Abstract
Introduction:
Diastasis recti (DR) is characterized by an abnormal separation between the rectus abdominis muscles. Traditional repair includes only plication; however, complications may arise in the presence of concurrent ventral hernias (VH). This study aims to evaluate the safety and feasibility of diastasis repair in a United Arab Emirates (UAE) population.
Methods and Procedures:
This retrospective cohort study was conducted with IRB approval. All patients who underwent a DR repair (DRR) with concomitant ventral hernia repair between October 2022 and February 2024 were included.
Results:
A total of 20 patients were included in the study. The cohort was 80% female, with a mean overall age of 44.05 years. The mean body mass index was 27.4 kg/m2. All patients (100%) presented with DR associated with an abdominal wall defect; 17 patients (85%) with umbilical hernia, 2 patients (10%) with umbilical and incisional hernia, and 1 patient (5%) with umbilical with epigastric hernia. A total of 12 (60%) patients underwent laparoscopic DRR concomitant with VH repair, 5 (25%) patients underwent open DRR with VH repair and abdominoplasty, and 1 patient (5%) underwent DRR with VH repair and liposuction. All cases were successful without complications or conversions. Complications within 30 days included only seromas in 6 patients (30%), one requiring drainage.
Conclusion:
Our initial experience suggests that DR repair with concomitant VH repair and/or abdominoplasty is feasible and safe in the UAE population. Our experience demonstrated surgical outcomes compared to other regions in the world.
Introduction
Diastasis recti (DR) is characterized by an abnormal separation of 2 cm or more between the rectus abdominis muscles, leading to a weakened linea alba. 1 The global prevalence of DR remains uncertain due to variations in measurement methods and judgment criteria. 2 Nonetheless, Wu et al. reported a prevalence of 28.4% in a survey of 644 adult women who underwent abdominal computed tomography. 3 In the Middle East and North Africa (MENA), the lack of documented prior experiences highlights the importance of establishing a Hernia Registry Program in the region.
Traditionally, diastasis recti can be corrected through plication of the linea alba with minimally invasive techniques or by using an open approach when there is excess skin or fatty tissue in combination with abdominoplasty.4,5 However, this relatively simple approach can become quite challenging when patients present with concomitant ventral hernias (VH). Kohler et al. reported higher recurrence rates in patients with both DR and (VH when compared with those with ventral hernias alone. 6 This correlation between DR and midline VH is significant due to the shared laxity of abdominal muscles in both conditions, which can potentially compromise a durable repair.2,7
Mesh-based repair is recommended by the European Hernia Society (EHS) and the Americas Hernia Society for patients with concurrent DR and VH. 1 Various surgical techniques and outcomes have been previously reported.8–11 Dong et al. published their institutional experience in the U.S, employing a subcutaneous onlay endoscopic approach for DR with small midline VH. 7 This study demonstrated a success rate of 100%, as all cases were completed without intraoperative complications and a short-term complication rate of 18.8%. Chang reported his experience with video endoscopy-assisted abdominoplasty for patients with DR in a population from Taiwan. 12 He reports that 3 weeks after the surgery, the most common complaint was numbness and paresthesia (100%), followed by ecchymosis (10.2%) and seroma (3.4%). De Figueiredo et al. reported their expertise in managing VH, including minimally invasive approaches and different techniques for mesh placement. 13 Among the 169 patients involved in the study, they found a surgical site occurrence (defined as seromas or skin necrosis) of 4%.
However, a significant knowledge gap exists concerning the applicability of these surgical techniques in the MENA population, in addition to the lack of reports of short-term outcomes. Therefore, this study aims to assess the safety and feasibility of diastasis repair in a tertiary referral academic medical center in the United Arab Emirates (UAE).
Methods
Study design and ethical approvals
This retrospective study was conducted between October 2022 through February 2024. We reviewed electronic medical records to collect data on demographic characteristics, preoperative comorbidities, intraoperative data, and postoperative outcomes. This study was approved by the Research Ethics Committee (REC) under the internal number A-2024–005 on 19th January 2024.
