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Fig. 29.2 Periumbilical incision

Fig. 29.3 Hernia sac dissected

we have different options in order to repair the fascia:

– Tissue-suture repairs (Herniorrhaphy):

(a) Simple primary suture

This technique is based on the

tissue- suture repair of the fascia

Fig. 29.4 Hernia defect

Fig. 29.5 Tissue primary suture

(Fig. 29.5 and Video 29.1), usually performed with nonabsorbable suture, but we may use as well long-acting absorbable sutures; monolament, multilament or barbed in a continuous or interrupted suture. Additionally, the defect closure may be vertical or

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horizontal [16]. Furthermore, the size of the suture is 1/0 or 2/0, depending on the magnitude of the defect. The main disadvantage of this technique is that it implies tension of the tissues, so it is related to a higher rate of recurrence.

(b) Mayo repair

This repair consists in overlapping 2–3cm the abdominal wall fascia in a “vest-over-pants” manner with two rows of sutures [18].

This is an uncommon technique, which uses two-layered of suture inverting the medial part of the rectus sheath and suturing both sides.

– Prosthetic repairs (Hernioplasty):

These techniques require more surgical time than the herniorrhaphies due to the ap dissection and the mesh reinforcement [19]. This reinforcement may be performed with absorbable or nonabsorbable suture. Whenever we close the fascia, we utilize nonabsorbable monolament suture, 2/0 or 1/0 depending on the size of the defect. Afterward, we place a polypropylene mesh and x it to the fascia with 2/0 nonabsorbable monolament suture. It is also important to make a repair without tension, overlapping the defect at least 5cm with the mesh. Mesh can be placed in different locations (Fig.29.6) with or without closing the defect.

ONLAY

Fig. 29.6 Mesh location

INLAY

SUBLA

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Fig. 29.7 Preaponeurotic/onlay mesh

(a) Preaponeurotic (Onlay mesh)

A wide subcutaneous dissection is performed in order to place the mesh (Fig. 29.7), with an increased rate of seroma and/or hematoma in the postoperative period leading to more surgical site infection [1]. When there is a large ap dissection, a drainage is usually placed in order to reduce the seroma, increasing the postoperative hospital stay [19].

(b) Fascial layer (xed to the ring, inlay

technique)

When the fascial defect is wide, we can place the mesh covering the defect and xing it to the ring, instead of closing the edges with tension. Usually, the peritoneum is closed under the mesh avoiding the contact with the viscera. If this is not possible, there are new bilayer devices that have been designed for this type of repairs. The mesh has a double side: one is polypropylene and the other is a nonadherent material that may be in contact with viscera. The main disadvantages are that these meshes are expensive, and they have a high recurrence rate [20].

mesh)

C. Tuero et al.

Fig. 29.8 Retromuscular dissection with posterior rectus sheath closed

This technique requires more surgical experience, especially when the neck of the hernia is narrow. Sublay mesh avoids a wide subcutaneous dissection and reduces the hematoma and seroma formation. The dissection is performed behind the rectus muscle and above the posterior rectus sheath (Fig. 29.8). The peritoneum and the posterior sheath are sutured, and then place the mesh. Afterward, suturing the anterior rectus sheath is recommended.

(d) Preperitoneal technique (Sublay mesh)

Placing a preperitoneal mesh also requires surgical experience and it is a longer procedure due to the wide dissection performed. This repair, as the retromuscular one, has a low rate of seroma and hematoma, because there is no subcutaneous dissection. If we suspect that the peritoneum is open, we should close it with continue suture before placing the mesh. Suturing the posterior and anterior rectus sheath is also recommended.

(e) Mesh plug

The mesh is inserted inside the defect. It is a simple technique, but there is scant literature comparing this repair to others. It is known that mesh plug implies a higher risk of migration and enterocutaneous stula formation.

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– Laparoscopic technique

There are several procedures, but laparoscopic intraperitoneal onlay mesh (IPOM) is the laparoscopic repair most performed worldwide.

