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C. Tuero et al.
toward the xiphoidal process. The umbilical stalk
is disconnected through the dissection so that,
afterward, we can repair the hernia and perform
the rectus plication and the abdominoplasty without periumbilical scarring or risk of umbilical
necrosis. This technique is not possible to be per-
Fig. 29.12 Algorithm for choosing the properly diastasis
technique in postnatal women
formed in obese patients; the ideal ones are
women after pregnancy with RAD and excess of
skin infraumbilical [62].
There are also several endoscopic/laparoscopic procedures (Table29.5) that vary depending on the space dissected to perform the rectus
plication, the trocar placement, the location of
the mesh, etc.
29.2.6 Postoperative Care
About postoperative care, recommendations are
the same to those after umbilical hernia repair.
Besides, 4–6weeks after this surgery, it is recommended to wear an abdominal binder to avoid
seroma [47].
29.2.7 Surgical Complications
andOutcomes
Overall complication rates vary between studies
and were primarily minor and related to the
simultaneously performed abdominoplasty. Only
a few authors reported major complications. The
main overall complications were hematoma and
Fig. 29.13 Algorithm for choosing the properly abdominal wall reconstruction technique in obese patients
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493
Table 29.5
SCOLA (Subcutaneous onlay laparoscopic approach)
REPA (Preaponeurotic endoscopic repair)
Totally endoscopic linea alba repair+preperitoneal
mesh in hernia defect
ELAR (Endoscopic-assisted linea alba reconstruction)
E-TEP (Extended totally extraperitoneal repair)
E-MILOS (Endoscopic mini/less open sublay
technique)
MILAR (Minimally invasive linea alba reconstruction)
TESLAR (Totally endoscopic supraaponeurotic linea
alba reconstruction)
THT (Endolaparoscopic sublay stapler repair)
E-ELHAR-glue (Extended endoscopic hernia & linea
alba reconstruction glue)
LIRA (Laparoscopic intracorporeal rectus
aponeuroplasty)
Endoscopic techniques
seroma formation, wound infection, necrosis of
the skin aps, and hypertrophic scarring [63–65].
Complications were more frequent with the use
of mesh [66]. Regarding the technique, the open
procedure has higher infection rate, and the laparoscopic one has higher incidence of bowel
obstruction/injury and adhesions. Besides, it is
believed that when we perform a plication of the
rectus sheath, the intra-abdominal pressure
increases, decreasing the venous return and
increasing the risk of deep vein thrombosis [67].
However, a systematic review found no deep vein
thrombosis [65]. About recurrence, results differ,
reporting rates from 0 [68] until 40% [69].
Satisfaction was generally reported to be high,
but only few studies provided means of assessing
the level of satisfaction [69].
29.2.8 Conclusions
RAD should not be misclassied as a ventral hernia. This entity is more prevalent between young
women with normal BMI with a history of pregnancies. The diagnosis is clinical, but in obese
patients, whose physical examination is more
challenging, a CT should be performed in order
to discard concomitant midline hernia.
Surgery is often performed due to cosmetic reasons and may be executed through open or laparoscopic approach. The open approach is the most
used technique worldwide, but of late, laparo-
scopic repair has been described and may be used
when there is no excess skin and there is no need
to associate an abdominoplasty. The RAD repair,
regardless of open or laparoscopic approach, consists in one or two-layer rectus sheath plication
and, depending on the size of the defect, places a
mesh. Sometimes, if RAD is concomitant with
umbilical hernia, we have to associate an hernioplasty. RAD concomitant with umbilical hernia is
a risk factor for hernia recurrence.
Take-Home Points
• Rectus abdominis diastasis does not present a
risk of incarceration; so, surgery is usually
performed due to cosmetic reasons.
• It is usually diagnosed through clinical examination, appears as an asymptomatic fusiform
bulge.
• In obese patients, a CT should be performed
before surgery, in order to discard midline hernia associated.
• Supraumbilical diastasis is more prevalent
than infraumbilical.
• If the diastasis is mild to moderate, a one- or
two-layer suture should be enough.
