ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Rectus abdominis diastasis

Rectus abdominis diastasis
Literature review current through: Jan 2024.
This topic last updated: Nov 28, 2022.

INTRODUCTION — Rectus abdominis diastasis (RAD; diastasis recti, divarication of the rectus abdominis, abdominal muscle separation) is an anatomic term describing a condition in which the two rectus muscles are separated by an abnormal distance [1,2]. Acquired RAD can result from any number of conditions that weaken the linea alba, resulting in protrusion of abdominal contents.

The definition, clinical features, and management of RAD are reviewed here, focusing primarily on management in adults with considerations for children briefly reviewed below. (See 'Pediatric considerations' below.)

RAD is not to be confused with abdominal wall hernia, which is a potentially serious condition that can lead to bowel obstruction. (See "Overview of abdominal wall hernias in adults".)

DEFINITION — The anterior abdominal wall consists of the abdominal rectus muscles separated by the linea alba, which is a fusion of the external and internal abdominal oblique muscle and transversus abdominis aponeuroses [3-5]. (See "Anatomy of the abdominal wall", section on 'Muscles'.)

RAD describes a condition in which an abnormally wide distance separates the two rectus muscles. However, there is controversy regarding what constitutes a normal inter-rectus distance, at what level measurements should be taken, and by what means, and thus when, the distance can be considered abnormal [1]. We consider any separation more than 2 cm to be abnormal. However, it is possible to have clinically evident RAD when the inter-rectus distance is less than 2 cm. The bulge associated with RAD is due to the attenuation of the linea alba between the paired muscles and may occur irrespective of the distance. The relationship between inter-rectus distance and symptoms related to RAD has been studied in 32 females three weeks postpartum [6]. The median inter-rectus distance was 2.97 cm with an interquartile range of 1.65 cm, demonstrating that RAD can occur in females with an inter-rectus distance <2 cm.

What is considered abnormal may differ below as compared with above the umbilicus. In one anatomic study, the normal width of the linea alba in nulliparous females from 20 to 45 years of age with a body mass index <30 was up to 15 mm at the xiphoid, up to 22 mm at 3 cm above the umbilicus, and up to 16 mm at 2 cm below the umbilicus [5]. In another anatomic study, the width of the linea alba ranged from 11 to 21 mm when measured from the xiphoid process to the umbilicus and decreased from 11 to 2 mm when measured from the umbilicus to the pubic symphysis. The thickness of the linea alba ranged from 900 to 1200 micrometers between the xiphoid and the umbilicus and increased from 1700 to 2400 micrometers from the umbilicus to the pubic symphysis [7]. In another study comparing the inter-rectus distance in pregnant and postpartum females, the inter-rectus distance ranged from 44 to 86 mm during pregnancy at various locations above and below the umbilicus [8]. Six months following pregnancy, the inter-rectus distance ranged from 9 to 28 mm at the same locations above and below the umbilicus.

In a biomechanical study, the subumbilical region exhibited a higher coefficient of elasticity than the supra-umbilical portion, but no significant difference in resistance was found between the different portions of the abdominal wall that were studied [9]. In this study:

<45 years of age diastasis was defined as a separation >10 mm above the umbilicus, 27 mm at the umbilical ring, and 9 mm below the umbilicus.

>45 years of age diastasis was defined as a separation >15 mm above the umbilicus, 27 mm at the umbilical ring, and 14 mm below the umbilicus.

CLASSIFICATION — Abdominal wall defects, including RAD, can be congenital or acquired. Acquired RAD is a condition with laxity of the linea alba. Several anatomic classifications for abdominal wall defects have been proposed [10]. Specifically for RAD, these include quantitative and qualitative classifications [5,9,10]. The Beer classification established the normal width (values between the 10th and 90th percentiles) of the linea alba at different locations in 150 nulliparous females. These measurements are 15 mm at the xiphoid, 22 mm 3 cm above the umbilicus, and 16 mm 2 cm below the umbilicus [5].

Congenital — Ventral wall formation is a circumferential convergence of the cephalic, caudal, and lateral abdominal wall folds toward the umbilicus [11]. Several congenital anomalies are associated with defects of the anterior abdominal wall [3,12]. The severity of the abdominal wall malformation depends on the timing and degree of involvement of the somatic and visceral layers. (See 'Pediatric considerations' below.)

Subtle anatomic variations may also contribute to separations that may manifest in response to acquired factors. In a retrospective review of computed tomography (CT) images, the role of the internal oblique aponeurosis was investigated [13]. Classic presentations describe this layer splitting into an anterior and posterior layer at the semilunar line as it wraps around the rectus abdominis muscle, contributing to the anterior and posterior sheath. Further review demonstrated that the expected anterior and posterior insertions were present in most subjects; however, in 11 of 100, only a posterior insertion was present. RAD was noted in 23 of 89 (26 percent) patients with the classic fascial split, but RAD was present in all 11 patients with only the posterior insertion.

Acquired — Acquired RAD is due to weakening of the abdominal wall tissues due to a variety of factors that result in abdominal muscle separation and laxity with or without protrusion of the abdominal contents. The risk factors for acquired RAD are below.

One question raised by some investigators is whether the protrusion of abdominal contents is due solely to laxity of the linea alba, or if other factors affecting the abdominal musculature also contribute [4]. In a study of 92 abdominoplasty patients, the authors concluded that abdominal wall protrusion is caused by the stretching of the entire abdominal wall and not only the linea alba [4]. Abdominal wall protrusions occurred without diastasis, and flat abdomens exhibited diastasis. The linea alba had a limited range of stretch regardless of the abdominal girth. The widest diastasis (supraumbilical/infraumbilical) frequently did not correspond to the site of the protrusion.