IPOM starts creating pneumoperitoneum in the left subcostal margin, and afterward, placing three trocars on the left ank. After exploring the abdominal cavity, the hernia is identied, and the sac reduced. Before placing the mesh, the hernia defect is measured to assure the size of the prothesis. Then, a special mesh that allows contact with abdominal viscera is located covering the defect with an overlap of 5cm at least. The mesh is usually xed with absorbable tuckers.

29.1.5.3 Technical Tips toImprove Outcomes andAvoid Complications

Mesh repair is usually the elected treatment due to the lower recurrence rate in comparison with herniorrhaphy [21]. The recurrence after simpletissue repair was 11% compared with 1% when mesh was used [22]. When the hernia is over 2 cm, prothesis repair is the elective treatment and furthermore, the latest literature also recommends the use of mesh when the hernia is <2cm [23]. A recent RCT concluded that at mesh is preferable than patch repair with lower recurrence and complication rate [24].

About wound infection and complications related to umbilical hernia repair, there is no evidence that the use of mesh is related to a higher morbidity rate [21, 22].

Regarding the type of mesh, standard polypropylene is the most frequently used. This prothesis is suitable for repairs when the peritoneum is closed and there is no contact with the viscera. Light-weight meshes are increasing its use, because this technology induces less foreignbody response, allowing a better tissue incorporation [1, 25].

29.1.6 Postoperative Care

The discharge is usually on the same day as the operation. We recommend avoiding heavy lifting and physical work for a month and start walking as soon as possible. It is possible to have tightness or pain on the rst few days, that will gradually disappear, and it can be managed with painkillers. Sometimes, when there is a wide dissection, a drain is placed, which is normally removed around 5–7days after surgery.

Regarding the wound, bruising and tenderness is normal on the rst few days. The stitches should be removed 10days after surgery. Some lotions will help in healing the wound; besides, sun protection of the scar is recommended on the rst year after surgery.

29.1.7 Outcomes andPrognosis

This surgery has relatively good outcomes, with low recurrence rate and scarce complications. As we mentioned before, recurrence is higher in repairs without mesh, besides, long-term followup results have found that periumbilical pain is more prevalent with herniorrhaphies.

29.1.8 Complications

The most prevalent complications are large seroma, bleeding in the immediate postoperative period, wound infection, and recurrence of the hernia.

Bleeding in the postoperative period may be avoided with a careful hemostasis during the intervention; we need to assure a correct bleeding control in order to avoid emergency reinterventions during immediate postoperative period. The emergency reintervention is related to an increase rate of wound infection. Furthermore, seroma formation may be prevented with the compartmentalization of the subcutaneous tissue during

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the closure by xating it to the fascia with a midterm absorbable multilament suture. Regarding wound infection, it should be prevented with a chary asepsis and with the administration of a single dose of antibiotic (Cefazoline 2g one dose during anesthetic induction). Furthermore, laparoscopic approach has lower wound infection rate compared to open approach. However, laparoscopic technique has risks related to intraperitoneal foreign body. Besides, tucker xation of the mesh may cause postoperative pain, adhesions, nerve injury or bowel obstruction.

The main risk factors for recurrence are: large seroma, surgical site infection, smoking, ascites, diabetes, hernia size >2cm, obesity with a BMI over 30kg/m

and excessive weight gain follow-

ing repair [1, 26].

29.1.9 Conclusions

Umbilical hernia repair is a simple procedure with low complications rate. It is important to diagnose this entity and be able to determine when is the best moment to perform the surgery, overall in fertile women.

We have to avoid emergency surgery related to incarcerated or strangulated hernia, because mortality and morbidity are increased. Sometimes, bowel resection is needed; instead, elective surgery gives satisfying results and a low rate of morbidity with no mortality associated.

Take-Home Points

• Hernioplasty is the elective procedure for

umbilical hernia repair with low recurrence

rate and low morbidity associated.

• Placing a mesh is recommended even when

the defect is small (<2cm).

• About mesh location, at mesh has better out-

comes than patch repair and preperitoneal

position performed better.