• If the RAD is moderate to severe, we should
place a mesh in order to reinforce the plication.
• RAD plication may be performed with nonabsorbable suture or slow-absorbable with similar results.
• 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.
• More studies are needed to clarify which is the
best surgical treatment for these patients.
• Rectus abdominis diastasis and umbilical hernia are frequently associated.
• RAD is a risk factor for herniorrhaphy recurrence; so, when present, we need to repair it as
well.
• Best treatment is herniorrhaphy with rectus
abdominis plication and mesh reinforcement.
• If there is skin excess associated an abdominoplasty may be also performed.
• The main risk of this technique is the umbilical necrosis.
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Endoscopic Diastasis Recti
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Plication
JuanBellido-Luque andBeatrizBascuas-Rodrigo
30
30.1 Introduction
The abdominal wall is an anatomical structure
responsible for the protection of the abdominal
viscera, maintaining its position during changes
in gravitational forces and increased intraabdominal pressure.
Diastasis recti (DR), also known as Diastasis
of the Rectus Abdominis Muscles (DRAM), is
dened as distancing from the muscular rectus
borders (inter-rectus distance or IRD) in the midline measured in relaxed state greater than 2.2cm
(according to the Beer classication) [1], and it is
characterized by bulging in the anterior wall of
the abdomen when the patient exerts contraction
of the abdominal musculature and/or increase of
the intra-abdominal pressure, which involves a
gradual thinning and widening of the linea alba,
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_30.
J. Bellido-Luque (*)
Minimally Invasive Gastrointestinal Surgery,
Quironsalud Sagrado Corazón Hospital,
Seville, Spain
Hepatobiliopancreatic Surgery Unit, Virgen Macarena
Hospital, Seville, Spain
B. Bascuas-Rodrigo
Gastrointestinal Surgical Department, Infanta Elena
Hospital, Huelva, Spain
combined with a general laxity of the ventral
abdominal wall muscles [2].
This condition appears due to a reduction of
the consistency of the intercrossed bers that
make the linea alba, generating a separation of
both aponeurosis of the rectus abdominis muscles [3], which, therefore, is clinically translated
as the appearance of a bulging of the midline
above and below the umbilicus (if the weakness
also affects the infraumbilical midline) [4] representing an aesthetic and symptomatic problem
that involves deterioration in the functions of the
abdominal wall muscles where patients can experience similar complaints as patients with ventral
hernias, such as lower back pain, functional, and
cosmetic impairment, although diastasis recti
does not pose any threat of strangulation [5, 6].
Diastasis recti is frequently misclassied as a
primary ventral hernia, though the musculofascial continuity of the midline and subsequent
absence of a true hernia sac is what sets this condition apart from a ventral hernia.
There is currently no consensus as to the denition and classication of diastasis recti. There
are only two studies, which try to dene diastasis
recti and classify it depending on the width of the
separation between the muscles. Beer et al.
dened the normal width from which the diastasis recti is considered, in 150 nulliparous women
between the ages of 20 and 45, using ultrasound
(Table30.1). Therefore, there is a physiological
distance between the two rectus muscles.
© 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_30
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J. Bellido-Luque and B. Bascuas-Rodrigo
Table 30.1
Level
Xiphoid 10 15
3cm above
umbilicus
2cm below
umbilicus
Beer classication
Normal width of the linea alba
Age<45years Age>45years
27 27
9 14
Diastasis recti occurs most frequently during
pregnancy, and 12months postpartum up to 33%
of women still experience diastasis [7]. Diastasis
recti is a common and frequent pathology during
pregnancy (specially third trimester) and puerperium, with a 30–70% [8] prevalence. DRAM usually regresses spontaneously after childbirth in
most women. However, it can be permanent in
15% of the patients, especially in multiparous
women. It is important to remember that RD is an
important mechanism in that the organism adapts
to the growth of the pregnant uterus, but when it
persists a year after giving birth, it can no longer
improve (and, on the contrary, it will be aggravated by any cause that increases the abdominal
pressure) [9].
