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REPA: the new 'gentle' surgery for diastasis of the rectus muscles

The word "diastase"comes from the Greek (diàstasis, 'separation'), and in medicine indicates all those conditions in which two normally side-by-side structures separate. The diastasis of the rectus abdominis muscles therefore consists of a separation of the rectus abdominis muscles - two long muscles located in the anterior wall of the abdomen and extending between the sternum and the ribs, above, and the pubis, below.

Under normal conditions, the rectus muscles are joined together by a thick fibrous cord, called dawn line. Under certain conditions, however, it thins and flattens (sometimes it becomes as thin as a sheet of paper...), widening: this causes a separation of the muscles (technically we speak of an increase in the IRD, Inter Recti Distanceinterrectal distance): and, if this separation is greater than 2.5 cm, there is the diastasis of the rectus abdominis muscles.

Below 2.5 cm the interrectal distance is considered physiological; this is because there are gender differences (below the umbilicus, for instance, it is greater in men than in nulliparous women, i.e. women who have not had children); it increases with pregnancies, and it also depends on the anatomical site (it is generally greater above the umbilicus). There are also risk factorsconditions that can cause an increase in IRD; these include age, number of pregnancies, caesarean section and overweight. According to a recent study, the diastasis recti affects the 60% of women at 21 weeks of pregnancy, and persists in 31.2% of women one year after delivery. It is therefore a common problem that can profoundly affect the well-being of women who suffer from it.

SYMPTOMS OF DIASTASIS OF THE RECTUS MUSCLES

As pregnancy progresses, the shape of the mother's abdomen changes profoundly, due to the increased size and weight of the uterus and fetus. The muscles of the abdomen, and among them especially the rectus muscles, lengthen and move laterally: this causes a alteration of muscle contraction vectorsi.e. the lines along which the muscles contract. In about one third of women one year after giving birth, these changes remain permanent: this causes a profound and definitive impairment of the ability to flex the trunk and to contract the muscles of the abdominal wall in a harmonious manner (the so-called 'abdominal press'). This has negative consequences on both the ability to keep the trunk upright (the upright posture being a result of the harmonious contraction of the back and abdominal muscles) - and the first effect is the appearance of hyperlordosis and lower back pain - as much as on pelvic floor performance, which can lead to the appearance of stress urinary incontinence, faecal incontinence (less frequently) and prolapse of pelvic organs such as the uterus or bladder. In addition to this, also the appearance of the abdomen changes profoundlyIts subumbilical portion remains prominent and tends to swell during the course of the day, so much so that many patients, when visiting me, tell me that they wake up 'flat' in the morning and arrive in the afternoon so swollen that they look like they are five months pregnant.

I digestive disorders related to 'prolapse' of abdominal organs are frequent: they range from simple meteorism, to the feeling of postprandial heaviness, to the constipation, at abdominal pain. La sensitivity to trauma of the wall of the abdomen increases enormously; and many patients notice some 'movements' under the skinwhich they compare to the 'kicks' given by foetuses during pregnancy and which are instead an expression of normal bowel movements (not visible when the abdominal wall is normal).

THE DIAGNOSIS

The first step in the diagnosis of diastasis of the rectus muscles is self-assessment; there are several tutorials on the netdiastasis of the rectus abdominis which show how to assess one's abdomen to understand whether or not one is a carrier of this disease.

The role in the diagnosis of the surgeon specialising in the treatment of abdominal wall diseases is fundamental, because he is the only professional able to measure with good accuracy the diameter of the diastase and assess the presence of any associated hernias. In fact, in almost all patients with postgravid abdominal rectus diastasis there is aumbilical herniaof great importance in the proper planning of the surgical strategy; and not infrequently associated with it are other hernias of the midlinesuch as theepigastric hernia.

L'ultrasound of the abdominal wall is one of the most frequently requested tests for diagnosis; however, its usefulness, in my experience, is limited, and not just for one reason: it is a strictly operator-dependent examination (i.e. it is only reliable if the experience in diagnosing abdominal wall defects of the radiologist who performs it is adequate), it is not standardised (often the diameters of the diastasis of the rectus abdominis or the presence of hernias) and almost always underestimates the true size of the problem. This becomes evident at the time of surgery, when one realises that the lengths and diameters reported on ultrasound scans are often not real.

