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30 Flap Reconstruction of the Abdominal Wall
321
on the deep inferior epigastric system (DIEP).
These fl aps can be transferred based on either the
DIEP vessels through microsurgical technique
or the external iliac for a macrovascular anastomosis. Cipriani et al. describe a series of 15
abdominal wall transplants with three episodes
of rejection salvage with modulating immunosuppression and two fl ap losses due to vascular
thrombosis [ 9 ].
Abdominal wall transplantation is a fi eld
in its early stage. It has virtually eliminated
the issue of donor site morbidity and future
advances will likely focus on improved recipient site function. To this end, refi ning fl ap design
even further to include dynamic neurotized fl ap
transfers that can provide stable abdominal wall
contour and preserved truncal core muscular stability will represent a new era in abdominal wall
reconstruction.
Summary
Most abdominal wall defects do not require formal fl ap reconstruction since there is often redundancy in both the musculofascia and skin. When
fl aps are required, it is generally best to fi rst consider local, then regional, and fi nally distant fl aps.
Regional pedicle fl aps are limited by their respective arc of rotation and may not reach the defect,
this is particularly true for hypogastric defects.
When free fl aps are required the thigh and back
are generally the best donor locations. The location of recipient vessels and fl ap pedicle length
are important to consider for these complex
reconstructions. Vein grafts are often required to
“extend” the length of the free fl ap pedicle in
order to reconstruct defects, particularly in the
upper abdomen. Reconstruction of composite
defects that include loss of musculofascia and
overlying skin require special attention. In general, we fi nd that the musculofascia is best reconstructed with mesh and component separation
rather than with fascia from the fl ap. Flap reconstruction of abdominal wall defects is often complex and is best performed with a multidisciplinary
approach including a plastic and reconstructive
surgeon.
References
1. Fortelny RH, Hofmann A, Gruber-Blum S, PetterPuchner AH, Glaser KS. Delayed closure of open
abdomen in septic patients is facilitated by combined
negative pressure wound therapy and dynamic fascial
suture. Surg Endosc. 2014;28(3):735–40.
2. Deeken CR, Eliason BJ, Pichert MD, Grant SA,
Frisella MM, Matthews BD. Differentiation of biologic scaffold materials through physicomechanical,
thermal, and enzymatic degradation techniques. Ann
Surg. 2012;255(3):595–604.
3. Glass GE, Murphy GF, Esmaeili A, Lai LM,
Nanchahal J. Systematic review of molecular mechanism of action of negative-pressure wound therapy.
Br J Surg. 2014;101(13):1627–36.
4. Booth JH, Garvey PB, Baumann DP, Selber JC,
Nguyen AT, Clemens MW, Liu J, Butler CE. Primary
fascial closure with mesh reinforcement is superior to
bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg. 2013;217(6):999–1009.
5. Disa JJ, Goldberg NH, Carlton JM, Robertson BC,
Slezak S. Restoring abdominal wall integrity in
contaminated tissue-defi cient wounds using autologous fascia grafts. Plast Reconstr Surg. 1998;101(4):
979–86.
6. Khouri JS, Egeland BM, Daily SD, Harake MS,
Kwon S, Neligan PC, Kuzon Jr WM. The keystone
island fl ap: use in large defects of the trunk and
extremities in soft-tissue reconstruction. Plast
Reconstr Surg. 2011;127(3):1212–21.
7. Selber JC, Angel Soto-Miranda M, Liu J, Robb
G. The survival curve: factors impacting the outcome
of free fl ap take-backs. Plast Reconstr Surg.
2012;130(1):105–13.
8. Lin SJ, Butler CE. Subtotal thigh fl ap and bioprosthetic mesh reconstruction for large, composite
abdominal wall defects. Plast Reconstr Surg.
2010;125(4):1146–56.
9. Selvaggi G, Levi DM, Cipriani R, Sgarzani R, Pinna
AD, Tzakis AG. Abdominal wall transplantation: surgical and immunologic aspects. Transplant Proc.
2009;41(2):521–2.
Diagnosis and Management of Diastasis Recti
Maurice Y. Nahabedian
3 1
Introduction
Contour abnormalities of the anterior abdominal
wall can present in various forms based on the
specifi c structural anatomic deformity . The most
common and notable is the abdominal wall hernia that is the result in a fascial defect with protrusion of abdominal viscera or omentum.