Objectives
This study aimed to evaluate the safety and feasibility of diastasis repair at a tertiary referral academic medical center in the UAE.
Population
Patients diagnosed with diastasis of recti with or without concurrent VH and/or excess skin and adipose tissue.
Inclusion and exclusion criteria
Patients older than 18 years and younger than 70 years, diagnosed with DR and VH or Panniculus, that underwent surgical repair were included. Patients who had the procedures between October 2022 and February 2024 were considered for study participation.
DR and VH definitions
We used the EHS guidelines to diagnose DR, which is defined as a separation of 2 cm or more of the rectus muscles. DR can be further characterized by its size and association with ventral hernias, as described by the EHS classification in Table 1. 1 VH were defined as any gap along the midline of the abdominal wall, regardless of the size. 14
European Hernia Society Diastasis Recti Classification
D, Inter-rectus distance; H, Concomitant ventral hernia status; T, Type.
DR and VH diagnosis
All defects were first evaluated during physical examination and later confirmed by computed tomography (Fig. 1).
Computed tomography. Arrow: Midline diastasis recti of 8.42 cm with omental fat and transverse colon protruding into it.
Surgical technique
Indication for the procedures
Clinical diagnosis of DR, confirmed by abdominal computed tomography, including a description of VH when applicable.
Diastasis and hernia repair
All procedures were performed under general anesthesia with endotracheal intubation in the operating room. Patients were placed supine with split legs and both arms tucked. After antisepsis, a 2 cm incision, three fingerbreadths from the pubic bone, was made at the midline. The dissection was carried to the anterior fascia using electrocautery. The subcutaneous tissue was dissected off the anterior fascia. A subcutaneous pocket was created, and a balloon-tip trocar was inserted. Two 5 mm ports were then placed laterally under direct visualization. The subcutaneous dissection continued laterally to the Linea semilunaris at both sides. The umbilical hernia and stalk were encircled, then the stalk was detached, and the hernia contents were reduced back into the abdominal cavity when applicable. Then, the subcutaneous dissection was carried out to the xiphoid process and laterally to the ribs. The edges of the diastasis were measured at the widest point, and the plication started from the xiphoid process and moved towards the pubis.
In most cases, the hernia defect was repaired primarily and incorporated into the plication. The subcutaneous space was measured, and a macroporous polypropylene mesh was fashioned, introduced, and fixated. In some cases, round Blake drains were placed on top of the mesh, exteriorized through the existing lateral ports, and secured with suture. Patients were then admitted for routine postoperative care.
Abdominoplasty and diastasis repair
All procedures were performed under general anesthesia with endotracheal intubation in the operating room. After antisepsis, an incision was made using a ten-blade scalpel along the inferior border of the pannus, starting above the mons pubis centrally and extending laterally a few centimetres above the inguinal ligament. With the electrocautery, dissection was performed down to the level of the deep fascia. Undermining of the pannus superiorly was carried out at the deep fascia level to the umbilicus level. Based on the preoperative design, the superior portion of the transverse ellipse was then incised above the umbilicus to remove all excess skin without creating tension in the abdominal flap.
Similarly, undermining was carried inferiorly until the entire pannus, along with the excised umbilicus, were removed and delivered to the back table. To begin the diastasis and hernia repair, the rectus sheath was identified, and both the diastasis and the hernia were measured. Then, the hernia was reduced, when applicable, and closed. The edges of the diastasis were approximated, and the linea alba was reconstructed. Mesh was placed and secured in an onlay fashion (except in one case that didn’t have a concomitant hernia).
To conclude the abdominoplasty, minimal undermining of the inferior and superior residual flaps was done to allow for tension-free closure. In some cases, depending on whether the panniculus adiposus was well represented, two Blake drains were placed on the deep fascia and exteriorized through the skin. The skin flaps were approximated and sutured together in several layers.
Postoperative care
Patients underwent routine care of the incisions, and drains were removed when output was less than 50 mL/day. Most patients were discharged on their second postoperative day. All patients had a follow-up visit scheduled 2 weeks after the surgery.