Certainly much more precise and useful in diagnosing abdominal wall pathologies is the Dynamic CT scani.e. a CT scan, performed without contrast medium, during which the patient is asked to perform manoeuvres (such as the Valsalva manoeuvre) that clearly and precisely show, regardless of the experience of the operator performing it, both the diastasis of the rectus muscles hernias, allowing their diameters, volumes, etc. to be measured.

However, the decisive, and in the vast majority of cases more than sufficient, examination for the diagnosis of a diastasis of the rectus abdominis is the clinical examination; if performed by an experienced surgeon, it allows for an accurate assessment of both the extent and width at the various points of the diastasis, as well as the presence of possibly associated hernias, allowing for the correct planning of surgery.

In my practice, I never ask for a pre-visit instrumental examination, even though patients often come to the practice having already had an ultrasound scan; and only if at the end of the clinical inspection I am not convinced, do I ask for a dynamic CT scan of the abdominal wall.

REPA, MINIMALLY INVASIVE ENDOSCOPIC SURGERY OF DIASTASIS OF THE RECTUS MUSCLES

The treatment of diastasis of the rectus abdominis must be realised by a experienced surgeon, specialising in the treatment of abdominal wall pathologieswho is familiar with its anatomy and familiar with the principles of prosthetic repair of abdominal defects.

The traditional intervention, and until recently the only one performed in Italy, for the treatment of diastasis of the rectus abdominis muscles is abdominoplasty. A procedure historically the patrimony of plastic/aesthetic surgeons, it involves a wide cut (side to side, we might say using unscientific terminology...), the detachment of the skin and subcutaneous tissue from the umbilicus and the stretching towards the pubis of the skin and adipose tissue it underlies. During the operation, the two rectus muscles are sewn together on the midline (the so-called 'plication' of the rectus muscles). In some cases and by some surgeons, if there is a pronounced prominence of the subumbilical portion of the abdomen, a 'vertical or shortening plication' of the oblique muscles is performed, in order to 'flatten' the abdominal wall. The latter procedure is rather painful and has, due to the high tension the muscles are subjected to, a high recurrence rate.

Abdominoplasty is useful in women with an 'adipose apron'i.e. with the lower portion of the abdomen hanging down towards the mount of Venus due to an excess of skin and adipose tissue; or in obese persons undergoing bariatric surgery, at the end of the weight-loss period. This is because abdominoplasty involves performing a dermolipectomyi.e. the removal of excess skin and underlying fatty tissue, which corrects the imperfection caused by the 'fat apron'. For thin patients, in good physical shape and without an 'adipose apron', however, abdominoplasty is undesirable, due to its very extensive scarring, long convalescence and risks related to the dermal flap (including necrosis of the skin and umbilicus).

minimally invasive surgery for diastasis of the rectus
Dr. Cuccomarino and Dr. Derlin Juares Muas, creator of the R.E.P.A. technique.

For some years now, a new minimally invasive intervention has been available for the treatment of diastasis of the rectus muscles: the endoscopic pre-aponeurotic repair (REPA)technique developed by Dr. Derlin Juares Muas, a well-known Argentinian abdominal wall surgeon. In this operation, through three small incisions (two of about 10 mm and one of about 5 mm) above the pubis (in women who have given birth by caesarean section, these incisions usually fall on the already existing scar), with techniques well known to surgeons who deal with advanced laparoscopic surgery the bands of the rectus abdominis muscles are sutured, reconstructing the linea alba and repairing the diastasis, and stabilises and reinforces this repair through the placement of an ultralight net - which significantly reduces the risk of recurrence. This surgery, with truly excellent results, is very popular in Ibero-American countries (Spain and Latin American countries), and is beginning to spread to many European countries. I learnt this intervention from the same Dr. Juarez Muasmy personal friend, and I made it for the first time in Europe in 2017.

