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J. Bellido-Luque and B. Bascuas-Rodrigo
Fig. 30.9 Mesh xation
Fig. 30.10 Rectus plication with barbed suture
The plication of both aponeurosis is achieved
with the use of a continuous nonabsorbable
barbed suture no 1 (VLOC™ PBT, Covidien©),
which facilitates this step enormously. The plication is carried out from the subxiphoid until the
suprapubic region (Fig.30.10).
After the plication of both aponeurosis, the
umbilicus is reinserted in its normal position
through a suture to the plicated fascia, with intracorporeal knotting.
Once this step is carried out, we place the subcutaneous suction drain (Blake©) through one of
the 5mm trocars (Fig.30.11). This drain will be
removed once the 24-h uid production is less
than 10mL.
30.5.3 Other Surgical Techniques/No
Surgical Techniques
Diastasis recti repair is challenging for most surgeons, since guidelines on indication and meth-
Fig. 30.11 Wounds and drain view
ods for repair do not exist. However, it is widely
accepted that if the condition is symptomatic or
associated with midline hernias, the simultaneous corrective surgery of both pathologies should
be recommended.
There exist different options for the surgical
correction of diastasis recti. The most commonly
used ones are
– Conventional surgery: the procedure
involves an incision along the length of the
diastasis, with a consequent increase in the
probability of wound infection and the esthetic
deterioration, which this supposes. After this,
the diastasis is corrected with the plication of
both supercial aponeurosis with or without
the use of reinforced meshes, depending on
the technique used by the surgeon.
– Abdominoplasty: plastic surgeons use a
suprapubic approach for the correction of dias-
tasis recti in those patients with excess abdom-
inal skin and subcutaneous cellular tissue
(Table30.3). Using retractors, the subxiphoid
region is reached from the incision made in the
suprapubic area and, with the plication of both
supercial aponeurosis, the diastasis recti is
corrected. The operation is nalized with the
removal of remaining skin and subcutaneous
cellular tissue. At the same time, the umbilicus
skin is deinserted, reinserting it once all the
abdomen skin has been stretched. The scar
made in abdominoplasty is ovoid between both
anterior superior iliac spines and the other scar
is circular periumbilical, with a more accept-
able nal esthetic outcome [10].
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Table 30.3
Abdominoplasty ++++ + + + ++ ++
Conventional open
surgery
Laparoscopic surgery ++ ++ +++ ++++ + ++
Endoscopic surgery + ++++ +++++ + + +++
DR Diastasis Recti, FT Fatty Tissue, SSI Surgical Site infection
– Laparoscopic procedure: the third option for
Main advantages/disadvantages comparing DR repair techniques
DR+ skin/FT
excess
Sthetic results
++ + +++ ++ +++ ++
DR− skin/FT
excess
Sthetic results
DR+ midline
hernias
the correction of diastasis recti is the minimally invasive laparoscopic approach. The
Intra-abdominal
complications
SSI
rate
30.5.4 Technical Tips toImprove
Outcomes andAvoid
Complications
Seroma
rate
correction is feasible through the prior plication of both aponeurosis in the context of an
abdominoplasty, and subsequent intraperitoneal placement of a reinforced mesh by laparoscopic access [22]. A completely
laparoscopic approach has also been employed
using intra-corporeal sutures or trans-fascial
stitches using a Reverdin needle, associated
with intra-abdominal reinforced meshes.
– Endoscopic approach: there is only one pub-
lished article in which a totally endoscopic
access for the treatment of parietal defects is
employed, through the use of conventional
– Lateral dissection: The suprafascial subcuta-
neous extension on both sides should reach up
to 3–4cm from the midline to avoid the chance
of skin vascular hipoperfussion.
– Drain removal: The drain should be removed
when the output is less than 10 mL/24 h to
avoid seroma formation. This tip is crucial to
decrease the seroma rate during the postopera-
tive period.
– Rectus plication: The anterior rectus sheaths
plication become easier when a barbed nonab-
sorbable suture is used.
endoparietal or percutaneous sutures [23].
