In recent years, the Endoscopic surgery for diastasis of the rectum has become increasingly popular and widespread. The first endoscopic operation for diastasis of the rectus, the REPAwas introduced by me in Italy in 2017, and to this day mine continues to be the only team that does it. In the wake of REPA's success, other groups have begun to use techniques of Endoscopic surgery for diastasis of the rectum.
Among them, the most widely used is the endoscopic version of the Rives-Stoppa technique.
The Rives-Stoppa technique in endoscopic rectus diastasis surgery
First of all, it must be made clear that Rives' technique was NOT born as an endoscopic surgical treatment of diastasis of the rectus, but rather as a treatment of laparoceles (i.e. abdominal hernias due to muscle-fascial suture failure) by the open route. Rives published his case history, comprising 258 patients, in 1992, reporting a recurrence rate of 6.2%. From acomprehensive analysis of medical literature published between that date and 2006the reported relapse rate is 7.5%. A paper published in 2007 in the World Journal of Surgery (a leading journal with a high impact factor) tells us more about the postoperative complications of this technique: seromas = 4%, prosthesis infections = 3%.
Very few works exist in literature on the Rives technique performed endoscopically. In one 2018 preliminary report26 cases are presented with a follow-up of about one year (very little to assess medium- and long-term results). Of another article, in Chinese, which reports another 11 cases of patients operated with this technique, with a follow-up of one year, we could only read the abstract.
In all cases, these are patients undergoing surgery for laparocele or hernia of the abdominal wall; there are, to my knowledge, no works devoted to the use of the Rives technique in the Endoscopic surgery for diastasis of the rectum.
To fully understand what Rives' technique is, it may be helpful to watch a cute animation posted on YouTube by the Hernia Institute of New Jersey.
Here again, an abdominal hernia repair is exemplified. The technique involves incision, on both sides, of the anterior leaflet of the fascia of the rectus muscles; the rectus muscles are then separated each from its posterior leaflet. The two posterior leaflets are reattached with a suture, and a mesh is placed behind the rectus muscles; at the end of the procedure, the two anterior leaflets of the rectus sheath are sewn back together to close the incision made at the beginning of the operation.
The international surgical community today agrees on the use of the Rives-Stoppa technique in abdominal wall defects between 5 and 10 cm in diameter.
Is it appropriate to incise the rectus sheath in endoscopic rectus diastasis surgery?
Diastasis of the rectus, however, is not a defect of the abdominal wall. So I asked myself the question: if the abdominal wall is intact, i.e. if, to simplify, there is no hole (a hernia or a laparocele) in it, is it appropriate to incise the fascia of the rectus and to detach the muscles from their posterior covering? Does one not run the risk of weakening the abdominal wall, and in any case of subjecting the patient to excessive surgery? In fact, if one looks at the recurrence rate reported in the above-mentioned studies (a rate that is quite acceptable in the case of repairing a hernia or a laparocele, BUT NOT of a pathology, such as diastasis, in which such defects are not present, or if there are they are usually much smaller than 5 cm), the answer could be: yes, the risk exists.
But it is obvious that mine is a biased judgement. So I thought I would turn the question over to fellow surgeons around the world who are experts in minimally invasive surgery, abdominal wall surgery and Endoscopic surgery for diastasis of the rectum. This 'audit' would have been very difficult only a few years ago, but today the internet gives the possibility to break down time and distances.
There are two major abdominal wall surgery forums on Facebook: that of the Sociedad Hispanoamericana de Hernia (SoHAH)in Spanish, and that of the International Hernia Collaborationin English. Both are closed forums, and only accessible to surgeons with proven and recognised (worldwide) experience in abdominal wall surgery.
Let's start with the SoHAH forum. This is the question I asked:
"Dear Colleagues, I am asking for your opinion. In recent months, several surgeons in Italy are proposing, as surgery for diastasis of the rectus, an open or endoscopic Rives-Stoppa. What do you think? Does this seem an adequate option to you or - and this is what I think - is it excessive surgery for a condition, such as diastasis, in which there is no wall defect? Wouldn't opening the rectus aponeurosis be interpreted as completely unnecessary iatrogenic damage in such cases?
Thank you for your opinions."
Let's see the answers.
Derlin Juarez Muas: "Good question, Salvatore. I believe that in surgery the most important thing is to do as little damage as possible. I believe that a Bezama technique with diastases associated with hernias of less than 3 cm, or a REPA with diastases of any size and hernias of less than 6 cm, are excellent options. In case of hernias larger than 6 cm, Rives-Stoppa technique, with any approach"..
So Rives-Stoppa according to Dr. Juarez Muas is only indicated when hernias larger than 6 cm in diameter are present together with diastasis.
But Derlin is the one who invented REPA, and he too could be considered biased. Let's see other answers.
Dr. Magdaleno Garcia is the Director of the Bajio Hernie Clinicin Mexico. Even for Dr. Magdaleno Garcia, Rives-Stoppa is only justified if a hernia is present.
Alfredo Moreno Egea. A few words about this great surgeon. Prof. Moreno Egea is Professor of Surgery in the Faculty of Medicine at the University of Murcia, and lecturer of the Master of Applied Clinical Anatomy at the same University. He is in charge of the Abdominal Wall Unit at the JM Morales Meseguer University Hospital, in Murcia; he is the author, together with Prof. Fernando Carbonell Tatay, of one of the most important treatises on hernia and laparocele surgery currently existing in the Spanish language, and is recognised as one of the world's leading abdominal wall surgeons.
