wall’. All clinical studies concerning general surgical or physiotherapeutic treatment of DRAM were eligible for inclusion.ResultTwenty articles describing 1.691 patients (1.591 surgery/100 physiotherapy) were included. Surgical interventions were classified as plication techniques (313 patients; 254 open/59 laparoscopic), modified hernia repair techniques (68 patients, all open), and combined hernia & DRAM techniques (1.210 patients; 1.149 open/40 hybrid). The overall methodological quality was low. Plication techniques with interrupted sutures and mesh reinforcement were applied most frequently for DRAM repair. Open repairs were performed in 85% of patients. There was no difference in postoperative complications or recurrence rate after laparoscopic or open procedures, or between plication and modified hernia repair techniques. Physiotherapy programmes were unable to reduce IRD in a relaxed state. Though reduction of IRD during muscle contraction was described.ConclusionBoth plication-based methods and hernia repair methods are used for DRAM repair. Based on the current literature, no clear distinction in recurrence rate, postoperative complications, or patient reported outcomes can be made. Complete resolution of DRAM, measured in a relaxed state, following a physiotherapy training programme is not described in current literature. Physiotherapy can achieve a limited reduction in IRD during muscle contraction, though the impact of this finding on patient satisfaction, cosmesis, or function outcome is unclear.

Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life

“…It is suggested that patients with DRA not causing dysfunction (DRA less than 30 mm, midline hernia or cosmetic issues) should first and foremost receive conservative management with weight control, limited hernia repair or purely aesthetic surgery. Evidence in the literature supporting physical training for symptomatic DRA is inconclusive. The main purpose of physical training is possibly to restore function, and not necessarily to reduce the diastasis.…”

“…Conservative management with training and weight loss is generally advised as first‐line treatment. There is no strong evidence that training during pregnancy and in the postpartum period decreases the risk of persistent DRA, although some studies have reported that specific exercises could increase abdominal trunk stability and reduce some of the associated symptoms. Surgical reconstruction has been reported to restore abdominal trunk function and improve lower back pain and urinary incontinence.…”

Management Strategies for Diastasis Recti

“…The benefit of exercise to prevent or correct diastasis recti is somewhat controversial and has been associated with mixed results. 1,17,18 Preventative exercise protocols include walking and abdominal core strengthening. Corrective exercise protocols include core strengthening, aerobic activity, and neuromuscular reeducation.…”

“…Diastasis recti is a common contour abnormality affecting the anterior abdominal wall. 1 It is often associated with a negative body image, musculoskeletal pain, and occasionally urogynecological symptoms. 2 Diastasis recti manifests as a midline abdominal bulge that is the result of an attenuated linea alba.…”

Endoscopic repair of ventral hernia and rectus diastasis

“…For these patients mesh-based repair of the midline is considered [1]. The technical variants described in the literature are diverse: open, minimally invasive and hybrid [4].…”