Data collection and statistical analysis
Data collection of the institutional medical records was retrospectively collected and reviewed. The data included, but was not limited to, patient demographics, indications for the procedure, intraoperative findings, operative times, length of hospitalization, reoperation, operative complications, follow-up period, and mortality. Descriptive statistics were computed for all variables, summarizing the categorical variables in frequencies and percentages while using the mean, median, and standard deviation for quantitative variables.
Results
A total of 20 patients were included in the study. The cohort was 80% female, with a mean overall age of 44.05 years. The mean body mass index (BMI) was 27.4 kg/m2. The cohort was relatively healthy, with only 6 patients presenting a significant medical comorbidity. Patient demographics and classification by the EHS are listed in Table 2.
Demographics and Baseline Characteristics
BMI, body mass index; COPD, chronic obstructive pulmonary disease; DM2, diabetes mellitus type 2; KG, kilograms; M2, square meters; SD, standardized deviation.
All patients presented with DR and concurrent VH. All patients were scheduled for elective surgery after clinical evaluation. Five (5/20) patients underwent open surgery with concomitant abdominoplasty. A minimally invasive approach was utilized in 15 patients (15/20) with either laparoscopic (12/15) or robotic surgery (3/15). All patients with VH exhibited umbilical hernias (20/20). Three patients (3/20) presented multiple defects; two (2/20) had both umbilical and incisional hernias, and one (1/20) had both umbilical and epigastric hernias. The mean defect size was 6.94 ± 2.36 centimeters for DR and 1.63 ± .28 cm for VH. All patients underwent computed tomography to evaluate the abdominal wall defect. The mean radiological size estimation for DR was 6.02 ± 3.08 cm. Eighteen patients were treated due to a primary hernia, while 2 patients (2/10) were treated for hernia recurrence. Operative characteristics are listed in Table 3.
Intraoperative Findings
CM, centimeters; SD, Standard Deviation; MIN, minutes; N, number; %, percentages.
The mean operative time was 169 ± 62 minutes for laparoscopic surgery, 196 ± 15 minutes for robotic surgery, and 245 ± 77 minutes for open surgery. Nineteen (19/20) of the 20 cases required the use of macroporous polypropylene meshes, which were fixated with absorbable tacks (10/19) or individual sutures in the cardinal points (9/19). Blake drains were placed on ten patients (50%). The mean length of stay was 2.35 ± .9 days. Postoperative characteristics are listed in Table 4.
Postoperative Outcomes
N, number; SD, Standard Deviation; %, percentages.
The mean follow-up time was 45.5 ± 28.53 days. Subcutaneous drains were removed during the first postoperative appointment, approximately one week after the surgery. Six patients (6/20) developed a seroma treated conservatively in five cases with binders. One case required drainage during a clinic visit, which had no complications. At the time of the analysis, no patients presented recurrence. Out of these 6 patients with seroma, 5 (5/6) patients did not have a drain placed during the surgery.
Discussion
The primary aim of this study was to evaluate the safety and feasibility of DRR in a tertiary referral academic medical center in the UAE, constituting one of the first reports in the region. This study represents the first clinical study after establishing a Hernia Registry in this academic center. Among the 20 patients who underwent DRR, the technical success rate was 100%. All patients underwent DRR with concomitant hernia repair, and five underwent abdominoplasty. The cohort had a complication rate of 30%, consisting only of seromas, of which one (5%) required drainage.