The fascia can become thinned due to stretching, which can be caused by elevated intra-abdominal pressure, such as in pregnancy and obesity [1], or prior abdominal surgery [4]. An association of RAD with other disorders known to affect connective tissue suggests an inherent tissue weakness [14].

RISK FACTORS — Patients with acquired RAD typically have one of two profiles: middle-aged and older males with central obesity, or small, fit females who have carried a large fetus or twins to term.

Female versus male sex — Although RAD is much more common in females, it can occur in males [15]. There are some anatomic differences of the anterior abdominal wall between males and females, with more transverse fibers found in infra-umbilical region in females. In general, males have a greater thickness of their transverse and internal oblique muscles at rest; however, females have a greater relative change in transverse muscle during contraction.

The etiology in females can be hereditary or acquired and is predominantly related to pregnancy and childbirth, but other factors (eg, obesity) can also be present. (See 'Pregnancy' below and 'Obesity' below.)

The etiology in males can also be hereditary or acquired. Acquired forms can be the result of absolute pressure due to visceral obesity as well as relative increased abdominal pressure caused by weightlifting or improper exercise. In males, RAD can occur also without abdominal obesity or abdominal skin relaxation (ie, related to dramatic weight loss) and is more likely to be associated with aneurysmal disease compared with females [16]. (See 'Obesity' below and 'Aneurysm' below.)

Pregnancy — Pregnancy increases the risk of developing RAD; however, not all females develop diastasis during the course of pregnancy, and among those who do, RAD is associated with conditions that are related to weakening of other tissues (eg, heavy lifting) [17]. The amount of the separation can increase, decrease, or stay the same in the postpartum period. While pre-emptive exercise may prevent diastasis, whether postpartum exercise can resolve it is reviewed below. (See 'Postpartum exercise' below.)

The inter-rectus distance was measured in females from 36 weeks of gestation to 12 weeks postpartum in one study [18]. The distance increased 200 to 400 percent at 12 weeks postpartum compared with the measurement at 36 weeks of gestation. A separate study used ultrasound to measure the inter-rectus distance for 84 healthy primiparous females at three locations along the linea alba at three points in time in the course of their pregnancy [19]. A diagnosis of RAD was defined as 16 mm at 2 cm below the umbilicus. The prevalence of diastasis was 100 percent at gestational week 35 and decreased to 39 percent at six months postpartum. Prepregnancy body mass index (BMI), weight gain, baby's birth weight, or abdominal circumference was not different between females with and without diastasis at six months postpartum. Females with diastasis at six months postpartum were not more likely to report lumbo-pelvic pain compared with females without diastasis.

In a study of females who needed abdominal hysterectomies, 38 percent had RAD, but most were mild [2]. A higher prevalence (52 percent) was found in other studies that have also identified older age, higher cesarean and parity, weak pelvic floor musculature, and recurrent cesarean section for patients with versus without RAD [20,21]. In a cross-sectional study, the incidence of RAD peaked in the third trimester group, remained high in the females in the immediate postpartum group, and declined, but did not disappear, in the later postpartum group [22].

In a review that included 38 females with RAD measuring at least 2 cm, at rest the mean inter-rectus distance was 25.7 mm (standard deviation [SD] 8.5 mm) at 2 cm above the umbilicus and 21.0 mm (SD 7.9 mm) 2 cm below the umbilicus [23]. With isometric muscle contraction (ie, transversus abdominis muscle, pelvic floor muscles, or both), the mean inter-rectus distance increased both above and below the umbilicus with mean differences (compared with rest) ranging from 1.2 to 3.9 mm.

A systematic review identified four studies that included 228 females evaluating the effect of exercise during the antenatal period [24]. Exercise significantly reduced the risk of developing RAD (relative risk [RR] 0.65, 95% CI 0.46-0.92).

Obesity — Obesity is a risk factor for incisional hernia related to increased lateral stress. A similar mechanism may contribute to the development of RAD in patients with obesity. Gradual weight gain can cause the rectus muscles to increasingly separate above the umbilicus [16]. However, there are few studies specifically documenting obesity as a risk factor.

Aneurysm — RAD may be associated with aneurysmal disease, which also results from weakening of the tissues. Some, but not all studies, support such an association. In one study, RAD was more prevalent in subjects with abdominal aortic aneurysm compared with subjects with peripheral artery disease (12/18 [67 percent] versus 4/24 [17 percent]) [14]. Another study found no significant difference in inter-rectus distance between those with AAA and controls [25].

CLINICAL FEATURES — RAD may or may not be associated with symptoms. Excessive abdominal muscle separation can compromise the function of the anterior abdominal wall.

RAD is usually quite apparent on physical examination. When a patient with RAD raises their head and begins to sit up, the increase in intra-abdominal pressure as the two rectus muscles contract can result in a diffuse fusiform bulge, often with a protrusion of abdominal contents into the thinned, bulged midline fascia, which can be seen as a prominent ridge extending from the xiphoid to the umbilicus. However, protrusion of abdominal contents may not occur. But, RAD does not represent an abdominal wall hernia; there is no fascial defect and, therefore, no risk of incarceration or strangulation. Ventral hernia can coexist with RAD, however, particularly if there has been a previous laparotomy, so differential diagnosis is important.