"Hello Salvatore. I completely agree. Not only is there no indication for a Rives, but it should even be discouraged at all times. Rectus diastasis, simple or with umbilical hernia (which in 90% of cases is a 1-2 cm defect), never justifies a technique like Rives, which is only recommended in 5-10 cm defects [...]"
Ezequiel Palmisano: "I completely agree with Alfredo Moreno Egea. Salvatore, ne we have already discussed outside the forum... Personally, and based on published evidence, I only indicate Rives (open or endoscopic) with defects from 5 cm upwards. However, in a diastasis of the rectus with defects smaller than 5 cm or simple [...] I prefer REPA. This is the algorithm we normally use, although sometimes adapting it to the patient: Pure rectus diastasis = REPA; rectus diastasis with defects less than 5 = REPA; diastasis in non-obese male patients = Bezama (??); rectus diastasis with defects greater than 5 cm = eTEP."
The Prof. Ezequiel Palmisano is one of Argentina's best-known abdominal wall surgeons, a lecturer in the postgraduate course of Surgery at the Faculty of Medical Sciences of the National University of Rosario, and a member of the Board of Directors of the High Tech Surgery Association, an important transnational society dealing with the application of new technologies in surgery.
Dr. Bezama Murray is the author of the technique that bears his name for the minimally invasive open treatment of diastasis of the rectus.
Manuel Martin: "Hello Salvatore. I completely agree with what has been said so far by Derlin, Bezama, Alfredo and Ezequiel. For rectus diastasis with umbilical hernia less than 5 cm, REPA technique. For defects between 5 and 10 cm, closure of the defect by reconstructing the midline using endoscopic (Rives-Stoppa with eTEP) or laparoscopic (IPD) techniques, depending on the surgeon's experience"..
Dr. Manuel Martin is the General Director of the Ispalense Institute of Surgery and Advanced Laparoscopy, as well as Director of the General Surgery Service of the 'Dr. Clemente Alvarez' Hospital in Rosario, Spain.
Summing up, so far the opinion is unanimous: no Rives-Stoppa in the Endoscopic surgery for diastasis of the rectumexcept in the presence of wall defects (e.g. umbilical or epigastric hernias) greater than 5 cm.
Let's move on to the International Hernia Collaboration. My question was:
"Dear Colleagues, in recent months in my country there are Surgeons who, for the treatment rectus diastasis surgery, they are proposing a technique they call TESAR (Totally Endoscopic Sublay Anterior Repair). In this technique, they actually perform a Rives procedure through an endoscopic approach, similar to the REPA / SCOLA approach. I would like to ask your opinion on whether a Rives-Stoppa procedure should be performed for a diastasis of the rectus. I think it is an excess: in these patients, you do not have a defect of the abdominal wall but "only" an insufficiency of the linea alba: opening the aponeurosis of the rectus to place a retromuscular mesh (sublay) is justified, in my opinion, only if you have a "real" abdominal defect of at least 5 cm. I believe that this type of surgery could cause "iatrogenic" damage due to the opening of the rectus aponeurosis. What is your opinion?"
Guillermo Pou Santonja: "I completely agree with your view in this case, Salvatore. I normally perform REPA in patients with diastasis associated with midline defects, but if the defect is greater than 5 cm, I prefer open surgery (Rives, SAC Carbonell). I have no experience with Rives-Stoppa for eTEP".
Dr. Pou is a surgeon from Valencia who deals almost exclusively with abdominal wall surgery.
Dr. Ramana Balasubramanian, a bariatric and abdominal wall surgeon at the BelleVue Clinic in Calcutta, is very trance-like: "Salvatore, this technique seems to have the disadvantages of both the front and rear approaches"..
Igor Belyansky: "Yes, it could be a problem if the dissection is performed in a manner incorrect.
Every time I ask myself if I am too 'far gone' when I perform a minimally invasive operation, I ask myself a question: how would I have solved the same problem 5 years ago. I used the posterior route (eTEP, Ed) to repair the diastasis by performing an open abdominoplasty in selected patients (I still do it in some patients). So, it is already something I was already doing: as I see it, in my minimally invasive interventions I am reproducing what I would otherwise have done through an open approach“.
The Dr. Belyansky is one of the authors of Manual of Hernia Surgery of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
Brief aside: I have often quoted the acronym eTEPwhich stands for Extended Totally Extra Peritoneal (approach). It is rather difficult to explain, but basically it is a minimally invasive route in which one enters posteriorly into the preperitoneal plane, behind the fascia of the rectus. So a completely different route from the endoscopic Rives, which involves an anterior approach to the rectus muscles of the abdomen.
But the point is exactly the one underlined by Dr. Belyansky: we reproduce, in a minimally invasive way, what used to be done by open means. The technique is the same: the minimally invasive way allows us to reduce the postoperative pain, the hospital stay, and, thanks to some technical corrections (the mesh), the possibility of recurrence. Honestly, the Rives-Stoppa technique for the treatment of a "simple" diastasis has practically never been used, for all the reasons mentioned so far.
Conclusion: which way forward for endoscopic rectus diastasis surgery?
We have, I think, examined in some detail the Rives-Stoppa technique performed endoscopically for the Endoscopic surgery for diastasis of the rectum. We used the most widely used system in the medical field for evaluating a topic: the peer reviewi.e., 'peer review', i.e., those doing the same job as you. And all the 'peers' argued at least the inappropriateness, if not the harmfulness, of the Rives-Stoppa technique for the repair of a diastasis not associated with wall defects of at least 5 cm in diameter (i.e., about 95% of diastases). The Rives-Stoppa technique remains one of the gold standards in the surgery of midline defects (particularly laparoceles) between 5 and 10 cm in diameter: but the advantage of performing it to repair a diastasis of the rectus is, indeed, still to be proven.