However, contour abnormalities may also present
without a fascial defect and are defi ned and classifi ed as a bulge due to laxity or attenuation of the
supportive layers of the anterior abdominal wall.
The location of the bulge can be along the anterior rectus sheath or the linea alba. Bulges over
the lateral abdominal wall or anterior rectus
sheath may be due to denervation of the abdominal wall musculature or to a violation of the anterior rectus sheath. Bulges over the midline
abdominal wall without a fascial defect are usually the result of attenuation of the linea alba with
a separation of the rectus abdominis muscles and
is referred to as diastasis recti. This chapter will
focus on the etiology, diagnosis, and management of diastasis recti.
M. Y. Nahabedian , M.D., F.A.C.S. (*)
Department of Plastic Surgery , Georgetown
University Hospital , 3800 Reservoir Rd NW ,
Washington , DC 20007 , USA
DrNahabedian@aol.com
e-mail:
A n a t o m y
The aponeurotic layers of the anterior abdominal
wall include the linea alba, anterior rectus sheath,
posterior rectus sheath, and the external oblique
fascia (Fig. 31.1 ). The anterior rectus sheath and
the linea alba are composed of collagen fi bers
arranged in an interwoven lattice. The width and
thickness of these structures will vary along the
surface and regions of the anterior abdominal wall
[ 1 ]. The width of the linea alba ranges from 11 to
21 mm between the xiphoid process and the
umbilicus and decreases from 11 to 2 mm from
the umbilicus to the pubic symphysis. The thickness of the linea alba ranges from 900 to 1200 μm
between the xiphoid and the umbilicus and
increases from 1700 to 2400 μm from the umbilicus to the pubic symphysis. The thickness of the
anterior rectus sheath ranges from 370 to 500 μm
from the xiphoid to the umbilicus and increases to
500–700 μm from the umbilicus to the pubic symphysis. The posterior rectus sheath is slightly
thicker than the anterior rectus sheath above the
umbilicus at 450–600 μm, but is thinner from the
umbilicus to the arcuate line at 250–100 μm
(Fig. 31.2 ). The vascularity of the anterior rectus
sheath and linea alba is derived from the perforating branches of the deep and superior inferior epigastric vessels as well as the superfi cial epigastric
vessels. The loose areolar fascia over the surface
of the anterior sheath and linea alba is highly vascularized and important to preserve (Fig. 31.3 ).
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_31
323© Springer International Publishing Switzerland 2016
324
M.Y. Nahabedian
Serratus anterior
Latissimus dorsi
Pectoralis major
abdominal part
Linea alba
Exterior oblique
abdominal muscle
Umbilicus
Anterior superior
iliac spine
Superficial fascia
outer layer
(panniculus adiposus)
muscle
muscle
muscle
Exterior oblique
abdominal muscle
aponeurosis
Spermatic
cord
Fundiform
ligament of penis
Pectoralis major muscle
Serratus anterior muscle
Costoxiphoid ligament
External oblique
abdominal muscle
Rectus sheath, anterior
layer
Anterior superior iliac
spine
Intercrural fibers
Medial crus of
superficial inguinal
ring
Cremaster muscle
Reflected inguinal
ligament
Suspensory ligament
of penis
Fig. 31.1 Illustration of the anterior abdominal wall demonstrating the anterior rectus sheath and the linea alba
Fig. 31.2 Photograph of the anterior abdominal wall
demonstrating the posterior rectus sheath and linea alba
following elevation of both rectus abdominis muscles
Fig. 31.3 The vascularized loose areolar fascia on the
surface of the anterior rectus sheath is demonstrated
31 Diagnosis and Management of Diastasis Recti
325
Serratus anterior
Transversus
abdominis
Internal oblique
External oblique
Aponeurosis of
the external
oblique
Fig. 31.4 The muscles and fascial layers of the anterior abdominal wall
The muscular layers of the anterior abdominal
wall are equally important and comprised of the
paired rectus abdominis muscles as well as the
paired external, internal, and transverse oblique
muscles (Fig. 31.4 ). The forces exerted by these
muscles, as well as intra-abdominal pressure, can
place tension on the midline linea alba and result
in separation or attenuation resulting in a diastasis recti.
92 women and demonstrated that stretching of
the linea alba is limited to 5 cm in 82% of patients
and can extend up to 6 cm in 2% [ 3 ]. Abdominal
laxity beyond that is usually due to attenuation of
the anterior rectus sheath.