In a systematic review, RAD was not demonstrated to be associated with lumbopelvic pain or incontinence; however, there was a small association with pelvic organ prolapse [26].

DIAGNOSIS — Most typically, RAD can be diagnosed based on a simple physical examination [2]. Distortion of the linea alba may best be noticed by a semi-curl-up, rather than a head lift maneuver, owing to differences in stiffness and distortion among patients without compared to with RAD [27].

A three-step diagnostic scheme has been described to aid in diagnostic evaluation and surgical decision-making [28]. It includes standing the patient in front of a mirror and assessing the bulge, placing the patient on their back with chin raised and leg raised to observe the bulge, and finally seating the patient in a chair to identify the crease of the lower part of the abdomen.

Measurements of the distance between the rectus abdominis muscles can be taken at rest and during contraction at several levels along the linea alba to determine if they are abnormal. A pair of dial calipers is used in many research studies, but these are not likely to be readily available to most physicians. The reliability of and the need for a more accurate measuring tool has been suggested [29,30]. In certain circumstances (eg, patient with obesity), imaging will be needed to demonstrate widening of the linea alba.

Imaging — If the diagnosis is in question, ultrasonography is a validated noninvasive, repeatable method that can be used to confirm RAD, exclude other sources for such a bulge, and plan surgery [5,31-34]. Computed tomography and magnetic resonance imaging of the abdomen can also be used to accurately determine the inter-rectus distance and further define abdominal wall anatomy [35]. Interestingly, however, cross-sectional imaging seems to slightly underestimate inter-rectus distance and thus severity of rectus distance when compared with intraoperative findings [36].

Other benefits of imaging are that it helps to distinguish RAD from a true hernia and may confirm their coexistence. Imaging may depict areas of muscle damage or avulsion, atrophy (which may be from denervation), or dysfunction.

DIFFERENTIAL DIAGNOSIS — The experienced practitioner can usually readily distinguish RAD from incisional, congenital, or acquired midline hernias of the abdominal wall. While a true hernia is associated with a fascial defect, patients with RAD have no detectable fascial defect when they are supine (figure 1 and figure 2).

Incisional hernias are found in the presence of an obvious surgical incision. Congenital or acquired midline hernias of the abdominal wall are confined to the umbilicus or the epigastrium. Epigastric hernias are generally focal and ≤2 cm in diameter. (See "Overview of abdominal wall hernias in adults".)

MANAGEMENT — There are few data to guide management of RAD. Two randomized trials have focused on comparisons of varying types of mesh, or sutures for the repair of RAD [35,37]. The remainder of studies consist of a handful of small, retrospective reviews [38]. In a systematic review of treatment options, no clear consensus was obtained as to the optimal treatment [39]. The review included 20 manuscripts and 1691 patients who had repair of RAD, including 313 patients who had plication techniques, 68 patients who had modified hernia repair techniques, and 1210 patients who had combined hernia and diastasis repair techniques. Open repair techniques were used in 85 percent. There were no differences in the incidence of complications or recurrences for open repair compared with the laparoscopic techniques.

RAD does not represent a true hernia, and thus, it does not necessarily require repair. Conservative management with weight loss and exercise are advised as a first-line treatment [1]. For symptomatic patients in whom conservative management does not improve RAD, abdominoplasty with rectus abdominis plication, with or without mesh reinforcement, is a surgical option and usually considered an elective cosmetic procedure.

Weight loss — Weight loss should be encouraged, but often does not improve the diastasis. If significant weight loss is achieved and maintained, elective plication of the linea alba can be considered. (See 'Surgical repair' below.)

Postpartum exercise — Exercise programs can be used to help regain some degree of strength in the midline in the postpartum setting [24]. Whether such exercises improve RAD has not been definitively determined.

A systematic review identified three studies, one of which was randomized [24]. In the randomized trial, 50 pregnant females were randomly assigned to a postpartum exercise protocol or no exercise in the immediate postpartum period [40]. The intervention group had a greater mean decrease in the inter-rectus distance compared with controls (0.44 cm [13 percent] versus 0.17 cm [5 percent]). However, in a separate trial, 175 primiparous females were randomly assigned to no exercise or a four-month exercise regimen (six exercises) that commenced six weeks postpartum [41]. Inter-rectus measurements were obtained 4.5 cm above and below the umbilicus. At the onset of the study, 55.2 and 54.5 percent of patients had evidence of RAD based on the inter-rectus distance. At 6 and 12 months postpartum, there were no significant differences in the inter-rectus distance between the group that exercised and the group that did not.

Numerous exercise regimens have been described to assist with RAD (picture 1). Most exercises are focused on strengthening the rectus abdominis muscles [42]. The six exercises included in the above mentioned randomized trial included draw-in while on knees and hands, draw-in while prone, half plank, side plank, oblique sit-ups, and straight sit-ups. Another exercise regimen incudes the Nobel technique that involves manual reapproximation or alignment of the rectus abdominis muscles while performing a partial sit-up. Interested females can be referred to a physical therapist, who can help develop a postpartum exercise program targeted at strengthening the anterior abdominal wall. For patients with RAD as a result of pregnancy, elective plication is a reasonable option once normal prepregnancy weight has been achieved and if there are no plans for future pregnancies.

The Tupler technique is a nonsurgical method for correcting or improving RAD. This technique is focused on allowing the damaged connective tissue to repair itself by offloading pressure by wearing an abdominal splint or binder-like device. The program typically takes 18 weeks, and a modified exercise program is initiated at 6 weeks [43]. However, outcomes data for this technique are lacking.