However, the majority of published studies on
this use endoscopic access without gas, as an
30.6 Postoperative Care
aid to conventional abdominoplasty or to
mini-abdominoplasty [24, 25]. In this technique, a totally endoscopic access is employed
through three suprapubic access trocars, using
working pressures of CO2 of 8mmHg, for the
simultaneous correction of primary defects of
the midline associated with diastasis recti.
After the procedure, a compressed bandage is
placed to diminish the dead space between the
aponeurosis and the subcutaneous cellular
tissue.
An abdominal girdle should be used at least
2months after surgery.
Postoperative clinical checkups usually are
Besides all different surgical options, diastasis
recti is mostly treated conservatively. If conservative therapy is preferred, patients can be
referred to a physiotherapist for training programs that specically target diastasis recti, with
the aim of reducing the inter-rectus distance and
improvement of quality of life.
established at 1, 7, 30, 180, and 360 days and
thereafter annually.
An ultrasound scan of the abdominal wall is
carried out preoperatively, 30 and 360days after
surgery and annually after the rst year of surgery in three locations (xiphoid, 3cm supraumbilical and 2cm infraumbilical positions).
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J. Bellido-Luque and B. Bascuas-Rodrigo
30.7 Outcomes andPrognosis
Controversy also exists over the analysis of the
duration of the plication of the diastasis recti.
Different studies value the recurrence of the diastasis after the plication of both muscular aponeurosis, but the majority of these have a small
sample size, are retrospective, and with a short
follow-up period.
In our experience, no clinical or ultrasound
recurrence has been observed in the diastasis and/
or the midline hernia in any of the patients during
the rst postoperative follow-up year. Of the 47%
of patients reviewed after 24 months, this was
also the case.
With the use of a totally supra-aponeurotic
endoscopic approach, it is feasible to simultaneously correct diastasis recti and symptomatic
midline hernias in patients without excess skin
or subcutaneous cellular tissue, with no recurrence of the diastasis recti being observed, either
clinically or ultrasonographically, during the
follow-up.
30.8 Complications
In the majority of published articles, the most frequent complication associated with diastasis recti
correction is the appearance of postoperative
seroma in around 20% of patients operated on.
With the change to an abdominal compressed
bandage linked to a medical corset positioned
once the operation was nished, we have noticed
that the rate of seroma can be easily reduced
(9%).
ogy of the abdominal wall, the surgical community has begun to wonder if there could be less
invasive techniques than abdominoplasty as treatment for the DR.
The use of a totally supra-aponeurotic endoscopic approach brings considerable esthetic
advantages, allowing the simultaneous correction of both pathologies, with minimal
complications.
Diastasis greater than 6–7 cm of separation
between the rectus, or those associated with
severe musculoaponeurotic laxity of the abdominal wall, could benet from the use of reinforced
prosthesis.
Eventually, this technique improves nal
esthetics results at rst postoperative year when
compared with the preoperative cosmetic state,
with high overall satisfaction, and diminishes
back pain when diastasis recti is surgically
corrected.
As a nal conclusion, we can state that DR, in
most of the cases, is not only a cosmetic defect
and, therefore, it should not be surgically managed just as a cosmetic defect. That is why
abdominal wall surgeons should begin to analyze
this condition in a different way and take it into
account as a pathology that deserves more consideration. The patient population is very large
and disorders associated with DR are sufciently
serious as to alter the quality of life of the patients.
Minimally invasive surgical techniques, associated with correct preoperative and postoperative
physiotherapy, allow us to offer an adequate
intervention for this condition.
References
30.9 Conclusions
In the last decade, with the claim of abdominal
wall surgery as a superspecialty of general surgery, the interest of the wall surgeons has also
focused on the DR and thanks to the technical
and cultural heritage of general surgery, which
includes the knowledge, use and development of
prostheses, techniques and equipment that allows
a minimally invasive approach, also in the pathol-
1. Beer GM, et al. The normal width of the linea alba
in nulliparous women. Clin Anat. 2009;22(6):706–11.
2. Brauman D. Diastasis recti: clinical anatomy. Plast
Reconstr Surg. 2008;122(5):1564–9.
3. Nardi WS, Busnelli GL, Tchercansky A, Pirchi DE,
Medina PJ. Diastasis recti associated with midline
hernias: totally subcutaneous video-endoscopic
repair. J Minim Access Surg. 2018;14:161–3.