DRR has traditionally been repaired through the plication of the linea alba.4,5 However, the coexistence of DR with midline ventral hernias complicates this approach due to the tissue laxity that both conditions share. 15 In such patients, an initial presurgical physical therapy assessment that evaluates the strength of the abdominal wall, known as prehabilitation, has shown promise in reducing recurrence rates. 16 Multiple techniques have emerged for DRR in association with abdominal wall hernias. Dong et al. published a prospective cohort study of 16 patients in the United States, utilizing a subcutaneous onlay endoscopic approach with mesh repair for small hernias with DR. 7 They utilized a laparoscopic approach for 14 patients with a mean operative time of 146 minutes compared with our 169 minutes. A robotic approach was used for 2 patients, with a mean operative time of 173 minutes compared with our 196 minutes. Like us, they used a prefascial only mesh in all patients. Yet, while they used a polypropylene mesh only in 43.7% of patients, we used this type of mesh in 100% of our patients. Shinde et al. applied a similar surgical technique in an Indian population of 30 patients. 17 They employed a polypropylene mesh fixated with tackers (n = 20) or interrupted sutures (n = 10). This approach is comparable to our cohort, as we also fixated the mesh with absorbable tacks (n = 10) or interrupted cardinal sutures (n = 9). Notably, our cohort exhibited a larger mean diastasis size (6.94 ± 2.36 cm) compared with Dong et al. (1.9 ± .7) and Shinde et al. (2.10 cm).7,17 Additionally, the mean estimated radiological size for the DR (6.02 ± 3.08 cm) was comparable to the actual size evaluated during surgery. The difference in size can influence the difference in mean operative time observed between these cohorts. The comparison of the technical aspects of each procedure allows us to conclude that these surgeries are feasible in our setting.
Our study reports a short-term complication rate of 30%, including exclusively seromas in patients who underwent a laparoscopic approach. These results align with the safety reported by Bellido Luque et al., 18 who state a complication rate of 23% after endoscopic repair in a Spanish cohort. 18 Another frequent technique involves DRR with concurrent abdominoplasty. Sood et al., 19 published a report on the safety of mesh repair versus suture plication during abdominoplasty. 19 Interestingly, in their cohort, more patients developed seromas in the plication group than in the mesh group. However, this result is hardly comparable to our cohort, as we used a mesh in almost all procedures. A crucial consideration is whether patients had a drain placed during the surgery. In our study, 5 out of the 6 patients who developed a seroma did not have a drain placed during surgery. In contrast, Dong et al. report that all patients in their cohort had a drain(s) placed during the surgery, and yet 3 patients still developed seroma. 7 Therefore, a larger sample size and additional high-quality evidence would be needed to establish a statistically significant relation between both in this specific context.
The analysis of this initial experience has allowed us to draw various conclusions. Minimally invasive techniques are viable for managing DR with VH in this region. In the future, we aim to increase the utilization of robotic surgery while considering its increased operative time, which is often due to docking and undocking. 20 Additionally, after evaluating the incidence of seromas, we will prioritize drain insertion in future procedures to mitigate this complication. Finally, we emphasize the importance of multidisciplinary collaboration among surgical specialties, which facilitates the execution of various surgical procedures within a single operative session.
Several limitations should be considered before interpreting and extrapolating the results. This retrospective study was conducted at a single center, introducing potential selection bias and limitations in available medical record data. The study’s small sample size poses challenges as it has limited statistical power, which may lead to a misinterpretation of the percentage of complications. Additionally, the study’s brief follow-up period can limit the time to detect recurrence and adequately evaluate long-term outcomes. Therefore, further research focusing on the long-term efficacy of DRR, both with and without concomitant hernias, is needed within the region. Nonetheless, this study remains relevant because it demonstrates that diastasis recti repair techniques are safe and feasible for the UAE population.
Conclusion
In conclusion, this study evaluates the safety and feasibility of diastasis recti repair with concomitant hernia repair and/or abdominoplasty in a population from the United Arab Emirates. The technical success rate was 100%, with a complication rate of 30% limited to seromas. These results are comparable to international studies conducted in several populations from various regions of the world. We provide awareness of the benefits of establishing hernia registries in the Middle East.
Footnotes
Authors’ Contributions
G.D.: Conceptualization, R.-R.G.: Writing-original draft, B.-G.J.: Methodology, G.-F.J.: Data curation, P.J.: Project administration, A.C.: Writing—review and editing, A.B.S.: Resources, B.M.: Validation, C.M.: Investigation, R.J.: Supervision.
Disclosure Statement
The authors declare that there is no conflict of interest.
Funding Information
The authors did not receive support from any organization for the submitted work.