For the minimally invasive treatment of diastasis recti robots and REPA are the two most effective techniques available to us today.
I immediately declare my conflict of interest: I am the REPA mantechnique that I introduced in Italy and that I love very much.
However, robotic surgery has always fascinated me, and I know how effective it is, in general, in treating abdominal wall pathology.
But as for the robot rectus diastasis and REPA are they equivalent? or is one technique better than the other? and why?
In both cases, these are minimally invasive techniques that involve, as the cornerstones of the procedure, the realignment of the rectus muscles on the midline of the abdomen (the 'linea alba'), their suturing and the placement of a mesh. However, in the two techniques these steps are not performed in the same way. Let us try to understand what the differences are, and then draw the appropriate conclusions.
Robot rectus diastasis and REPA: comparing techniques
- Access route. Both the robotic technique and REPA involve reaching the rectus muscles through three small incisions on the abdomen. With the robotengravings are made on the left flankwhile in the REPA just above the pubisThus, with REPA, the incisions are practically invisible while the same cannot be said for the robot. Moreover, in REPA, one or two of the incisions are of 5 mm about, while with the robot the smallest incision cannot be less than 8 mm.
- Working pressure. With both the robot and REPA, to create the working space, a gas, carbon dioxide, has to be insufflated at an adequate pressure to stretch the abdominal wall. With the robot, as is also the case in laparoscopy, the pressure with which carbon dioxide is insufflated inside the abdominal cavity is about 12 mm Hg, whereas in REPA gas is NOT insufflated into the abdominal cavity, and the working pressure is 1/3 lower, about 8 mm Hg, with quite long moments of the surgery when it is further decreased to 3-4 mm Hg. Another important consequence is that, as mentioned, in robotic surgery the gas is insufflated within of the peritoneal cavity: the peritoneum greedily absorbs carbon dioxide, which causes an increase in its concentration in the blood (hypercapnia). In REPA, insufflation is extraperitonealThe concentration of carbon dioxide in the blood does not change. Finally, carbon dioxide is an irritant gas for the peritoneum, and contributes to the pain (even in 'strange' locations, such as the right shoulder) experienced in the postoperative period. This problem, with REPA, is non-existent.
- Workspace. As already mentioned, the robotic technique for the repair of diastasis of the rectus (and associated hernias) involves the insertion of surgical instruments inside the peritoneal cavity, where many 'noble' organs are contained (liver, spleen, pancreas, stomach, intestine...): this results in the minimal but real risk of injury to these organs during surgery. The REPA workspace is instead suprafascial: completely outside the peritoneal cavitywithout no risk of injury to peritoneal organs.
- Anatomy of the rectus muscles. In practice, from what we have said so far, the Robotic surgery repairs diastasis of the rectus by looking at them 'from behind'from within the abdominal cavity; while in REPA the muscles look 'in front'.by framing their anterior surface, outside the abdominal cavity. It seems like a small difference, but in reality it is substantial. This is because the rectus muscles are enclosed within a sheath (the 'sheath of the righteous'precisely) consisting of two leaflets, one front and one rear. There is an important difference between the two sheets: the front one is in fact completeextending from the chest to the pubis; the rear one is incompleteending just below the navel with a margin known as the arcuate line. On In practical terms, this means that, since muscle sutures must be made on the fascia and not directly on the muscle tissue (which is 'fragile' and tends to tear, bleed, etc.), in robotic repair, diastasis can only be effectively closed up to the arcuate line (unless below this the stitches cross the muscles 'full-thickness', including in the suture the anterior leaflet of the rectus sheath: but in this case the muscular traumatism would be truly remarkable); whereas with REPA the diastasis can be repaired along its entire length, from the sternum to the pubis.
- Timing of the intervention. Robotic intervention can be displayed in this video. In practice, with this technique the peritoneum is incised along the entire length of the rectus muscles, until the posterior leaflet of their fascia is uncovered and the diastasis is revealed, the diastasis is closed by suturing (i.e. stitching) the two rectus muscles between them (always remembering the famous arcuate line...); then the peritoneum is closed, and a network. In the REPA, of which you can see a video with the main technical moments at the bottom of this article, once the surgical space has been created the perimeter of the diastasis is identified with small electric shocks (which allow us to discover many things about these two muscles... for example the fact that, precisely because of diastasis, very often below the navel they contract very little, or not at alland this is the cause of the abdominal 'bombé', i.e. that swelling which is one of the first things that patients complain about when they come to the practice); that done, the muscles are realigned to the midline and suturedreconstructing the linea alba: performing this surgical time on the anterior leaflet of the rectus sheath allows us to suture the diastasis to its full extent, from sternum to pubis. Finally, there is the network.
- The network. Both in robotic surgery and with REPA, a network is used. The networks that are used, however, are profoundly different. In the case of the robota so-called 'dual mesh'i.e. a relatively heavy net with two surfaces of different material. One of these two surfaces is theoretically designed to be placed in contact with the abdominal viscera (intestines, stomach, etc.). However, even the most advanced of these networks causes always the formation of adhesions with these organs. Adhesions may give no sign of themselves even for life, but they can, on the other hand, be the cause, for example, of intestinal obstruction or enteric fistulas, quite serious problems that are not easy to solve surgically. In the case of REPAInstead, the mesh is placed over the anterior leaflet of the rectus fascia. A ultralight mesh (we use a net of approximately 19 g/sqm, which, in relation to the surface area of the net normally used, means less than 0.5 g of placed prosthesis). The network is not in contact with any organ and has no chance of causing injury to 'noble' structures. On the other hand, it is possible, though rare, for seromas and haematomas to form, the treatment of which is almost always conservative, and the frequency of which is greatly reduced by leaving the drain in place for a few more days postoperatively.
So if we are to speak of robot rectus diastasis and REPA comparing the techniques, there is not much more to add. I don't want to draw any conclusions, as I said the robot fascinates me: but for the treatment of the diastasis recti I am, and will always remain, theREPA man.