Other risk factors for DR appearance, with
uniform distribution between both sexes, are
weight gain or active practice of sport activities
that imply an intense use of the abdominal
muscles.
The symptomatology of these patients
includes low back pain without other apparent
clinical causes (70.2%), empirically expressed as
the reduction of trunk exion capacity, and disorders related to “abdominal prolapse" (93.6%),
including meteorism, slow transit, abdominal
pain and increased the sensitivity of the abdominal wall to traumas, as well as urinary incontinence (44.42%), mainly, but not exclusively, of
effort.
Until very recent times, DR has been considered as an almost exclusively aesthetic condition
and their treatment has been conducted to plastic
surgeons, who employed techniques such as
abdominoplasty, which were not always a correct
indication for this type of patients.
At present, there is no consensus among the
international surgical community on the surgical
treatment of diastasis recti regarding indications
or surgical technique.
Currently, there is neither consensus on the
preferred surgical management of diastasis recti,
otherwise, the most commonly used surgical
technique is the plication of the supercial aponeurosis of both recti muscles [10, 11], by way of
an abdominoplasty; thereby achieving the relocation of both muscles to their normal position and
balancing once again all the abdominal wall
musculature.
However, in the recent years, the evolution of
laparoscopic and endoscopic techniques is leading to a mini-invasive approach of thin condition
presenting these approaches as an alternative procedure to the most commonly used techniques
for its treatment.
30.2 Patient Selection
Nowadays, the most accepted surgical indications of diastasis recti are (Table 30.2) as
follows:
– Presence of symptoms: a negligible propor-
tion of patients suffering from diastasis recti
have discomfort at this level, which is
increased with abdominal movements.
– Esthetic deterioration: with the contraction
of the abdominal muscles and standing, a
lump appears, above all in epigastric place.
This lump is caused by the bulging of the
weakened linea alba, which could lead to a
serious esthetic defect. This esthetic problem
is even more evident in young multiparous
women: surgical correction is more frequently
employed in such women.
Table 30.2
General indications Specic indications
>2 cms DR size No fatty tissue/skin excess
Symptomatic DR Symptomatic midline hernia
Sthetic
deterioration
DR Diastasis Recti
Endoscopic rectus plication indications
associated
No previous mesh in “onlay”
position
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499
– Association with a symptomatic umbilical
hernia: this problem occurs in those patients
with a symptomatic umbilical hernia, associated with diastasis recti above and/or below
the umbilicus. If we surgically correct just the
hernia, we will be correcting the defect on
anatomically weak tissue, which is the damaged linea alba. As a consequence, the probability of a hernia recurrence could increase,
and the esthetic result would be uncertain.
Therefore, in the case of the co-existence of
diastasis recti and a symptomatic umbilical
hernia, the simultaneous correction of both
pathologies would be recommended. There
are currently no studies published on the minimally invasive surgical treatment of diastasis
recti associated with umbilical hernias.
Treatment of DRAM, associated or not with
abdominal wall hernias, in patients with excess
skin is usually performed by a large transverse
incision in the lower abdomen associated with
dermolipectomy [12–14]. Plication techniques
are the most commonly used and may or may not
be associated with mesh placement. However,
there is a group of patients in whom there is no
need for skin resection, in which conventional
operation with midline longitudinal incisions
results in unfavorable results from the aesthetic
point of view [15, 16].
In order to improve these results, in the 1990s,
the rst alternatives of DRAM correction with
the use of endoscopic techniques without the
need for large cutaneous incisions were described
[17, 18].
According to these facts, we propose as candidates for this endoscopic technique those patients
that suffered from diastasis recti associated to
primary midline hernias, which were 2 cm or
larger in diameter.
midline abdominal bulge following pregnancy is
usually diagnostic.
Physical examination can conrm the diagnosis based on a midline bulge above or below the
umbilicus that is amplied by having the patient
lie at and perform a straight leg raise [19].
Conrmation of rectus diastasis can be made
using computed tomography (CT), magnetic resonance imaging, or ultrasound, but these tests are
usually not necessary.