4. Bellido Luque J, Bellido Luque A, Valdivia J, Suarez
Gráu JM, Gomez Menchero J, García Moreno J,
Guadalajara JJ.Totally endoscopic surgery on diastasis recti associated with midline hernias. The advan-
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tages of a minimally invasive approach. Prospective
cohort study. Hernia. 2015;19(3):493–501.
5. Parker MA, Millar LA, Dugan SA. Diastasis rectus abdominis and lumbo-pelvic pain and dysfunction—are they related? J Womens Health Phys Ther.
2009;33(2):15–22.
6. Emanuelsson P, etal. Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves
abdominal wall muscle strength: a randomized,
prospective trial comparing retromuscular mesh
repair to double-row, self- retaining sutures. Surgery.
2016;160(5):1367–75.
7. Sperstad JB, et al. Diastasis recti abdominis during
pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br
J Sports Med. 2016;50(17):1092–6.
8. Mota P, Pascoal AG, Sancho F, Bø K. Test- retest
and intrarater reliability of 2-dimensional ultrasound measurements of distance between rectus
abdominis in women. J Orthop Sports Phys Ther.
2012;42(11):940–6.
9. Cuccomarino S. ¿Por qué el cirujano de pared
abdominal debería operar la diástasis de rectos? Rev
Hispanoam Hernia. 2019;7(2):43–6.
10. Pitanguy I. Abdominoplastias Hospital
1967;71(6):1541–1556.
11. Ramirez OM. Abdominoplasty and abdominal wall
rehabilitation: a comprehensive approach. Plast
Reconstr Surg. 2000;105:425–35.
12. American Society of Plastic Surgeons. Plastic surgery statistics report. http://www.plasticsurgery.org/
news- and- resources/2012- plastic- surgery- statistics.
html.
13. Kato JM, Iuamoto LR, Suguita FY, Essu FF, Meyer
A, Andraus W.Impact of obesity and surgical skills in
laparoscopic totally extraperitoneal hernioplasty. Arq
Bras Cir Dig. 2017;30(3):169–72.
14. Veríssimo P, Nahas FX, Barbosa MV, de Carvalho
Gomes HF, Ferreira LM.Is it possible to repair diasta-
sis recti and shorten the aponeurosis at the same time?
Aesthet Plast Surg. 2014;38(2):379–86.
15. Hickey F, Finch JG, Khanna A.A systematic review
on the outcomes of correction of diastasis of the recti.
Hernia. 2011;15:607–14.
16. Köckerling F, Botsinis MD, Rohde C, Reinpold W,
Schug-Pass C.Endoscopic-assisted linea alba reconstruction: new technique for treatment of symptomatic umbilical, trocar, and/or epigastric hernias with
concomitant rectus abdominis diastasis. Eur Surg.
2017;49(2):71–5.
17. Corrêa MA. Videoendoscopic subcutaneous techniques for aesthetic and reconstructive plastic surgery.
Plast Reconstr Surg. 1995;96(2):446–53.
18. Zukowski ML, Ash K, Spencer D, Malanoski M,
Moore G. Endoscopic intracorporal abdominoplasty: a review of 85 cases. Plast Reconstr Surg.
1998;102(2):516–27.
19. Nahabedian MY.Management strategies for diastasis
recti. Semin Plast Surg. 2018;32(3):147–54. https://
doi.org/10.1055/s- 0038- 1661380.
20. Nahas FX, Ferreira LM, Augusto SM, Ghelfond
C.Longterm follow-up of correction of rectus diastasis. Plast Reconstr Surg. 2005;115:1736–41.
21. de Almeida Mendes D, Nahas FX, Veiga DF, et al.
Ultrasonography for measuring rectus abdominis
muscles diastasis. Acta Cir Bras. 2007;22:182–6.
22. Huguier V. Laparoscopic coupled with classical
abdominoplasty in 10 cases of large rectus diastasis.
Ann Chir Plast Esthet. 2012;57:350–5.
23. Champault G. Video-parieoscopic surgery of the
abdominal wall. A study of 15 cases. Chirurgie.
1998;123(5):474–7.
24. Eaves F.Endoscopic abdominoplasty and endoscopically assisted miniabdominoplasty. Clin Plast Surg.
1996;23:599.