Liaw has compared the inter-rectus distance
between nulliparous women and postpartum
women and demonstrated a doubling of the interrectus distance from approximately 0.5–1.0 cm
to 1.2–2.3 cm using ultrasound-assisted measurements [ 2 ]. In the postpartum group, there was a
Etiology
gradual decrease in the distance over time; however, baseline values were never achieved at
The etiology of diastasis recti is typically the
result of increased intra-abdominal pressure that
usually occurs following pregnancy; however,
obesity and prior abdominal operations can also
be the cause (Fig. 31.5 ). It has been demonstrated
that the intra-abdominal pressures associated
6-month assessments. Pregnancy also has a notable effect on the strength of the abdominal musculature with nulliparous women having 5/5
strength of the trunk fl exors and rotators compared to 4/5 in women that were 6 months
postpartum.
with pregnancy will increase the distance between
the rectus abdominis muscles [ 2 ] (Fig. 31.6 ). It
has been observed that the myofascial laxity
Diagnosis
associated with diastasis recti is both vertical and
horizontal and can involve the entire anterior
abdominal wall and not just the linea alba [ 3 ].
Bauman has measured the inter-recti distance in
The diagnosis of diastasis recti is made on physical examination and presents as a midline bulge
that can occur above or below the umbilicus
Pectoralis major
Linea alba
Tendinous
intersection
Rectus abdominis
Inguinal ligament
(formed by free
inferior border of
the external oblique
aponeurosis)
326
Fig. 31.5 Separation of the
paired rectus abdominis
muscles associated with
pregnancy is illustrated
M.Y. Nahabedian
abdominus
Obliquus externus
Obliquus internus
Transversus
Rectus
abdominus
Obliquus externus
Obliquus internus
Transversus
Rectus
Linea
alba
Aponeuroses
of the obliqui
and transversus
Linea
alba
Aponeuroses
of the obliqui
and transversus
Fig. 31.6 Illustration demonstrating a normal and widened inter-rectus distance associated with a rectus diastasis
31 Diagnosis and Management of Diastasis Recti
327
Fig. 31.7 A woman with rectus diastasis is depicted
demonstrating the midline bulge
(Fig. 31.7 ). It is amplifi ed by having the patient
lie fl at and perform a straight leg raise.
Confi rmation of rectus diastasis can be made
using CT, MRI, or ultrasound, but these tests are
usually not necessary [ 4 – 6 ]. All imaging modali-
ties can be used to measure the inter-rectus
distance, however, they are more often obtained
to assess the success of the repair.
Classifi cation
There are three classifi cation systems that have
been described for rectus diastasis. The Nahas
classifi cation is based on the myofascial deformity and the etiology [ 7 ] (Table 31.1 ). The Rath
classifi cation is based on the level of the attenuation relative to the umbilicus and the patient
age [ 8 ] (Table 31.2 ). The Beer classifi cation is
based on the normal width of the linea alba as
determined from 150 nulliparous women [ 9 ]
(Table 31.3 ).
Table 31.1 The Nahas classifi cation based on the myofascial deformity
Deformity Etiology Correction
Type A Pregnancy
Type B Myoaponeurotic
laxity
Type C Congenital
Type D Obesity
Table 31.2 The Rath classifi cation based on the level of
the attenuation relative to the umbilicus and the patient age
Level Age < 45 (mm) Age > 45 (mm)
Above umbilicus 10 15
At umbilicus 27 27
Below umbilicus
Table 31.3 The Beer classifi cation based on the normal
width of the linea alba
Normal width of the linea alba (mm)
Level Width
At Xiphoid 15
3 cm above umbillicus 22
2 cm below umbillicus 16
9
Anterior sheath
plication
External oblique
plication
Rectus abdominis
advancement
Anterior sheath
plication and
rectus abdominis
advancement
14
documented. Visualization of the midline diastasis
is easily demonstrated with the patient supine performing a straight leg raise. Ideal candidates for a
diastasis repair include patients with an isolated
diastasis, low BMI, and no prior abdominal operations. Less ideal candidates include obese patients,
extensive comorbidities, desire to have more children, and multiple abdominal procedures.