It should be remembered that endoscopic surgery and laparoscopic surgery are not the same thing. In laparoscopic surgery of the abdominal wall - unless one masters very advanced techniques of component separation, nowadays the patrimony of few surgeons in the world - what is normally done is to place a mesh to repair a defect in the wall. Therefore, no plication of the fascia of the rectus is performed, with respect to which the surgeon's point of view and the instruments with which he works are located posteriorly.

With the technique for endoscopic repair of diastasis of the rectus abdominis muscles (REPA)Instead, plication is performed anteriorly, exactly as in traditional abdominoplasty, but without the abdominoplasty scar. We can say that endoscopic surgery is, like laparoscopic surgery, minimally invasive; but the spaces in which we move, and therefore the technical gestures that can be performed, are very different.

An alternative to laparoscopic surgery for diastasis of the rectus abdominis (which, as we have said, is a 'non-surgery' in that it does not repair the diastasis itself) is the robotic surgery. With the robot it is possible to access, less safely than with REPA, the posterior surface of the rectus abdominis muscles and thus suture them before placing the mesh. However, it is an 'insufficient' repair for anatomical reasons: the posterior fascia of the rectus abdominis muscles, in fact, is incomplete, being absent in the lower third of the abdominal wall; a separation of the muscles at this level, therefore - which is present in the vast majority of patients - cannot be repaired with the robot. Another not minor disadvantage of robotic surgery is its high cost. Also, in robotic surgery the surgical incisions are made on the patient's side and not above the pubis, thus becoming much more obvious. Finally, since with robotic instruments one enters inside the abdominal cavity, there is always a risk of injury to the intracavitary organs (intestine, stomach, liver, etc.), a risk that is absent in endoscopic surgery, even if limited.

The use of the network in endoscopic surgery of diastasis of the rectus muscles is a fundamental part and notdiastasis of the rectus abdominis muscles: the network renunciation of the technique. All surgeons dealing with abdominal wall surgery know that any repair of an abdominal wall defect, even a small umbilical hernia, without the use of a prosthesis is likely to fail: the recurrence rates increase to values that are no longer acceptable, and in fact there are works in literature reporting double-digit incidences of diastasis recurrence after abdominoplasty (plastic surgeons do not like the use of mesh). The mesh has a fundamental 'scaffolding' function, and favours the formation of fibrous tissue that stabilises the suture of the rectus fascia. It is this fibrous tissue that makes the repair solid: the suture alone, over time, would be destined to be reabsorbed or fragment.

Regarding the postoperative complications of the REPA techniqueThe main one is the formation of seromas or haematomas, which can be minimised by leaving a drain in place for a few days and with the application of compression and ice on the abdomen; and, when it does occur, in most cases it can be easily resolved with conservative techniques without having to re-operate. The recurrence rate, thanks to the use of mesh, is much lower than for traditional abdominoplasty, being below 4% (alas, 0% and 100% do not exist in medicine).

The operation usually involves an overnight stay in hospital. Patients will have to wear an abdominal band immediately and for one month, and for the same time they will have to avoid exertion or sports activities.

Then they will have to perform, under the guidance of a specially trained physiotherapist, cycles of lymphatic drainage of the abdominal wall and, above all, of hypopressive gymnasticsAt the end of which she will be able to return to her normal activities, both daily and sporting. Physiotherapy is a central part of my multidisciplinary approach to the treatment of diastasis of the rectus muscles - I often tell patients that only 50% of the credit for successful treatment is due to surgery, because the other 50% is due to physiotherapy - and is aimed at 're-teaching' the muscles to contract correctly and the patient to assume the correct posture, which the alteration of the vectors of muscular contraction I mentioned at the beginning has caused him to lose over time. In many patients, at the time of surgery, I note that, especially in the lower part of the abdomen, the muscles have completely lost their ability to contract: this accounts for the 'prominence' of the lower part of the abdomen mentioned earlier, and which can only be permanently resolved with adequate muscle recovery, and not with those surgical practices of shortening the oblique muscles that I mentioned earlier.

Rectus diastasis and REPA: the video

 

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