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Home " What are the surgical procedures for diastasis of the rectus?

What are the surgical procedures for diastasis of the rectus?

We can start by dividing the interventions into two broad categories: invasive e minimally invasive.

Invasive intervention by definition for the treatment of diastasis of the rectus is theabdominoplastywith all its variations. In this operation, with a large suprapubic cut 'from side to side', peeling off the skin and the underlying subcutaneous tissue (and detaching the umbilicus from the skin of the abdomen) the fascia of the rectus muscles and the linea alba are reached: the latter is plicated, closing the diastasis. The dermolipectomyi.e. the removal of excess skin and fat, the belly button is re-inserted onto the skin of the abdomen and the suprapubic surgical wound is sutured.

What are the limitations of abdominoplasty?

First of all its invasivenessthe pain and the long postoperative incapacity. Let us say it clearly: the abdominoplasty cut hurts, scarring can be horrible despite all the care put in by the surgeon and still the final result may not be accepted by the patient. Moreover, both suprapubic and periumbilical scars are, by definition, scars with vascularisation problemsif something goes wrong (and these are often situations that are difficult to assess prior to surgery) you can have the necrosis of the umbilicus and abdominal flapserious and otherwise complex events. Not to be overlooked is the diastasis recurrence rate after abdominoplasty, which can go as far as (according to the literature) up to 40%. This can make sense if, along with the diastasis, the patient has a excess skin or a fat apron to be removed: but how can such an invasive operation with such postoperative risks be justified in patients without excess skin?

There is only one answer: it is not justifiable. Abdominoplasty has no indication, and is not justifiable, for the repair of diastasis of the rectus in patients who do not have excess skin or an adipose apron to remove.

Minimally invasive interventions

The minimally invasive interventions are those made with laparo-endoscopic and robotic techniques.

Le laparoscopic techniques are the 'oldest' and few surgeons now perform them. In them, through small cuts in the abdominal wall, one enters the abdominal cavity, sutures the diastasis "from behind" (i.e. on the posterior surface of the rectus muscles) and reinforces the suture by placing an intra-abdominal mesh (the so-called IPOM technique: Intra Peritoneal Onlay Mesh).

These techniques have several critical points. 1) The 'suture from behind' of the rectus muscles is, by the same anatomical conformation of the rectus, limited. On the posterior surface of the rectus the fascia is interrupted just below the umbilicus: and it is only the fascia that can be sutured, if the muscle is sutured it tends to tear and bleed (and in any case the tightness of muscle sutures, due to the very characteristics of the tissue, is much less than that of fascial sutures). The consequence is that "from behind" the diastasis suture is incomplete. 2) Operating inside the abdominal cavity increases the risk of injury to intracavitary organs (liver, stomach, intestines, spleen...). 3) The greatest limitation of laparoscopic techniques, however, is the mesh, which is placed inside the peritoneum in direct contact with the intracavitary organsThis causes the formation of serious adhesions between the mesh itself and the abdominal organs. This fact, obviously opposed by those who use these techniques, is however shared by all surgeons specialised in abdominal wall surgery and - what is more important - clearly established by the international scientific literature. A this link one can find a thorough review of complications due to nets placed inside the peritoneum in one of the world's leading surgical journals. The picture at the bottom of the page, perhaps a little strong, shows an intraperitoneal mesh penetrated inside an intestinal loop. Such complications, the frequency of which varies between 6 and 20% in different studies, can lead to intestinal erosions and occlusions, peritonitis and chronic enterocutaneous fistulas, which can be life-threatening for patients.

Le robotic techniques are those that use one of the various surgical robots available today to perform the operation. Robots are extremely complex and sophisticated instruments that help - in some cases very substantially - the Surgeon to perform laparoscopic factual interventions. So beware of the substance: a) the robot is an aid for the surgeon, not for the patientEverything that is done in robotic surgery can be done with normal laparoscopic instruments just as satisfactorily; the limit is the skill of the surgeon: the robot makes movements easier that are a little more complex with traditional laparoscopic instrumentation; (b) the operation that is performed is, in essence, a laparoscopic operationto which the robot adds nothing. What was written above in points 1) and 2) therefore applies. As far as the position of the mesh is concerned, the robot makes it easier to place it in the preperitoneal site (an operation that can be performed perfectly well with normal laparoscopic techniques: a this link can be seen in a video I made in 2017 for the repair of an epigastric hernia): this significantly reduces the risks related to the mesh, but does not improve the serious limitations due to incomplete suturing of the diastasis. c) the robot is very expensive, and this for two reasons: the first is the actual cost of the equipmenthigher than with traditional laparoscopy; the second is marketingIn a not entirely transparent manner, some surgeons increase their fees for the very fact that they have used a robot, without explaining to the patient that - at least for diastasis of the rectus - they will have no benefit from the use or non-use of such complex technology.

Endoscopic techniques: REPA. REPA (Endoscopic Pre Aponeurotic Repair, also called SCOLA: Sub Cutaneous OnLay Approach by Anglo-Saxon Authors) was developed in 2014 by an Argentinian surgeon, Dr. Derlin Juares Muas. Using the common instruments of laparoscopy (and also the micro-invasive ones of minilaparoscopy, where available) through 3 small suprapubic incisions (one 1 cm, two 5 or 3 mm, the latter being much smaller than any robotic incision) and without penetrating the peritoneal cavity one reaches the anterior fascia of the rectus muscles; the perimeter of the diastasis is identified and sutured, along its entire length (the anterior fascia of the rectus muscles, as opposed to the posterior, is complete), from the sternum to the pubis; finally, the suture is reinforced by placing a light or ultralight mesh in the pre-aponeurotic situation, far from the abdominal organs. The advantages of this technique are obvious from its description: minimal invasiveness, reduced postoperative pain compared to laparo-robotic techniques (there is no chemical peritonitis induced by the gas used to create the surgical space with these techniques), complete repair of the diastasis along its entire length.

Today, REPA is the most widely used minimally invasive technique in the world for the repair of diastasis of the rectus and associated hernias.

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