The Initial Consultation
During the initial consultation , it is important to
obtain a thorough history and physical examination. Relevant information related to prior abdominal operations, previous pregnancies, and history
of weight gain is obtained. On physical examination, abdominal scars, concomitant hernias,
abdominal pannus, and extent of the diastasis are
Indications for Surgery
Indications for diastasis repair are based on symptoms and physical fi ndings [ 10 ]. Many patients
with diastasis recti will have discomfort at the
level of the defect. This is often exacerbated with
movement. The appearance of the abdominal wall
is often noticeably distorted in women with
328
M.Y. Nahabedian
diastasis recti. The midline bulge is exacerbated
with muscle contraction and is common in multiparous women. The pathophysiology of diastasis recti often results in the development of an
umbilical hernia as well. Correction of the umbilical hernia alone without correction of the diastasis
is often associated with recurrence due to the poor
quality of surrounding tissue.
Not all patients will require surgery for correction. Time and conservative measures such as
core strengthening are often useful. Surgery is
usually indicated in women that have failed conservative measures and when the degree of rectus
diastasis interferes with activities of daily living
and is bothersome.
Treatment
There are several options for management of diastasis recti ranging from exercise to simple plication
of the linea alba and anterior rectus sheath to more
advanced excisional techniques with or without the
use of mesh. Endoscopic and laparoscopic techniques can also be used i n select situations where a
small midline hernia is present as well. In many
cases, an abdominoplasty is also indicated.
Exercise
The benefi t of exercise to prevent or correct diastasis recti is somewhat controversial and has been
associated with mixed results [ 11 ]. Preventative
exercise protocols include walking and abdominal core strengthening. Corrective exercise protocols include core strengthening, aerobic activity,
and neuromuscular re-education. Although mild
benefi t was noted in terms of inter-rectus distance
from some studies, there was insuffi cient evidence to recommend exercise as a means of preventing or treating rectus diastasis.
Abdominoplasty
In most women with mild-to-severe diastasis recti,
the overlying adipocutaneous component of the
anterior abdominal wall has also become stretched
and fl accid. An abdominoplasty is typically performed in these women to further improve the
abdominal contour [ 12 – 14 ]. This is usually achieved
using a low transverse incision incorporating the
aesthetic subunits of the abdominal wall (Fig. 31.8 ).
The anterior superior iliac crest is palpated and
marked bilaterally. A curved low transverse line is
drawn connecting the two points with the midpoint
just above the pubic hairline. The incision extends
to the anterior rectus sheath. The adipocutaneous
tissues are elevated off the anterior rectus sheath
preserving the vascularized loose areolar layer. The
umbilicus is incised and preserved on its stalk. The
undermining usually extends to the mid to upper
abdomen and correlates to the length of the diastasis. The diastasis repair is commenced at this juncture utilizing a variety of techniques that will be
described in the following sections. Following the
repair, the patient is gently fl exed at the hip and the
excess skin is redraped and then excised. One or
two closed suction drains are placed and the skin is
sutured with a 3-layer closure.
Plication with or Without Excision
For mild-to-moderate diastasis recti, midline plication of the linea alba can be considered
(Fig. 31.9 ). With this technique, the attenuated
linea alba is delineated. Contraction of the attenuated fascia can be achieved using a low-set cautery device to create thermal contraction.
Following this, a 2-layer plication can be achieved
using an absorbable or nonabsorbable suture. The
triangular suture technique incorporating the lateral edges of the fascia and the midline of the
posterior rectus sheath is frequently used [ 15 ].
Excision of the midline fascia can also be considered when severely attenuated (Fig. 31.10 ).
Studies evaluating absorbable and nonabsorbable sutures have demonstrated no signifi cant difference in the inter-recti distance as measured by
CT scan 6 months following correction [ 16 ]. The
fi rst layer of sutures was usually an interrupted
fi gure-of-8 and the second layer of suture was running continuous to reinforce the repair and to bury
to suture knots from the fi rst layer. In patients with
31 Diagnosis and Management of Diastasis Recti
Separate
skin
Scars
Resection
Incision
Fig. 31.8 A schematic illustration of an abdominoplasty demonstrating the location of the scar and degree of
undermining
329
Fig. 31.9 Midline plication of the rectus abdominis muscles
330
M.Y. Nahabedian
Fig. 31.10 Escision of redundant fascia and triangulation sutures to reapproximate the rectus abdominis muscles
signifi cant laxity of the anterior rectus sheath, lateral plication can also be performed on both sides
to further improve and tighten the abdominal contour. A 2-layer repair technique is usually performed using an absorbable interrupted suture
followed by a running continuous suture for further
reinforcement. The length of this repair can extend
from approximately 2 cm below the costal margin
to approximately 2 cm above the pubic bone.