Spontaneous resolution — Spontaneous resolution has been reported for acquired RAD, usually in the postpartum setting and sometimes associated with specific physiotherapy efforts [18]. (See 'Pregnancy' above.)

SURGICAL REPAIR — The indications for repair of RAD depend upon the clinical setting. Some have suggested that the abdominal protrusion, rather than the amount of muscle separation, is more important for determining whether or not to proceed with surgical repair [4,16]. Larger RAD can be repaired if the patient has significant symptoms, but it is doubtful that smaller defects require any repair at all [1,44]. However, for females who do not resolve their diastasis in the postpartum period, particularly those with loss of abdominal musculature following multiple pregnancies, repair can improve pulmonary and abdominal wall function. Repair is often performed as a cosmetic abdominoplasty by plastic surgeons. However, plication alone is an option for those without excessive skin laxity, a procedure that is also performed by general surgeons [16]. Depending upon the magnitude of the procedure, an inpatient or outpatient setting may be appropriate [45].

Approaches — There are many methods by which to repair RAD. These differ by approach (open versus laparoscopic), numbers of layers of sutures, the position of suture placement, suture material used, and whether or not mesh is used [38,39,46]. The selected surgical technique will depend upon the amount of excess skin, need for liposuction, the presence of coexisting hernia, and the general body habitus of the patient.

The approach may differ for males versus females. In males, the approach is usually through a vertical incision, whereas in females it is through a low transverse Pfannenstiel-type incision [47].

Regardless of approach, to provide an effective repair, plication of the rectus sheath is required. If the defect is congenital, some suggest plication of the posterior as well as the anterior sheath [48]. Vertical plication only is generally not felt by some to be enough to improve the waistline [49]. For this reason, transverse plication of the rectus abdominis fascia is also performed to prevent epigastric bulging.

Laparoscopic repair — Laparoscopic approaches have been reported [35,50-53]. Indications for total laparoscopic repair include midline/umbilical hernia measuring >2 cm, no prior hernia repair or laparotomy, and no need for abdominoplasty. The only randomized trial comparing open and laparoscopic repair reported a lower rate of complications for the laparoscopic compared with open abdominoplasty groups (15 versus 24 percent) [52]. Four patients required operative reintervention in the open abdominoplasty group for complications of wound healing and hematoma formation.

In a retrospective review of 94 patients, three surgical repair techniques were compared and included two open techniques (laparo-abdominoplasty and laparo-miniabdominoplasty) with one laparoscopic technique (totally endoscopic sublay anterior repair) [54]. Major surgical complications occurred in three (4.2 percent) cases, all after open operations. Ischemic changes of the skin were noted in 13 open surgery cases requiring vacuum-assisted closure (ie, negative pressure wound therapy). No patient developed a recurrence within the follow-up period. The authors concluded that the laparoscopic approach resulted in fewer complications, shorter length of hospital stay, and improved quality-of-life compared with the open approach.

Similarly, in a systematic review of 28 studies comparing open with laparoscopic techniques, open techniques were associated with a significantly higher rate of skin dehiscence (6.79 versus 2.86 percent) and hematoma (4.73 versus 1.09 percent), but a significantly lower rate of postoperative seroma formation (2.47 versus 8.29 percent) [55]. However, most importantly, RAD recurrence rates were similar for open compared with laparoscopic repair techniques (0.22 versus 0.63 percent).

Abdominoplasty — RAD is often corrected in the course of abdominoplasty [35,44,45,48,49,56-66]. The standard abdominoplasty approach is performed by removing excess skin. Liposuction is commonly combined with abdominoplasty to remove excess fat [59,67,68]. Then, the skin of the anterior abdominal wall is undermined up to the xiphoid to expose the fascia of the rectus muscles [45]. The umbilicus stays in its native position and a new orifice is made to accommodate it after advancing the abdominal skin inferiorly. The diastasis can be repaired by removing a strip of the widened linea alba and reapproximating the edges of the rectus muscles using running sutures [35]. Another method uses interrupted triangulation stitches to anchor the anterior rectus sheath to the midline (figure 3).

Plication alone — For mild-to-moderate RAD, suture plication alone can be considered. The fascia medial to the rectus abdominis muscles can be sutured together (ie, plicated) along the vertical midline. This can be performed using a one or two-layer suture technique or via the triangular suture technique (figure 3), incorporating the lateral edges of the fascia and the midline of the posterior rectus sheath [10].

The authors of a qualitative review of suture material and suture techniques for the correction of RAD, which included 2 randomized trials [63,69] and 20 other observational studies and case reports, concluded that slowly absorbable or permanent suture were both acceptable [70]. Sufficient data were available to recommend continuous single-layer plication. In some patients, an interrupted triangular suture is an alternative option. Optimal suture sizes provided in the review were size 0 (ie, 1-0; 0.35 mm) for slowly absorbable suture and 2-0 (0.30 mm) for permanent suture.

In a small trial (20 patients) that compared nylon (permanent suture) with polydioxanone (slowly absorbable suture) for plication, all the repairs remained intact with no evidence for recurrence on computed tomography at six months [35]. Other suture comparisons have also not shown a significant difference in outcomes for types of suture [71,72].

In another small trial that randomly assigned 30 females to two-layer versus single-layer plication, single-layer plication was performed more quickly with no apparent differences in outcomes [69].

