The following article is a translation, supplemented and in some places simplified, of theeditorial I wrote at the invitation of the Sociedad Hispanoamericana de Hernia in his magazine.
Until very recently, the diastasis recti was considered a defect mainly, if not exclusively, aestheticand left it to the attention of plastic surgeons; who repaired it using techniques such as theabdominoplastywhich, apart from their considerable invasiveness, are not always correctly indicated in patients with diastase. If, in fact, the indication to a
abdominoplasty operation is undoubtedly correct in a patient such as the one in Fig. 1, in whom a pendulous abdomen is evident, justifying the dermolipectomy (i.e. the removal of excess skin), what can be said in the case of the patient in Fig. 2, who has neither a fat apron or other localised adiposity to justify plastic surgery?
Yet both patients, beyond the personal psychological distress arising from difficulties in accepting their appearance, they come to the surgeon's observation complaining of a range of symptoms (from back pain at swelling
abdominal, from slowing down of digestive processes to theurinary incontinence by effort, from constipation at abdominal pain to theinability to perform certain trunk movements...) that seriously impair their quality of life: and this becomes a problem, including a social one, all the more important because they are generally young, highly active, sporty patients with important family responsibilities and an intense social life. The disorders that these patients complain of may be, in part or in full, a consequence of diastasis of the rectus, with pathophysiological mechanisms that we will examine below. But the most important point of the problem is that, in the vast majority of cases, patients such as the one in Fig. 2 do not accept abdominoplasty surgery, because of its invasiveness and significant scarring, preferring to maintain their symptoms, which will inevitably worsen over time.
In the last decade, with the emergence of the abdominal wall surgery as a super-speciality of general surgery, the interest of wall surgeons has also focused on the diastasis rectiand, thanks to the technical and cultural background that has always been the heritage of general surgery, which includes the knowledge, use and development of prostheses, techniques and equipment that allow a minimally invasive approach to wall pathology, the surgical community began to wonder if there could be less invasive technical options than abdominoplasty for the treatment of diastasisTechnical options, ultimately, that could also be accepted by the patient in Fig. 2, helping her to solve her problems.
Answers to this question soon arrived; and it must be admitted that the Ibero-American surgical world played a leading role in this, with the techniques of Bellido (currently little used), Bezama and Juarez Muas. In particular, the latter - the REPA, Endoscopic Pre-Aponeurotic Repair - has spread rapidly thanks to the establishment of social networks on the web exclusively dedicated to abdominal wall surgery, and can now be considered as the most standardised, rational, effective and widely used minimally invasive technique for the rectus diastasis repair.
ABDOMINAL WALL PATHOPHYSIOLOGY IN RECTUS DIASTASIS
For many years, the abdominal wall was considered a kind of 'box' whose main, perhaps only, function was to contain noble structures; the role of the abdominal muscles in processes such as breathing was considered secondary, and the relationships between the anterolateral wall of the abdomen, the muscles of the spine and the pelvic floor have been greatly underestimated (proof of this is that most publications on the subject are by physiotherapists and not doctors).
Actually, the abdominal wall is a 'magic box' which has precise and important functions in the breathingin the support and in the protection of abdominal viscerain the maintaining correct postureof the both urinary and faecal continencein the pregnancy and in the childbirth. This complex set of functions is closely linked to its structure: the abdominal wall is the segment of the body with the highest muscle:bone ratio (i.e., it is predominantly made up of muscle, the bone component is minimal) and is formed by muscle units with very distinctive and unique characteristics: for example, the rectus muscles are the only polygastric muscles in our body. What does that mean? A polygastric muscle is a muscle consisting of several functional units, called muscle gizzardseach capable of contracting autonomously and independently of the others. Each rectus muscle consists of 4 or 5 ventricles each with its own motor innervation, which can contract synchronously - i.e. simultaneously: which means that they can participate in processes such as theforced exhalation, the cough, the defecation and the trunk flexion - or diachronicallyi.e. in sequence one after the other: and this is one of the main mechanisms behind the contractions that occur during the childbirth. And, for example, regarding the latter, one vote more structure is functionIn their lower third, the rectus muscles lack the posterior leaflet of their sheath, which gives the lower part of the abdominal wall greater elasticity, which is essential for the development of the gravid uterus.