25. Lockwood T. Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg. 1996;101(6):1685–91.
Part VII
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Genitalia
Anatomic Changes inExternal
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andInternal Reproductive Organs
BorjaFernández-Ibarburu, JesúsOlivas-Menayo,
andMónicaGomes-Ferreira
31
Take-Home Points
• The external genital organs and the vulva
include the labia majora and minora, the clitoris, the vulvovaginal glands, and the perineum.
The understanding of the anatomical purpose
and function of these structures, as well as to
the changes during gestation, are essential for
giving adequate medical attention to patients.
• The fundamental understanding of the internal
genital anatomy of women (uterus, ovaries,
fallopian tubes, cervix, vagina), and its changes
during pregnancy, facilitates the compression
of pathology associated with the structures and
enables the surgical treatment of the same.
• The female reproductive system contains two
main parts: the uterus, which hosts the fetus,
produces uterine and vaginal secretions, and
passes the male sperm through to the fallopian
B. Fernández-Ibarburu (*)
Hospital General Universitario Gregorio Marañón,
Madrid, Spain
e-mail: borja.fernandez@salud.madrid.org
J. Olivas-Menayo
Department Plastic Reconstructive and Aesthetic
Surgery, MS Medical Institutes, Lisbon, Portugal
e-mail: doctor@olivasmenayo.com
M. Gomes-Ferreira
Department Obstetrics and Gynecology, MS Medical
Institutes Lisbon, Portugal, Lisbon, Portugal
e-mail: info@drmonicagomesferreira.com
tubes; and the ovaries, which produce the
female egg cells.
31.1 Introduction
The female reproductive system is a collection of
internal and external organs. The external genitalia comprise the structures outside of the true pelvis, including the labia majora and minora,
vestibule, Bartholin glands, Skene glands, clitoris, mount of Venus, perineum, urethral meatus,
and periurethral area. The internal genitalia is
within the true pelvis, including the vagina, cervix, uterus, fallopian tubes, and ovaries.
The reproductive system is for the purpose of
procreating. Due to its vital role, many scientists
argue that the reproductive system is among the
most important systems in the entire body.
After pregnancy, the female reproductive system can change signicantly. It is important for
medical professionals to know why these changes
occur and how we can reverse some of them, if it
is the woman’s desire.
31.2 Female External Genital
Organs
The female external genital organs are found in
what is commonly referred to as the vulva
(Fig.31.1). This includes the mount of Venus, the
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_31
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Mons pubis
Posterior labial commissure
Anus
Fig. 31.1 Anatomy of the vulva. (Reprinted from Firoozi F.Female pelvic surgery. Springer 2015 with permission)
labia majora, labia minoras, vestibule, clitoris,
vulvovaginal glands, and the perineum.
Regarding the arterial supply of the external
genital apparatus, it is derived from the deep
external pudendal branches of the superior femoral artery and the internal inferior pudendal artery
on each side (Fig.31.2).
Vulvar cutaneous venous drainage occurs
through the outer pudendal veins, to its mouth in
the saphenous vein. The clitoris carries out its
venous drainage through the deep dorsal veins
(they ow into the internal pudendal vein) and
through the supercial dorsal vein, to the external
pudendal vein, and nally the greater saphenous
vein.
There is a wide network of interconnected
lymphatic vessels responsible for draining the
external genitalia and perineum. These extend
Perineal raphe
drain directly into the deep inguinal nodes or
through the inguinal canal to the external iliac
nodes. This complex lymphatic drainage network
has clinical relevance, as these are the nodes in
which the vulvovaginal and cutaneous vulvar
neoplasms nd their way of dissemination [2].
Regarding nerve supply, the predominant
injector of the vulva comes from the pudendal
nerve (S2, S3 and S4) through its lower rectal and
perineal branches, and the dorsal nerve of the clitoris (Fig. 31.3). The sensory insertion of the
anterior third of the labia majora comes from the
ilioinguinal nerve (LI), while it is the pudendal
nerve, which, through the posterior labial
branches of the perineal nerve (S3), innervates
the posterior 2/3 of the same. The lateral region
receives inertia in addition to the perineal branch
of the posterior femoral cutaneous nerve (S2) [1].