Plication with mesh — For moderate-to-severe RAD, repair can be considered using suture plication and mesh [47,73,74]. The mesh can be placed on the surface of the anterior rectus sheath following plication or between the rectus abdominis muscle and posterior rectus sheath, also known as the retrorectus space.

The onlay technique consists of a permanent or resorbable mesh placed over the anterior rectus sheath to reinforce its strength, and typically extends from the costal margin to the pubic region. The mesh is usually fixed in position with absorbable sutures [73]. In a review of 63 females following open repair of RAD, four also had placement of an onlay mesh [75]. The mesh was polypropylene in three patients and silk-based in one patient. Of the four patients, all tolerated the operation well without morbidity. Natural contour was established in all. There were no infections, seromas, delayed healing, or mesh removals. All drains were removed by seven days.

With the retrorectus technique, the redundant posterior sheath is plicated or excised, and a permanent or absorbable mesh is placed and anchored with absorbable sutures [47]. Retrorectus mesh placement for management of RAD was reported in a review of 56 patients that included 40 females and 16 males [76]. The approach was vertical in most patients. Superficial surgical site infection requiring oral antibiotics occurred in three patients. Soft tissue revision for improved cosmesis were performed in 23 percent of females and 6 percent of males.

When RAD occurs in conjunction with a true hernia, one investigator recommended first managing the hernia followed by a retrorectus dissection, reapproximation of the posterior rectus sheath, placement of a midweight polypropylene mesh, and midline plication of the rectus abdominis muscles [47]. No recurrence of hernia or bulge occurred in 32 patients at 1.5 years using this technique.

Postoperative care and follow-up — Heavy lifting (more than five pounds) is restricted for six weeks postoperatively. Closed suction drains are usually placed and remain for a few days until the output is <30 cc/24 hours. An abdominal binder is considered in females with severe RAD for compression and comfort. Patients are usually instructed to follow up every three to four days following surgery until the drains are removed, and then again at six weeks.

Complications — Major complications following surgery are uncommon [1]. The nature of complications differs depending upon the surgical approach. Most complications are primarily due to seroma or wound complications, such as skin or flap ischemia, surgical site infection, or hypertrophic scarring [16,38,49,52,62,77].

Despite the theoretical risk for deep vein thrombosis (DVT) due to a reduction in venous return and venous pooling due to increased intra-abdominal pressure, a systematic review found no DVTs [38].

Complications may be more frequent when mesh is used. In one trial of 64 patients that compared suture repair with mesh repair, short-term superficial wound infection occurred in 31 percent following mesh repair and 18 percent following suture repair, and seroma occurred in 17 percent following mesh repair and 14 percent following suture repair [37].

Recurrence and other outcomes — Repair of RAD has high rates of initial success, but the reported rate of recurrence is high [38,44,65]. In a systematic review, recurrence occurred in 40 percent of cases, but there was high variability between the reports [38].

Few recurrences are reported in studies with short- or intermediate-term results [47,63,65,71,78]. As examples, in a review of 20 females for whom RAD was repaired using midline plication after abdominoplasty, no recurrences were apparent on magnetic resonance imaging evaluation to 25 months [79]. In another study of retrorectus repair using polypropylene mesh, there were no recurrences at 18 month follow-up [47].

Several studies have assessed longer-term results following RAD repair. In one small study that used plication alone, no recurrences occurred at an average of 81.2 month follow-up [63]. However, in the report of 63 patients, after a mean follow-up period of 64 months following plication with absorbable mesh, recurrence occurred in 40 percent [49]. In another review where absorbable mesh was used, only one recurrence was reported among 52 females over a mean follow-up of 54 months [67].

Patient-reported outcomes and quality-of-life (QoL) considerations are becoming increasingly relevant when considering repair of RAD. A limitation of the various studies is the absence of standardized instruments for assessing outcome, making comparisons difficult. Following surgery to correct RAD, patient satisfaction with the procedure appears to be generally high [38]. In one trial, patient satisfaction was 90 percent among those repaired using mesh reinforcement and 82 percent for those undergoing suture repair [37]. The authors concluded that there were no appreciable differences between the two techniques in terms of early complications and perceived pain three months following the procedure.

In a review of QoL issues using several methods of measurement (eg, Body-Q, Body-QoL, RSES), QoL outcomes were similar for three different surgical methods used to repair RAD [80]. The authors concluded that abdominal appearance alone is not the only factor important for QoL improvement and suggested that there is a complex interplay between abdominal aesthetics and resolution of troubling physical symptoms, psychology, and resultant QoL.

Regardless of method of surgical repair, repair of RAD is safe and effective treatment and also improves functional outcomes [81]. In most of the studies evaluating functional abilities and QoL, significant functional outcomes improvements were measured. Surgical repair provides improved self-reported physical function, abdominal core muscle strength, posture, as well as improvements in urinary incontinence and lower back pain.

PEDIATRIC CONSIDERATIONS — RAD in newborns and the pediatric population is very uncommon, and there is very little literature about it. It is not usually acquired, and when present, it is usually a component of a congenital syndromic anomaly. A congenital-type RAD can occur as an abdominal wall maturation deficiency without an associated sequence or syndrome through an autosomal dominant transmission [3]. Nonsyndromic RAD often spontaneously resolves as the infant grows and their rectus abdominis muscle strengthens and hypertrophies.