Diastasis of the rectus is not a defect of the abdominal wall like hernia or laparoceleand this is important to emphasise - although endoscopic surgery techniques such as the Pre-Aponeurotic Endoscopic Repair of Juarez Muas have allowed us to 'discover' that in more than 90% of cases, it is associated with an umbilical hernia; it can be correctly defined as a dawn line failurewhich is extremely thinned and widened, causing a protrusion (a kind of prolapse) of the abdominal viscera. Not infrequently, the linea alba is so thinned that patients report seeing movements on their abdominal wall that remind them of the movements and kicks of the foetus during gestation. I speak of female patients because diastasis of the rectus is an extremely frequent condition in women who have given birthis present in about 1/3 of them, and has, among its risk factors, the multiparity (i.e. the number of pregnancies)the caesarean section and thehaving raised childrenOther important risk factors, this time evenly distributed between the two sexes, are theweight gain and the practice of sporting activities involving intense use of the abdominal muscles. The diagnosis is almost always clinical (i.e. it is made by examining the patient)and radiological imaging methods, especially ultrasound, are of relatively little help. It is important to remember that diastasis of the rectus is an important mechanism for the organism to adapt to the growth of the gravid uterus: but when it persists a year after delivery, it will have no chance of improving (and will, indeed, be aggravated by anything that increases the pressure inside the abdomen). In recent years, studies have appeared associating the occurrence of diastasis with a congenital defect in type I and type III collagen synthesis, but this is still awaiting more solid scientific evidence.
La symptomatology complained of by patients with diastasis of the rectus includes a low back pain with no other apparent clinical cause (70.2%), for which a negative correlation can be observed between interrectal distance and abdominal muscle function, expressed empirically as a reduction in the ability to flex the trunk (i.e. the wider the diastasis, the lesser the patients' ability to make bending movements of the trunk); disorders related to 'abdominal prolapse' (93.6%), including the abdominal bloating, the strenuous digestionthe abdominal pain and theincreased sensitivity to trauma of the abdominal wall; and theurinary incontinence (44.42%), mainly, but not exclusively, from stress.
The question then arises as to what relationship exists between diastasis of the rectus and, for example, lumbago or urinary incontinence. Once again, we discover that structure is function, and that an alteration in structure can correspond to a more or less pronounced alteration in function.
One of the main and earliest consequences of diastasis of the rectus is that in the lateral muscles
of the abdominal wall, in particular the internal oblique and, even more so, the transverse, the ability to perform contractions is reduced.effective. This is reflected in a reduction of intra-abdominal pressure and the traction performed on the thoracolumbar fascia. La thoracolumbar (or lumbodorsal) band is made up of longitudinal and transversal connective fibres to which the fascia of the transverse muscle (and, indirectly, that of the internal oblique muscle) connects, on the one hand, and which connects, on the other, to the costal angles and the iliac crest, laterally, and to the dorsolumbar spine (through the quadratus quadratus lumborum and sacrospinalis muscles) and the sacrum medially. In practice, through the dorsolumbar fascia, a complex and delicate counterweight mechanism takes place between muscles of the anterolateral wall of the abdomen and
paravertebral muscles that regulates thoracic kyphosis and lumbar lordosis angles of the spinethe physiological curvatures of the spinal column, allowing one to maintain correct posture when standing. The disruption of this mechanism caused by the diastasis of the rectus - let us not forget that the aponeuroses of the internal oblique and transverse contribute to the formation of the sheath of the rectus, and that diastasis therefore causes a decrease in the efficiency of their contraction - causes a increased angles of thoracic kyphosis and lumbar lordosiscausing the appearance of back pain due to increased pressure on the intervertebral discs, particularly in the lumbar region. The righteous plication rebuilds the correct vector geometry of the abdominal muscles, re-establishing the conditions necessary to restore correct intra-abdominal pressure and the correct value of the angles mentioned earlier.
However, the problem is more complex. The 'simple' reconstruction of the muscle vectors of the abdominal wall alone is not sufficient to guarantee neither the tension of the thoracodorsal fascia nor the increase in intra-abdominal pressure. When I operate a diastasis of the rectus with the Juarez Muas technique, I use a simple stratagem to mark the actual perimeter of the diastasis: I administer small electric shocks to the rectus muscles. Incredibly, this often does not result in the muscle contracting either before or after the plication: it is as if the righteous have forgotten how to contract. This is particularly true in the subumbilical portion of the diastasis (which is almost always present, whatever the preoperative imaging studies say) and is the reason why often patients undergoing rectus plication continue to present discrete abdominal swelling. The reason for this we understood indirectly by observing the effects of the physiotherapy which our patients perform regularly one month after surgery.
This physiotherapy includes a series of postural and hypopressive exercises which my team, over time, grouped into a real protocolwhich is now also used preoperatively with the aim of 'preparing' the abdominal muscles for surgery (and which, in fact, I have also started to use in patients with abdominal wall defects other than diastasis, such as in large laparoceles). Physiotherapy, based on the hypopressive gymnastics devised by Dr. Marcel Caufriez, comprises a set of exercises that allows the integration and memorisation of propioceptive messages associated with a certain posture. The concept is quite complex, but in practice, it is as if the muscles of the abdominal wall in patients with rectus diastasis no longer give off propioceptive signals (proprioceptive sensitivity is that which informs the brain, at every instant, of the position our muscles have in space) towards the brainwhich, consequently,
would, at least in part, no longer be able to properly regulate its tone and contraction. Hence the persistent abdominal swelling after surgery before the start of physiotherapyand for which patients return for a visit certain to have an early recurrence of diastasis. This is why it is absolutely essential to explain well to patients that the treatment of diastasis of the rectus is a multidisciplinary course of which surgery is the 50% - the first, propaedeutic 50%, but ultimately only the 50%.