Anterior labial commissure
Prepuce of clitoris
Glans of clitoris
Frenulum of clitoris
Urethral opening (meatus)
Labium minus
Labium majus
Opening of paraurethral (Skene’s)
ducts
Vaginal opening
Vestibule
Opening of greater vestibular
(Bartholin’s) gland
Hymenal caruncle
Vestibular (navicular) fossa
Frenulum of labium
from the skin of the lips, clitoris, and surround
regions to form three or four main trunks that join
the supercial inguinal nodes (on the cribriform
31.2.1 Mont ofVenus
fascia). From there they reach deep into the
inguinal nodes, medial to the femoral artery (the
last deep inguinal nodes, which are located under
the inguinal ligament in the femoral canal, are
often called Cloquet’s node). These, in turn, drain
through the femoral canal to the pelvic nodes [1].
Deep lymphatic vessels from the clitoris can
The mount of Venus consists of an adipose prominence that covers the public symphysis, which,
after adolescence and adulthood, becomes more
prominent, hair grows, and atrophies well after
menopause. The hymen frames the vaginal opening and is considered a portion of the vestibule.
P
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Posterior
labial artery
Perineal
membrane
Transverse
perineal artery
Perineal artery
Internal
pudendal artery
Inferior
rectal artery
511
Dorsal artery
of clitoris
Deep artery
of clitoris
Perineal membrane
(cut away)
Artery to bulb
of vestibule
Deep transverse
perineal muscle
Internal pudendal
(clitoral) artery
Fig. 31.2 Vulvar blood supply. (Reprinted from Firoozi F.Female pelvic surgery. Springer 2015 with permission)
Anterior labial branch
of ilioinguinal nerve
Dorsal nerve
of clitoris
osterior labial
nerves
Pudendal
nerve
Inferior rectal
nerves
Perineal branch of
posterior cutaneous
nerve of thigh
Superficial branch
of perineal nerve
Deep branch
of perineal nerve
Perineal nerve
Perforating
cutaneous nerve
Fig. 31.3 Vulvar innervation. (Reprinted from Firoozi F.Female pelvic surgery. Springer 2015 with permission)
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31.2.2 Labia Majora
The labia majora consist of two prominent,
bresuper-elongated and longitudinal skinfolds on
either side of the vaginal introitus. They are the
prominent ones of the vulva, and they make up its
lateral margins [3]. Each lip has a hairy pigmented outer surface and a pink-looking inner
surface with prominent sebaceous glands. The
content between both surfaces consists of loose
connective tissue and subcutaneous fat (they have
a supercial fatty layer similar to Camper’s fascia, and a deeper membranous layer—Colles’
fascia—which is in continuity with Scarma’s fascia of the anterior wall of the abdomen), interconnected with smooth muscle bers (similar to the
dartos muscle of the scrotum in the male), vessels, nerves, and glands [1]. The lips meet anteriorly to form the anterior commissure, while
posteriorly they join at a slightly elevated connecting ridge, called the posterior commissure
(supercial to the period body), constituting the
posterior limit of the vulva [2]. It is the subcutaneous fatty deposits that cause the lips to rise on
either side of the vaginal cleft (they decrease in
thickness with age), and it is through them that
the vessels and supercial nerves responsible for
their sustenance circulate. The main arterial supply comes from the supercial branches of the
pudendal artery, while the incitation comes from
cutaneous branches of the pudendal nerves,
nerve, and femoral skin nerves [4].
31.2.3 Labia Minora
The labia minora consist of two thin skin folds of
small size devoid of hair, found between the labia
majora. They delineate the vaginal vestibule laterally, and each lip forks anteriorly to surround
the clitoris [2]. They are homologous to the
median raphe of the penis and scrotum in men,
and contribute to the structure of the clitoral fren-
ulum and sheath (When the labia minora are
bifurcated, the upper layer on each side passes
over the clitoris forming the foreskin, while the
lower layer passes under it to form the frenulum
[1]). They have abundant sebaceous and sweat
glands (apocrial glands, as well as in the perianal
oor) in addition to presenting a rich venous
drainage, and an important nervous supply, which
makes them more sensitive to touch than the labia
majora [4].