Syndromes associated with hypoplasia of the abdominal wall muscles and/or separation of the midline musculature may include prune-belly syndrome, Beckwith-Wiedemann syndrome, Simpson-Golabi-Behmel syndrome, and midline defect syndromes. Treatment parameters for diastasis recti in these patients are poorly defined due to the complexity of the syndromes and any cognitive impairment associated with them. These syndromes are reviewed separately.

Prune-belly syndrome is a triad of abdominal muscle deficiency, urinary tract abnormalities, and bilateral cryptorchidism in males. (See "Prune-belly syndrome".)

Beckwith-Wiedemann syndrome is characterized by various abdominal wall defects that may include omphalocele, which is a midline defect of variable size related to the umbilicus, umbilical hernia, and RAD [82]. (See "Beckwith-Wiedemann syndrome", section on 'Clinical manifestations'.)

Simpson-Golabi-Behmel syndrome is characterized by various morphologic abnormalities but can also include RAD or umbilical hernia [83]. (See "The child with tall stature and/or abnormally rapid growth", section on 'Other overgrowth syndromes'.)

Midline defect syndromes such as the Cantrell pentalogy (thoracoabdominal syndrome), Opitz G/BBB syndrome, and PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome may include a variety of midline defects (eg, hypertelorism, cleft palate, tracheolaryngeal abnormalities, sternal or abdominal wall defects, genitourinary abnormalities) [84]. (See "PHACE syndrome".)

SUMMARY AND RECOMMENDATIONS

Rectus abdominis diastasis – Rectus abdominis diastasis (RAD) is an anatomic term describing a condition in which an abnormal distance separates the two rectus muscles. There is controversy regarding what constitutes a normal inter-rectus distance. We consider a separation of more than 2 cm to be abnormal. (See 'Definition' above.)

Classification – Abdominal wall defects, including RAD, can be congenital or acquired. Acquired RAD is due to weakening of the abdominal wall tissues due to a variety of factors that can result in abdominal muscle separation. Risk factors for RAD include elevated intra-abdominal pressure, such as in pregnancy or obesity, prior abdominal surgery, and known connective tissue disorder. (See 'Classification' above.)

Risk factors – Patients with acquired RAD typically have one of two profiles: middle-aged and older males, or small, fit females who have carried a large fetus or twins to term. In males, RAD can occur without abdominal obesity, or abdominal skin relaxation. (See 'Risk factors' above.)

Clinical features – RAD is usually quite apparent on physical examination. It can usually be easily distinguished from acquired midline hernias of the abdominal wall, but in certain circumstances, ultrasound (or computed tomography) of the abdomen may be needed. (See 'Clinical features' above.)

Management – RAD does not represent a true hernia, and thus, it does not necessarily require repair. Conservative management with weight loss and exercise are advised as a first-line treatment. Surgical repair can improve pulmonary and abdominal wall function. (See 'Management' above.)

For those who develop RAD during pregnancy, postpartum abdominal wall strengthening exercises can improve RAD. Pre-emptive exercise may prevent RAD during pregnancy. (See 'Postpartum exercise' above.)

For females and males who do not resolve RAD despite conservative measures, abdominoplasty can be considered.

Plication of the rectus sheath is often performed in conjunction with abdominoplasty; however, plication alone is an option for those without excessive skin laxity. Major complications following surgical repair of RAD are uncommon and depend upon the surgical approach. Recurrence rates vary depending on the length of follow-up; long-term recurrence rates may be as high as 40 percent. (See 'Surgical repair' above.)