• Women planning or during pregnancy with

small and asymptomatic hernias should

undergo surgery after childbirth, preferably

1year after.

• Women planning pregnancy with large or symptomatic hernias should undergo surgery and wait 1year until pregnancy.

• Women during pregnancy with large and symptomatic hernias may undergo surgery during the second trimester.

• Irreducible hernia should undergo emergency repair even during pregnancy.

29.2 Rectus Abdominis Diastasis

29.2.1 Introduction

Rectus muscles are normally fused in the midline with an approximate distance of 1 or 2 cm between them, forming the linea alba. This linea reaches from the xiphoid process to the pubic symphysis varying its width, which is higher in the periumbilical area [27].

A diastasis of the abdominal rectus (RAD) is

an acquired condition characterized by a midline abdominal wall protrusion when the intraabdominal pressure increases. This pathology appears due to the laxity of the ventral abdomen musculature and the widening of the linea alba and may be measured by the inter-recti distance (IRD) [28].

Sometimes this entity is misclassied as a pri-

mary or a ventral hernia, but the continuity of the midline is preserved, so there is no fascial defect [3]. However, this weakness of the abdominal wall is a risk factor for the development of midline hernias due to the deterioration of the connective tissue. A 45% of patients with umbilical and/or epigastric hernias had concomitant RAD [29].

29.2.2 Patient Selection

RAD can be congenital or acquired and may occur in male and female and in a wide range of ages. We have normally two different prole of patients: middle-aged and older men with central obesity and t young women with normal BMI with a history of pregnancies.

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RAD in pregnancy appears mostly in the third trimester and remains until the rst week following childbirth [30]. This appearance is due to hormonal changes, the increased intra- abdominal pressure, and the increase in the uterus size. Other risk factors for the development of RAD are previous abdominal interventions, body weight-loss related to diet or bariatric surgery, high age, and genetically conditioned defects in collagen structure [31, 32].

Some studies describe a relationship with abdominal aortic aneurysm with a higher prevalence in this population (67% versus 17%) [33].

RAD Risk Factors:

Multiparity

Heavy lifting

Previous abdominal interventions

High age

Defects in collagen structure

High body Mass index

29.2.2.1 Normal Values ofInter-recti

Distance (IRD)

There are few studies dening the normal width of the linea alba, which varies regarding the reference location. The rst of all, published by Rath etal. in 1996 (Table29.2), concludes that this line is widest at the umbilicus, and in people over 45 years, this linea increases above and under the umbilicus 5 mm; conversely, the umbilical area is not affected by age [34]. Afterward, Beer etal. measured the linea alba in 150 nulliparous women with ultrasound at three different positions: at the xiphoid, 3cm above the umbilicus, and 2 cm below the umbilicus (Table 29.3). They considered normal values between the tenth and the 90th percentile, which

Table 29.3

Location Width Xyphoid 15mm Above umbilicus 22mm Below umbilicus 16mm

Table 29.4

Deformity Etiology Correction Type A Pregnancy Anterior sheath

Type B Myoaponeurotic

Type C Congenital Rectus abdominis

Type D Obesity Anterior sheath

Beer classication

Nahas classication

laxity

plication External oblique

plication

advancement

plication and rectus advancement

were the following distances: 15 mm at the xiphoid, 22mm above the umbilicus and 16mm below the umbilicus [27].

Mota et al., also measured the linea alba at three different locations (2cm below the umbilicus and 2 and 5cm above the umbilicus) in four time points: pregnancy weeks 35–41, 6th, 12th and 24th week postpartum. They conclude that in primiparous women, the IRD may be considered normal up to values wider than for nulliparous women because the values for IRD obtained were higher than in nulliparous women [35]. We have another classication made by Nahas etal. based on the myofascial deformity and the etiology (Table29.4) [36].

The reported prevalence of DRA or increased IRD varies and may be inaccurate due to the few studies, the different cut-off points for the diagnosis and the lack of consensus on the best measurement location. However, based on Beer study, we consider there is a diastasis when the distance between the two rectus muscles is over

2.2cm.