30.3.2 Imaging Tests
For the study of diastasis recti, imaging methods
such as CT scan or ultrasound have been
employed (Fig.30.1).
The CT scan has the advantage of being able
to use bony ridges for the measurement of the
separation of the rectus muscles [20].
The advantages of using ultrasound are that it
is a noninvasive method, cheap, and without
exposure to radiation [21]. At the same time,
ultrasound is sure to measure the real distance of
the separation of the rectus muscles [21].
30.3.3 Markings
Before surgery, we mark the following landmarks
(Figs.30.2 and 30.3):
30.3 Preoperative Evaluation
30.3.1 Physical Examination
The diagnosis of rectus recti is made on the history and physical examination. The presence of a
Fig. 30.1 CT scan: 4 cm size infraumbilical diastasis
recti
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Fig. 30.2 Preoperative view in rectus diastasis and
umbilical hernia
Fig. 30.3 Diastasis and umbilical hernia (Continous line)
with incision locations. Subcutaneous dissection limits
(Dotted line)
J. Bellido-Luque and B. Bascuas-Rodrigo
30.5 Surgical Technique
30.5.1 Patient Positioning
The patient is positioned in the supine position,
slightly in the Trendelenburg position, to avoid
the subcutaneous dissemination of the gas toward
the chest wall and the possible appearance of
subcutaneous emphysema. Both arms and legs
are open. The surgeon is located between the legs
of the patient, the assistant on his right, and the
surgical nurse on the left.
30.5.2 Procedure Step by Step
A 10mm incision is made in the suprapubic midline and a space is created between the subcutaneous cellular tissue and the supercial
aponeurosis of the linea alba using retractors
(Fig. 30.4). In the case of a previous caesarian
scar, the incisions will be made on this scar,
therefore not adding any esthetic deterioration to
the patient.
Once the suprapubic linea alba is exposed, a
10 mm BTT trocar is introduced (Blunt Tip
Trocar, Covidien©) for the optic. Sliding on the
supercial aponeurosis and under direct vision,
two 5mm trocars are placed, one on each side of
the BTT trocar separated by around 5 cm
– Subxiphoid area
– Suprapubic optic trocar access
– Left and right 5mm trocar accesses
– Diastasis recti area
– Dissection area
30.4 Anesthetic Considerations
The patients are subjected to general anesthetic
and antimicrobial prophylaxis with 1 g of
Amoxicillin-Clavulanic in the induction of the
anesthesia.
Fig. 30.4 Open midline fascial dissection
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(Fig. 30.5); 8–12 mmHg CO2 pressure is used,
being sufcient to maintain an adequate working
space.
Under endoscopic vision, the supraaponeurotic space is dissected, exposing the linea
alba and both supercial aponeurosis until reaching the umbilical region (Video 30.1).
The umbilicus is deinserted above the hernial
sac, reintroducing this into the intra-abdominal
compartment, and the supraaponeurotic dissection is resumed above the umbilicus until the subxiphoid region. It is important that the lateral
dissection does not exceed more than 3cm from
the lateral rim of both rectus muscles to minimize
the probability of ischemic skin and subcutaneous cellular tissue and the appearance of postoperative seroma (Figs.30.6 and 30.7).
Subsequently, and once all of the linea alba
has been dissected until the subxiphoid region
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Fig. 30.7 Rectus diastasis
Fig. 30.5 Trocars placement
Fig. 30.6 Endoscopic view
Fig. 30.8 Mesh placement through the defect
and until both supercial aponeurosis, we introduce a prosthesis (Polypropylene on the parietal
face and PTFE on the visceral face, VentralexTM
hernia patch, Bard©) through the BTT trocar
(Fig.30.8).
The mesh will be placed in every patient in
order to perform a complete abdominal wall reparation and avoid recurrence.
The size of the mesh depends on the size of
the defect. In defects of 2cm size, the prosthetic
size will be 4.3× 4.3 cm. For bigger defects, a
size of 6.4×6.4cm will be selected.
Once placed in the preperitoneal space, we x
both arms of the polypropylene mesh on the edge
of the defect with two reabsorbable sutures
(Fig.30.9).
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