The same applies to theurinary incontinence. Much of what we know on the subject we owe to the work of H. M. Bush et al. and R. R. Sapsford et al. As early as 2001, Sapsford observed that a reduction in muscle tone of the anterolateral wall of the abdomen is associated with a reduction in pelvic floor muscle activity, which correlates with urinary incontinence. These data were confirmed in 2014 by Bush, who observed that in women with chronic low back pain due to reduced activity of the transverse muscle of the abdomen, a reduction in the tone of the pelvic floor muscles is observed, concluding that there is a significant association between chronic low back pain and stress urinary incontinenceand that it is reasonable to think that all the muscles of the trunk - abdominal muscles, spinal muscles and pelvic floor muscles - act in an integrated manner in maintaining both correct posture and continence.
What conclusion can we draw from what we have observed so far? I believe it is one, and one only: diastasis of the rectus, in the majority of cases, is not (only) an aesthetic defect and should therefore not be managed surgically. And that is why we abdominal wall surgeons should start looking at this condition with different eyes, and take it into account as a condition that deserves our
consideration. The range of patients is very wide, and the disorders that are
associated with diastasis are severe enough to considerably worsen their quality of life. Minimally invasive surgical techniques - which for the abdominal wall are the unique patrimony of general surgeons - and in particular Derlin Juarez Muas' R.E.P.A., associated with a correct pre- and post-operative physiotherapy course, allow us today to offer a truly minimally invasive operation that is particularly appreciated by patients, such as the one in Figs. 5, 6, 7 and 8, whom I operated some time ago, whose appearance is similar to that of the patient in fig. 2 and who, like this one, do not accept abdominoplasty because of its invasiveness and the long and difficult postoperative course.
Admittedly, minimally invasive techniques are still young and need long-term testing: but REPA, for example, replicates the rectus plication that has always been performed for diastasis of the rectus, combining the use of an ultra-light macroporous mesh that, even more than guaranteeing a better
containment of the abdominal wall, functions as
scaffold to induce fibroblast proliferation, collagen deposition and ultimately the formation of a large 'scar' that guarantees the stability of the repair much more than simple plication can do. This latter aspect, in particular, is poorly accepted by plastic surgeons, whereas it has always been part of the armamentarium of resources used daily by abdominal wall surgeons: ed it is precisely this different 'point of view' that can make a wall surgeon's surgical strategy successful in the treatment of diastasis of the recti. At a recent meeting organised by the Associazione Diastasi Donna in Rome, a well-known lecturer from a university in Rome, a renowned plastic surgeon in the capital, criticised the use of mesh, saying that he would never leave a foreign body in the body of a patient with diastasis of the rectus. Earlier he had said that he uses Prolene stitches (the same non-absorbable material as the mesh that I use) for rectus plication because he does not trust the use of resorbable stitches. I pointed out to him that the net I apply in REPA is so light (19 g/m2) that the amount of foreign body remaining in patients less than half a gram) is less than the amount of sutures he used to plicate the recti. He could not answer this objection. This marks the big difference between general surgeons and plastic surgeons: although the latter are used to using implants (far more invasive, think of breast implants) they often have no knowledge of what a mesh is for abdominal wall surgery. Finally, the effectiveness of REPA, the only one among the minimally invasive operations proposed for the treatment of diastasis of the rectus (of the others we have spoken in this article) was recently demonstrated by a multicentre study conducted on 215 patients from 10 different surgical teams worldwide (including mine). Patients were followed for a time varying 2 to 4 years after surgery; low back pain has disappeared in the 80% of cases within 30 days of surgery, and urinary incontinence in 89.8% during follow-up. Postoperative complications were extremely limited: 9.7% of seromas, 1.4% of haematomas. Relapses were 0.46%! No other minimally invasive technique, neither robotic nor laparoscopic, can boast such scientific evidence.
In conclusion, REPA is an intervention based on a profound
knowledge of the pathophysiology of the abdominal wall, safe, standardised, and with excellent postoperative results, both in functional and cosmetic terms (although it is not an aesthetic operation). It would be a pity if patients with a constitution similar to those in Figures 2 and 5-8 were to undergo mutilating incisions with possible serious postoperative complications, such as necrosis of the umbilicus and the dermoepidermal flap (Fig. 9) and a painful and lengthy postoperative procedure, such as that of abdominoplasty, when REPA is able to treat their complaints with only three small holes ( and a lot of surgical skill).