  1. Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg Hand Surg 2014; 48:163.
  2. Ranney B. Diastasis recti and umbilical hernia causes, recognition and repair. S D J Med 1990; 43:5.
  3. Digilio MC, Capolino R, Dallapiccola B. Autosomal dominant transmission of nonsyndromic diastasis recti and weakness of the linea alba. Am J Med Genet A 2008; 146A:254.
  4. Brauman D. Diastasis recti: clinical anatomy. Plast Reconstr Surg 2008; 122:1564.
  5. Beer GM, Schuster A, Seifert B, et al. The normal width of the linea alba in nulliparous women. Clin Anat 2009; 22:706.
  6. Keshwani N, Mathur S, McLean L. Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period. Phys Ther 2018; 98:182.
  7. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths. I. General scheme and morphological aspects. J Surg Res 2001; 96:127.
  8. Mota P, Pascoal AG, Carita AI, Bø K. Normal width of the inter-recti distance in pregnant and postpartum primiparous women. Musculoskelet Sci Pract 2018; 35:34.
  9. Rath AM, Attali P, Dumas JL, et al. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat 1996; 18:281.
  10. Nahas FX. An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg 2001; 108:1787.
  11. Christ B, Jacob M, Jacob HJ. On the origin and development of the ventrolateral abdominal muscles in the avian embryo. An experimental and ultrastructural study. Anat Embryol (Berl) 1983; 166:87.
  12. Okayasu I, Kajita A, Shimizu K. A variant form of median defect syndrome. Syndrome of combined congenital defects involving the supraumbilical abdominal wall, sternum, diaphragm, pericardium, and heart. Acta Pathol Jpn 1978; 28:287.
  13. Cavalli M, Aiolfi A, Bruni PG, et al. Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia 2021; 25:883.
  14. McPhail I. Abdominal aortic aneurysm and diastasis recti. Angiology 2008; 59:736.
  15. Nienhuijs SW, Berkvens EHM, de Vries Reilingh TS, et al. The male rectus diastasis: a different concept? Hernia 2021; 25:951.
  16. Lockwood T. Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg 1998; 101:1685.
  17. Sperstad JB, Tennfjord MK, Hilde G, et al. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016; 50:1092.
  18. Hsia M, Jones S. Natural resolution of rectus abdominis diastasis. Two single case studies. Aust J Physiother 2000; 46:301.
  19. Fernandes da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015; 20:200.
  20. Turan V, Colluoglu C, Turkyilmaz E, Korucuoglu U. Prevalence of diastasis recti abdominis in the population of young multiparous adults in Turkey. Ginekol Pol 2011; 82:817.
  21. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:321.
  22. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988; 68:1082.
  23. Theodorsen NM, Strand LI, Bø K. Effect of pelvic floor and transversus abdominis muscle contraction on inter-rectus distance in postpartum women: a cross-sectional experimental study. Physiotherapy 2019; 105:315.
  24. Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy 2014; 100:1.
  25. Moesbergen T, Law A, Roake J, Lewis DR. Diastasis recti and abdominal aortic aneurysm. Vascular 2009; 17:325.
  26. Benjamin DR, Frawley HC, Shields N, et al. Relationship between diastasis of the rectus abdominis muscle (DRAM) and musculoskeletal dysfunctions, pain and quality of life: a systematic review. Physiotherapy 2019; 105:24.
  27. Beamish N, Green N, Nieuwold E, McLean L. Differences in Linea Alba Stiffness and Linea Alba Distortion Between Women With and Without Diastasis Recti Abdominis: The Impact of Measurement Site and Task. J Orthop Sports Phys Ther 2019; 49:656.
  28. Mughal M, Ross D. Management of the post-pregnancy abdomen: the plastic surgical perspective. Hernia 2021; 25:929.
  29. Chiarello CM, McAuley JA. Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. J Orthop Sports Phys Ther 2013; 43:495.
  30. Bursch SG. Interrater reliability of diastasis recti abdominis measurement. Phys Ther 1987; 67:1077.
  31. Mota P, Pascoal AG, Sancho F, Bø K. Test-retest and intrarater reliability of 2-dimensional ultrasound measurements of distance between rectus abdominis in women. J Orthop Sports Phys Ther 2012; 42:940.
  32. Liaw LJ, Hsu MJ, Liao CF, et al. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. J Orthop Sports Phys Ther 2011; 41:435.
  33. Mendes Dde A, Nahas FX, Veiga DF, et al. Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cir Bras 2007; 22:182.
  34. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther 2008; 13:112.
  35. Nahas FX, Augusto SM, Ghelfond C. Nylon versus polydioxanone in the correction of rectus diastasis. Plast Reconstr Surg 2001; 107:700.
  36. Plumb AA, Windsor ACJ, Ross D. Contemporary imaging of rectus diastasis and the abdominal wall. Hernia 2021; 25:921.
  37. Emanuelsson P, Gunnarsson U, Strigård K, Stark B. Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up. J Plast Reconstr Aesthet Surg 2014; 67:1082.
  38. Hickey F, Finch JG, Khanna A. A systematic review on the outcomes of correction of diastasis of the recti. Hernia 2011; 15:607.
  39. Mommers EHH, Ponten JEH, Al Omar AK, et al. The general surgeon's perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc 2017; 31:4934.
  40. Mesquita LA, Machado AV, Andrade AV. Physiotherapy for Reduction of Diastasis of the Recti Abdominis Muscles in the Postpartum Period. Rev Bras Ginecol Obstet 1999; 21:267.
  41. Gluppe SL, Hilde G, Tennfjord MK, et al. Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Phys Ther 2018; 98:260.
  42. Michalska A, Rokita W, Wolder D, et al. Diastasis recti abdominis - a review of treatment methods. Ginekol Pol 2018; 89:97.
  43. https://diastasisrehab.com (Accessed on May 25, 2015).
  44. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesthetic Plast Surg 1997; 21:285.
  45. Williams TC, Hardaway M, Altuna B. Ambulatory abdominoplasty tailored to patients with an appropriate body mass index. Aesthet Surg J 2005; 25:132.
  46. Nahas FX, Ferreira LM. Concepts on correction of the musculoaponeurotic layer in abdominoplasty. Clin Plast Surg 2010; 37:527.