Table 29.2 Rath classication

Location Width <45years Width >45years Above

umbilicus Umbilicus 27mm 27mm Below umbilicus 9mm 14mm

10mm 15mm

29.2.2.2 Prevalence ofRAD

inPregnancy

The incidence of RAD is higher at the third trimester and in the puerperium and resolves gradually in the postpartum period with individual variability [30, 37, 38], a 33% of women still have RAD at 12months postpartum [32].

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The female pattern of DRA is focused on the umbilicus, but it can be extended supraumbilical and infraumbilical. The prevalence is higher above the umbilicus than below [31, 38]. These results are due to the anatomical disposition of the rectus sheath; the area of change is located at the arcuate line. Above this line there is only an anterior layer formed by the aponeuroses of the external and internal obliques and the transverse preventing rectus separation.

Regarding the number of pregnancies, Rett et al. concluded that, RAD above the umbilicus has similar prevalence between primipara and multipara, however, RAD below is most prevalent in multipara, with a signicant difference [39].

29.2.2.3 RAD Classication

In 2019, the German Hernia Society and the International Endohernia Society established a classication in order to assess and unify RAD treatment [40].This classication includes

1. Length of the rectus diastasis, based on the

European Hernia Society Classication [2]: (a) Subxiphoidal (M1) (b) Epigastric (M2) (c) Umbilical (M3) (d) Infraumbilical (M4) (e) Suprapubic (M5)

2. Width based on Ranney’s classication [41] (a) W1 <3cm (b) W2 3–5cm (c) W3 >5cm

3. Previous abdominal surgery within the width

and length of the RAD

4. Concomitant hernias (epigastric, umbilical,

post-incisional)

5. Number of pregnancies

6. Skin condition (skin laxity and skin folds)

7. Methods of diagnosis (clinical, calipers, ultra-

sound, TC)

8. Severity and localization of preoperative pain

ally appears standing and also when the intra-abdominal pressure increases and reduces its size with the decubitus.

It has also been postulated that the diastasis may alter trunk mechanics, compromise pelvic stability, and change posture, increasing the risk of low back and pelvic girdle pain [42, 43]. Some authors have found a moderate positive and signicant association between RAD and lumbopelvic pain and between RAD and fecal incontinence and pelvic organ prolapse [37, 44].

29.2.3.2 Diagnosis

The main diagnosis is clinical, based on a physical examination, but the ultrasound and calipers are an adequate method to assess the diagnosis. Ultrasonography is an accurate technique to measure RAD above the umbilicus and at the umbilical level [45, 46]. Besides, it is simple, noninvasive and it can be repeated many times. The main drawback is that this procedure depends on the radiology skills [27]. Ultrasound has replaced CT as the method of choice, due to the expense and the radiation exposure.

Regarding surgery planication, the most important entity we have to discard is a concomitant midline hernia. In obese patients, where physical exploration is more problematic, a CT before surgery should be performed.

29.2.4 Anesthetic Considerations

Anesthetic considerations about rectus abdominis diastasis are the same as the ones mentioned before regarding umbilical hernia. We can perform regional or general anesthesia and in case of choosing the later, add a TAP blockage in order to reduce painkillers intake. There is still no consensus regarding the best choice, but both seem adequate alternatives. When the repair is performed through laparoscopic approach, general anesthesia is required.

29.2.3 Preoperative Evaluation

29.2.3.1 Physical Examination

The most frequent presentation is an asymptomatic fusiform bulge above the umbilicus. It usu-

29.2.5 Surgical Technique

Treatment of RAD is challenging, because there is still a lack of consensus, without guidelines

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resuming the indications or comparing the different surgical techniques. Besides, there are scant studies with high scientic quality.

We have to consider that RAD is not a true hernia; so, there is no risk of strangulation. That is why most patients undergo conservative treatment, and surgery is mainly performed due to cosmetic reasons, severe functional impairment, or when there is a concomitant hernia.