31.2.4 Clitoris
The clitoris consists of a small, cylindrical, and
erectile structure, partially encompassed by the
anterior edges of the labia minora after bifurcation [1] (Fig.31.4). It is located in front of the
urethra and is made up of the glans (the only part
visible externally between the folds formed by
the bifurcation of the labia minora), body and
two crura (“legs”) [3]. The body of the clitoris is
covered with a loose tissue foreskin and can be
felt through the skin. It consists of two corpora
cavernosa composed of erectile tissue surrounded by dense brous tissue and divided
medially by an incomplete brous pectineal septum (by adhering superiorly to the pubic symphysis, this brous tissue forms a suspensory
ligament). The corpora cavernosa separates as
they extend superiorly, and each of them ends in
a crura that joins the periosteum of the ischiopubic branch on each side [1]. Each end of the clitoris is covered by the corresponding
ischiocavernosus muscle [3]. The glans of the
clitoris is a small tuberosity of spongy erectile
tissue distal to the body and connected to the
vestibular bulb on each side by thin bands of
erectile tissue. Its epithelium presents great cutaneous sensitivity (the dorsal nerve of the clitoris
accesses the glans after crossing the urogenital
diaphragm [2]), which represents an important
aspect in the sexual response [1].
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ab
513
Fig. 31.4 Anatomic drawing of the clitoral organ (colorations of original drawings from the author). (a) (Left)
Drawing showing the clitoral organ anked by the symphysis and the inferior rami of the pubic bone (description
given from inside to outside): bulbi vestibuli being covered by the bulbo-cavernosi muscle; clitoris comprising
the clitoral tip and clitoral bodies radially stretched by the
31.2.5 Greater Vestibular Glands:
Bartholin’s Glands
The vestibule is the cavity between the labia
minora and presents on its surface different structures that should be known. Among them are the
external vaginal and urethral orices, and the
opening of the two maternal vestibular glands
(Bartholin glands) and the numerous minor vestibular glands [1], vaginal and external urethral
orices, and the opening of the two major vestibular glands (Bartholin glands) and the numerous minor vestibular glands [1]. The vestibule
bulbs (equivalent to the spongy body of the penis
in the male [3]) consist of two elongated structures of erectile tissue, about 3cm long, which
rest on either side of it and ank the vaginal
opening. In front of it, they are joined by a narrow joint (in contact with the glans of the clitoris), while its posterior edge expands and contacts
the major glands and stables. The deep face of
each vestibular bulb is in contact with the lower
portion of the perineal membrane, while supercially, each one is covered by the bulbo- cavernous
muscle [1] (in addition to serving as an aid in the
constriction that occurs to avoid Venous drainage
suspensory ligament, as well as the clitoral crura paralleling the bulbi vestibuli at their lateral border. (b) (Right)
Illustration of clitoral topography projected on the vulva.
(Reprinted from Dan mon O’Dey. Vulvar Reconstruction
Following Female Genital Mutilation/Cutting (FGM/C)
and other Acquired Deformities. Springer 2019 with
permission)
of the erectile bulbs and stables, it can act as a
vaginal sphincter [3]). The external urethral
meatus is located in the superior portion of the
vestibule and is located in a papillary elevation
with a sagittal cleft approximately 2 cm below
the clitoris and above the vaginal opening. The
opening of the ducts of the paraurethral glands
(Skene’s glands) is located on each side of the
urinary opening (posterolateral aspect of it).
Skene’s ducts run parallel and inferior to the urethra, at a distance of approximately 1–1.5cm [2].
The major vestibular glands (Bartholin’s glands)
are homologous to the male bulbourethral glands.
They consist of two small, oval, or rounded structures that ank the vaginal opening (at 5 and 7
o’clock), in contact and often covered by the
lower part of the vestibular bulb [1]. In addition,
they are very close to the posterolateral wall of
the vagina, around 15mm deep from the vestibule surface, slightly posterior and lateral to the
opening of the corresponding duct [4]. These
ducts (1.5-cm-long each) are also visible on each
side of the vestibule, in the groove formed by the
hymenal ring and the labia minora, at the junction of the middle and posterior one-third of the
lateral margin of the vaginal opening [2]. The
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