09 Apr 2024 In Pursuit of Rectus Diastasis

Rectus diastasis is not a hernia but sometimes it needs to be repaired!

Rectus diastasis (Divarification) has become a popular topic among hernia surgeons recently. The definition, classification, and whether rectus diastasis should be treated or not are subjects of debate, with insufficient clinical studies on these matters. Previously considered a cosmetic problem falling within the scope of plastic surgeons, it has now become a concern for hernia surgeons due to problems such as back pain, respiratory issues, and increased risk of accompanying hernia recurrence.

The rectus muscles are a pair of muscles in front of our abdomen, extending from the chest to the pubis, with the fascial area between them called the linea alba. Rectus diastasis (#DiastasisRecti) refers to the condition where the gap between the rectus muscles exceeds the physiological value without a fascial defect. Normally, the distance between them should not exceed 2 cm. Measurements >2 cm are considered as diastasis.

It is commonly seen in middle-aged, obese men (especially those with central obesity), or overweight women with multiple pregnancies or twin pregnancies. It is characterized by bulging, particularly in the upper part of the abdomen at the midline, when intra-abdominal pressure increases. Muscle thinning and weakness accompany this condition. In our study presented in the selected abstracts section at the 2015 World Hernia Congress in Milan, we demonstrated that diastasis increases in obese individuals and the thickness of the rectus muscles decreases. We also found that the rectus muscles thin out and the distance between them increases with age.

Is rectus diastasis a hernia? No.

Rectus diastasis is an acquired condition and is not a hernia. However, the thinning and weakening of the linea alba predispose to midline hernias such as umbilical hernia, incisional hernia, and trocar site hernia. Rectus diastasis accompanies almost half of these hernias. Studies show that simultaneous repair of rectus diastasis during the repair of these hernias contributes to reducing recurrences.

As I mentioned in the introduction of my writing, there is no consensus on the definition and classification of rectus diastasis yet. There are also insufficient studies on its repair and outcomes. However, according to a proposed classification, rectus diastasis is classified into 3 degrees: Mild <3 cm, Moderate 3 – ≤5 cm, Severe >5 cm

Should every rectus diastasis be repaired? No.

Advanced rectus diastasis can cause back pain due to destabilization of the abdominal wall. Similarly, it can create respiratory problems by preventing the coordination and proper use of abdominal muscles, thus hindering adequate intra-abdominal pressure. Intervention for rectus diastasis without hernia is being discussed due to these two complaints. However, there is still no high level evidence.

There are various options for repair: besides open methods, minimally invasive endoscopic techniques and mesh repairs are also treatment options. While plastic surgeons generally prefer suture repairs, as I mentioned above, repairs performed without using a mesh in severe rectus diastasis cases have a higher recurrence rate. With hernia surgeons recently getting involved in rectus diastasis treatment, there has been an increase in diversity in repair techniques. Techniques such as SCOLA, REPA, eTEP, eMILOS, LIRA are used in correcting rectus diastasis.

For the repair of non-aesthetic rectus diastasis, patients should be selected carefully, their complaints should be evaluated accurately, and imaging methods such as ultrasound or computed tomography should be used to plan treatment. If there will be excess skin after repair, it is advisable to seek the assistance of a plastic surgeon.

Finally, I would like to mention the guideline published by the European Hernia Society in 2021 regarding this matter. In this comprehensive study conducted on rectus diastasis, answers to 9 key questions were sought, revealing that scientific data are still insufficient and recommendations are weak. Therefore, the surgeon’s individual expertise becomes paramount on a case-by-case basis. It is imperative to have a decision-making process in which the patient is also involved.