Conservative management based on exercise and weight loss is usually the rst management step. Sometimes the help of a physiotherapist is required, with some training programs [42]. Numerous exercise regimens have been described, but an accepted protocol for therapeutic exercises has not been published so far. These exercises are focused on strengthening the rectus muscles. There is a nonsurgical 18-week program named “The Tupler Technique.” This program consists ofwearing an abdominal splint, which helps to repair the connective tissue by relieving the pressure on the zone [47].

Several papers have found an improvement on RAD with exercise [42, 48], showing that pregnant women who underwent exercises after delivery had signicantly lower RAD compared to sedentary women (12.5% vs 90%) [49]. But, some authors, instead, do not nd any signicant differences between groups who underwent exercise program and sedentary ones [50].

Another technique that has also been described is the neuromuscular electrical stimulation. This procedure ameliorates the DRAM in postnatal women and, when combined with exercise, its effect increases [51].

Physiotherapy achieves a limited improvement in the size of the diastasis and its symptoms. Surgery, instead, signicantly improves pain and abdominal wall function. Physiotherapy should be an alternative in patients who are unable to undergo surgery, and overall, an addition to surgical intervention in order to achieve a satisfying functional outcome [52].

29.2.5.1 Patient Positioning

Similar to umbilical hernia surgery, there is no special arrangement. The patient is placed in the operating table mattress in supine position, with

arms open, and xed to avoid shifting although no angulation of the table is usually required.

29.2.5.2 Procedures Step by Step

In symptomatic patients, when conservative treatment is not enough or the diastasis is wider than 3 cm, surgery is the elective treatment. Sometimes, there is no correlation between the clinical features and the site of widest diastasis. In many patients, the site of highest abdominal protrusion does not correlate with the biggest IRD, so the decision whether or not undergo surgery is more inuenced by the upright examination of the patient [28].

Regarding surgery, there are different approaches varying from the type of suture, the use of mesh, the number of layers of suture, etc. A review performed with 1591 patients did not nd any signicant differences between surgical procedures [52].

When there is excess skin, rectus plication is combined with abdominoplasty, but a systematic review performed with both techniques concluded that most evidence is of low quality and RCT are required to make some conclusions [53]. When there is no excess skin, surgery may be performed through open, laparoscopic or hybrid approach. Notably, the main indications for surgery are cosmetic reasons, but the 85% of surgical interventions are open procedures [52].

29.2.5.3 Surgical Technique

– Open approach – Open repair begins with a phannenstiel inci-

sion, with a superior ap dissection toward

xiphoidal process (Fig. 29.9). If we do not

associate an abdominoplasty to the rectus pli-

cation, the incision may also be performed on

the midline. However, better esthetical results

are obtained with the phannenstiel incision.

When the ap is dissected, we mark the rectus

sheath with a purple line (Fig.29.10) in order

to signalize the suture path.

– Once the dissection is performed, the repair

may vary. When the RAD is mild to moderate,

suture plication alone is a good option

(Fig.29.11 and Video 29.2). Meanwhile, if the

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Fig. 29.9 Superior ap dissection

Fig. 29.10 Rectus sheath marked in purple

Fig. 29.11 Rectus abdominis plication

C. Tuero et al.

RAD is moderate to severe, we can plicate the

rectus sheath and place a mesh.

1. Tissue-Suture Repair

An RCT comparing two-layer linea alba plication versus one layer using nonabsorbable suture found no differences regarding outcomes, but did nd a recurrence rate of 33% when barbed suture was used [54].

(a) Simple suture

In this technique, the anterior sheath of the abdominis rectus is sutured in a single-continuous layer with slow-absorbable suture or a permanent one. The length of the closure goes from de xiphoidal process to 2cm above the pubic symphysis.

(b) Two-layer technique

The two-layer repair is based on one absorbable interrupted suture and over it a running continuous for further reinforcement and bury the knots from the rst layer [55].