  47. Cheesborough JE, Dumanian GA. Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs. Plast Reconstr Surg 2015; 135:268.
  48. Nahas FX, Ferreira LM, Mendes Jde A. An efficient way to correct recurrent rectus diastasis. Aesthetic Plast Surg 2004; 28:189.
  49. van Uchelen JH, Kon M, Werker PM. The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography. Plast Reconstr Surg 2001; 107:1578.
  50. Palanivelu C, Rangarajan M, Jategaonkar PA, et al. Laparoscopic repair of diastasis recti using the 'Venetian blinds' technique of plication with prosthetic reinforcement: a retrospective study. Hernia 2009; 13:287.
  51. Chang CJ. Assessment of videoendoscopy-assisted abdominoplasty for diastasis recti patients. Biomed J 2013; 36:252.
  52. Zukowski ML, Ash K, Spencer D, et al. Endoscopic intracorporal abdominoplasty: a review of 85 cases. Plast Reconstr Surg 1998; 102:516.
  53. Claus C, Cavazzola L, Malcher F. SubCutaneous OnLay endoscopic Approach (SCOLA) for midline ventral hernias associated with diastasis recti. Hernia 2021; 25:957.
  54. Fiori F, Ferrara F, Gobatti D, et al. Surgical treatment of diastasis recti: the importance of an overall view of the problem. Hernia 2021; 25:871.
  55. ElHawary H, Barone N, Zammit D, Janis JE. Closing the gap: evidence-based surgical treatment of rectus diastasis associated with abdominal wall hernias. Hernia 2021; 25:827.
  56. Yousif NJ, Lifchez SD, Nguyen HH. Transverse rectus sheath plication in abdominoplasty. Plast Reconstr Surg 2004; 114:778.
  57. Ferreira LM, Castilho HT, Hochberg J, et al. Triangular mattress suture in abdominal diastasis to prevent epigastric bulging. Ann Plast Surg 2001; 46:130.
  58. Asaadi M, Haramis HT. A simple technique for repair of rectus sheath defects. Ann Plast Surg 1994; 32:107.
  59. Brauman D, Capocci J. Liposuction abdominoplasty: an advanced body contouring technique. Plast Reconstr Surg 2009; 124:1685.
  60. Dabb RW, Hall WW, Baroody M, Saba AA. Circumferential suction lipectomy of the trunk with anterior rectus fascia plication through a periumbilical incision: an alternative to conventional abdominoplasty. Plast Reconstr Surg 2004; 113:727.
  61. Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000; 105:425.
  62. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg 2000; 105:2583.
  63. Nahas FX, Ferreira LM, Augusto SM, Ghelfond C. Long-term follow-up of correction of rectus diastasis. Plast Reconstr Surg 2005; 115:1736.
  64. Veríssimo P, Nahas FX, Barbosa MV, et al. Is it possible to repair diastasis recti and shorten the aponeurosis at the same time? Aesthetic Plast Surg 2014; 38:379.
  65. Tadiparthi S, Shokrollahi K, Doyle GS, Fahmy FS. Rectus sheath plication in abdominoplasty: assessment of its longevity and a review of the literature. J Plast Reconstr Aesthet Surg 2012; 65:328.
  66. Cardenas Restrepo JC, Munoz Ahmed JA. New technique of plication for miniabdominoplasty. Plast Reconstr Surg 2002; 109:1170.
  67. Batchvarova Z, Leymarie N, Lepage C, Leyder P. Use of a submuscular resorbable mesh for correction of severe postpregnancy musculoaponeurotic laxity: an 11-year retrospective study. Plast Reconstr Surg 2008; 121:1240.
  68. Kanjoor JR, Singh AK. Lipoabdominoplasty: An exponential advantage for a consistently safe and aesthetic outcome. Indian J Plast Surg 2012; 45:77.
  69. Gama LJM, Barbosa MVJ, Czapkowski A, et al. Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique. Aesthet Surg J 2017; 37:698.
  70. Nahas FX, Faustino LD, Ferreira LM. Abdominal Wall Plication and Correction of Deformities of the Myoaponeurotic Layer: Focusing on Materials and Techniques Used for Synthesis. Aesthet Surg J 2019; 39:S78.
  71. Mestak O, Kullac R, Mestak J, et al. Evaluation of the long-term stability of sheath plication using absorbable sutures in 51 patients with diastasis of the recti muscles: an ultrasonographic study. Plast Reconstr Surg 2012; 130:714e.
  72. Rosen A, Hartman T. Repair of the midline fascial defect in abdominoplasty with long-acting barbed and smooth absorbable sutures. Aesthet Surg J 2011; 31:668.
  73. Nahabedian MY. Diagnosis and management of diastasis recti. In: Hernia Surgery: Current Principles, Novitsky YW (Ed), Springer, Switzerland 2016.
  74. Emanuelsson P, Gunnarsson U, Dahlstrand U, et al. Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures. Surgery 2016; 160:1367.
  75. Nahabedian MY. Diastasis recti repair with onlay mesh. Hernia 2021; 25:855.
  76. Dumanian GA, Moradian S. Mesh abdominoplasty for rectus diastasis in women and men. Hernia 2021; 25:863.
  77. van Uchelen JH, Werker PM, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconstr Surg 2001; 107:1869.
  78. de Castro EJ, Radwanski HN, Pitanguy I, Nahas F. Long-term ultrasonographic evaluation of midline aponeurotic plication during abdominoplasty. Plast Reconstr Surg 2013; 132:333.
  79. Elkhatib H, Buddhavarapu SR, Henna H, Kassem W. Abdominal musculoaponeuretic system: magnetic resonance imaging evaluation before and after vertical plication of rectus muscle diastasis in conjunction with lipoabdominoplasty. Plast Reconstr Surg 2011; 128:733e.
  80. Edmondson SJ, Ross DA. The postpartum abdomen: psychology, surgery and quality of life. Hernia 2021; 25:939.
  81. Olsson A, Kiwanuka O, Sandblom G, Stackelberg O. Evaluation of functional outcomes following rectus diastasis repair-an up-to-date literature review. Hernia 2021; 25:905.
  82. Cohen MM Jr. Beckwith-Wiedemann syndrome: historical, clinicopathological, and etiopathogenetic perspectives. Pediatr Dev Pathol 2005; 8:287.
  83. Sajorda BJ, Gonzalez-Gandolfi CX, Hathaway ER, et al. Simpson-Golabi-Behmel Syndrome Type 1. In: GeneReviews, University of Washington, Seattle, 2006.
  84. De Falco F, Cainarca S, Andolfi G, et al. X-linked Opitz syndrome: novel mutations in the MID1 gene and redefinition of the clinical spectrum. Am J Med Genet A 2003; 120A:222.
Topic 100494 Version 17.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