riorly and also extends to the anterior axillary
line bilaterally. Non-resorbable mesh is usually
preferred in these cases because the patients are
typically healthy with few, if any, comorbidities
and are at low risk of infection or adverse outcome. The edge of the mesh is typically anchored
in an interrupted manner using an absorbable
suture. The central portion of the mesh is secured
in a quilting pattern also using an interrupted
absorbable suture. A sing le closed suction drain
is used.
Plication and Onlay Mesh
The use of a mesh can be considered in cases of
extensive laxity requiring a lengthy repair [ 12 ].
Typically a resorbable or non-resorbable mesh is
selected and placed over the anterior rectus
sheath. It is trimmed to fi t the dimensions of the
anterior abdominal wall and extends from the
costal margin superiorly to the pubic region infe-
Figures 31.11 , 31.12 , 31.13 , 31.14 , 31.15 ,
31.16 , 31.17 , 31.18 and 31.19 illustrate a multipa-
rous woman with severe rectus diastasis and skin
laxity. The preoperative photographs are illustrated
(Figs. 31.11 and 31.12 ). The plan is to plicate, rein-
force with non-resorbable mesh and excise the
redundant skin and fat. The lower abdominal skin
is marked and incised extending from one anterior
superior iliac crest to the other. Dissection proceeds
31 Diagnosis and Management of Diastasis Recti
331
Fig. 31.11 Preoperative image of a multiparous woman
with diastasis recti
Fig. 31.12 Lateral view demonstrating signifi cant
abdominal laxity and bulge
the amount of skin redundancy and then dividing it
along the midline (Fig. 31.16 ). The excess skin is
excised and the remaining skin is closed in a 3-layer
fashion (Fig. 31.17 ). Six- month follow-up demon-
strates a signifi cant improvement in abdominal
contour without recurrence (Figs. 31.18 and 31.19 ).
Retrorectus Repair with Mesh
In cases of moderate-to-severe diastasis recti, a
retrorectus repair can be considered [ 17 ]. With this
technique, an anterior paramedian incision is made
adjacent to the lateral aspect of the linea alba
extending from the xiphoid to the pubic bone. The
medial aspect of the rectus abdominis muscle is
appreciated and the muscle is undermined preserv ing the vascularity and laterally based innervation.
The rectus abdominis muscle is completely
released from the posterior rectus sheath. The
degree of redundancy of the posterior rectus sheath
is approximated and then plicated along its midline using a resorbable suture in an interrupted
manner (Fig. 31.20 ). The repair can then be rein-
forced using a resorbable or nonresorbable mesh.
The mesh is placed on the surface of the posterior
rectus sheath in the retrorectus space and anchored
with interrupted absorbable sutures. The purpose
of the mesh is to offl oad the pressure placed on the
midline fascial repair. The umbilical stalk is passed
through an opening created in the mesh. Following
the repair, the released rectus abdominis muscles
are aligned in their natural location with the medial
edge of both muscles positioned along the midline.
The anterior rectus sheath is repaired using interrupted absorbable sutures.
to the anterior rectus sheath and then extends in a
cephalad direction toward the xiphoid process preserving the loose areolar layer (Fig. 31.13a ). The
attenuated midline fascia is delineated and then plicated using the 2-layer technique. Plication lateral
to the midline on both sides can also be considered
in severe cases (Fig. 31.13b ). The degree of abdom-
inal tightening is demonstrated on Fig. 31.14a, b . A
synthetic mesh is trimmed to fi t the anterior abdominal surface and then sutured at the periphery and
centrally in an interrupted technique (Fig. 31.15 ).
The abdominoplasty is performed by fi rst assessing
Endoscopic/Laparoscopic
Luque has described using a totally endoscopic
technique for diastasis repair in patients with a
concomitant midline hernia [ 10 ]. The most com-
mon midline hernia associated with a diastasis is
the umbilical hernia (85%) [ 10 ]. The indications
for total endoscopic repair include midline/
umbilical hernia measuring >2 cm, no prior hernia repair or laparotomy, and no need for abdominoplasty. The technique involves placing a trocar