2. Repair with mesh (a) Preaponeurotic (onlay mesh)

The mesh is usually placed over the rectus anterior sheath, covering the whole abdominal wall: from the costal margin to the pubic symphysis and until the anterior axillar line bilaterally. It is xed with absorbable suture or tuckers.

(b) Rives (Retrorectus repair)

In this technique, a dissection behind the rectus is performed separating it from its posterior sheath, in order to put the mesh retrorectal. Before placing the mesh, we can plicate the posterior sheath in the midline and afterward, suture as well the anterior sheath. The main disadvantage of this procedure is the risk of developing an incisional hernia due to the opening of the anterior rectus sheath.

The current literature evidence is not enough to determine which technique is better, but there is an RCT that concludes that

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absorbable midline plication was as efcient as nonabsorbable [56].

– Laparoscopic technique

Minimally invasive procedures are recommended when skin removal is not necessary [57]. There are several approaches, from hybrid to robotic going through laparoscopic [57]. These techniques are not frequently used, because they are technically difcult, and they require advanced laparoscopic surgical skills. The placement of the trocars changes depending on the type of the procedure, but they are usually placed suprapubic and periumbilical.

– ELAR (endoscopic-assisted linea alba recon-

struction): This hybrid procedure consists of performing and umbilical skin incision with a cranial extension of 2–3 cm. The space between the subcutaneous tissue and the anterior rectus sheath is widely dissected. Afterward, the anterior rectus sheath is open at 2cm from the medial margin till the xyphoid process. Then, this anterior sheath is sutured with continuous, nonabsorbable suture and a mesh is placed above. The mesh is sutured to the incision margin of the anterior rectus sheath with continuous suture. After the procedure, it is recommended to locate a redon and also to wear binders for 6weeks after the operation [58].

– THT (Endolaparoscopic reconstruction of the

abdominal wall midline with linear stapler): Two trocars are placed to create pneumoperitoneum and discard or remove adhesions to the abdominal wall. Afterward, an umbilical incision is performed, the umbilicus is disinserted, and the anterior fascia of the two rectus abdominis is open. The space is dissected, leaves the rectus muscles laterally, and each branch of an endostapler is inserted inside each sheath of the rectus in cranial direction. Then a second stapler charge is used and once we have enough space, we can insert a single port access and continue the section with the staplers cranially, up to the costal margin. Then, we can place a mesh and create pneu-

moperitoneum again to check the correct execution of the surgery [59].

– eTEP (extended totally extraperitoneal

repair): This technique starts placing an epigastric trocar on the left side to insert the camera and dissect the retrorectus space. Once dissected, the camera is shifted to the right epigastric side to dissect the contralateral retrorectus area. Afterward, two more trocars are placed and the diastasis is sutured. A medium weight macroporous polypropylene mesh is placed, and no xation is usually needed.

29.2.5.4 Surgical Modications: Umbilical Hernia Concomitant withRectus Abdominis Diastasis

Rectus divarication and concomitant umbilical hernia are often associated and consequently, they need a combined repair. Most patients are women with a normal BMI in a good physical shape handicapped by the bulge and the weakness of the abdominal wall and male patients with abdominal obesity. Concomitant RAD was dened as the most important risk factor for hernia recurrence (31 vs. 8%); so when it is present, it is important to repair the defect. The recommended treatment for these patients is an herniorrhaphy with rectus plication (Video 29.1) and some authors rmly recommend mesh reinforcement due to the high recurrence rate [29]. Sometimes, when there is an excess of infraumbilical skin, an abdominoplasty may be associated to the procedure (Figs.29.12 and 29.13).

Standard abdominoplasty with herniorrhaphy presents a “vascular challenge” with higher risk of complete devascularization of the umbilicus with higher necrosis (4.2%) and higher wound complication rates (11.7% vs. 6.3%) [60, 61]. However, some authors have tried to address this challenge proposing a lateral approach to the hernia leaving the contralateral blood supply or approaching the defect through a midline incision. Another technique is a mini- abdominoplasty, performing a suprapubic incision and dissecting the ap above the abdominal fascia upward,

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