E. H. H. Mommers

The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options

BackgroundDiastasis of the rectus abdominis muscles (DRAM) is characterised by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This causes the midline to “bulge” when intra-abdominal pressure is increased. Plastic surgery treatment for DRAM has been thoroughly evaluated, though general surgical treatments and the efficacy of physiotherapy remain elusive. The aim of this systematic literature review is to evaluate both general surgical and physiotherapeutic treatment options for restoring DRAM in terms of postoperative complications, patient satisfaction, and recurrence rates.MethodMEDLINE®, Embase, PubMed, PubMed Central®, The cochrane central registry of controlled trials (CENTRAL), Google Scholar, and the Physiotherapy Evidence Database (PEDro) were searched using the following terms: ‘rectus diastasis’, ‘diastasis recti’, ‘midline’, and ‘abdominal wall’. All clinical studies concerning general surgical or physiotherapeutic treatment of DRAM were eligible for inclusion.ResultTwenty articles describing 1.691 patients (1.591 surgery/100 physiotherapy) were included. Surgical interventions were classified as plication techniques (313 patients; 254 open/59 laparoscopic), modified hernia repair techniques (68 patients, all open), and combined hernia & DRAM techniques (1.210 patients; 1.149 open/40 hybrid). The overall methodological quality was low. Plication techniques with interrupted sutures and mesh reinforcement were applied most frequently for DRAM repair. Open repairs were performed in 85% of patients. There was no difference in postoperative complications or recurrence rate after laparoscopic or open procedures, or between plication and modified hernia repair techniques. Physiotherapy programmes were unable to reduce IRD in a relaxed state. Though reduction of IRD during muscle contraction was described.ConclusionBoth plication-based methods and hernia repair methods are used for DRAM repair. Based on the current literature, no clear distinction in recurrence rate, postoperative complications, or patient reported outcomes can be made. Complete resolution of DRAM, measured in a relaxed state, following a physiotherapy training programme is not described in current literature. Physiotherapy can achieve a limited reduction in IRD during muscle contraction, though the impact of this finding on patient satisfaction, cosmesis, or function outcome is unclear.

Baseline performance of the ischaemic button model for induction of adhesions in laboratory rats

The ischaemic button model is frequently used for the induction of adhesions in laboratory rats. Male rats are often used because of the common belief that the peritesticular (intra-abdominal) fat in males facilitates adhesion formation, although this theory is not evidence based. Comparing the model’s performance in both sexes is an important aspect of refining animal experiments. The aim of this study is to compare baseline performance of the modified ischaemic button model in both male and female rats. Follow-up was 1 week and noted endpoints were intra-abdominal adhesion formation and differences in welfare assessment. A total of 192 ischaemic buttons (96 male/96 female) were created in 24 Wistar Han rats (12 male/12 female). After 1 week of follow-up, 93 buttons survived in the male group (96.9%) compared with 91 in the female group (94.8%) (p = 0.409). In the male group, 85 out of 93 (91.4%) buttons induced adhesions compared with 84 out of 91 (92.3%) in the female group (p = 0.881). All but one animal had a Zühlke score of 3. There were no clinically relevant differences in welfare scores. Male animals increased in weight significantly faster compared to females (p < 0.001), after correcting for physiological growth. The ischaemic button model resulted in equal quality and quantity of intra-abdominal adhesions in both male and female Wistar Han rats. Both male and female Wistar Han rats are suitable for the induction of experimental adhesions in the ischaemic button model.

Reply to Comment to: A modified Chevrel technique for ventral hernia repair: long-term results of a single centre cohort. Li, J., Zhang, W.

We thank Li and Zhang for their comments on our study ‘A modified technique for ventral hernia repair: long-term results of a single centre cohort’. The author raises two questions regarding the modified Chevrel technique presented in Hernia [1, 2]. The first regards the overlap of the mesh, which in the opinion of Li and Zhang is insufficient. It is well established that the overlap for laparoscopic hernia repair must be at least 5 cm to ensure a durable repair, as mesh overlap directly correlates to recurrence rates in laparoscopic hernia repair. For open single layer repairs, the correlation between mesh overlap and recurrence rate is not as well established, though generally considered an important factor [3]. The modified Chevrel repair presented by us is essentially a dual layer repair where both the sutured anterior fascia and the onlay mesh provide support the ventral abdominal wall. Although Li and Zhang are correct in stipulating the importance of mesh overlap, to the best of our knowledge, there is no evidence to support their claim regarding minimal mesh overlap in dual layer repairs such as the modified Chevrel technique. On the contrary, recurrence rate has never been the main concern of the original or modified Chevrel technique, as evidence shows a recurrence rate almost similar to the open sublay repair [4–6]. The main concern of the original Chevrel technique was surgical site occurrences, or more specifically, seroma formation due to the proximity of the dissection plane to the skin. Our study shows that clinical seromas occur in approximately 10% of patients, of which the majority will regress either spontaneously or after fine needle aspiration. The second point raised by Li and Zhang regards to the meticulous suturing technique. As described in the original article, accurate continuous suturing of the mesh to the lateral remnant of the anterior fascia is required to ensure an equal tension force transfer from the mesh to the abdominal wall surrounding the mesh. The entire modified Chevrel procedure will take about 2 h to complete, including approximately 45 min needed for mesh positioning and suturing. In hernia repair, there is no ‘one size fits all’ approach. Managing ventral hernias depends on patient, hernia, local hospital, and healthcare factors. The modified Chevrel technique offers a straightforward option with good results.

Complex Ventral Situation

Introduction: Estimating the risk of postoperative complications of large ventral hernia repair remains challenging. Usually only general risk factors such as age, Body Mass Index (BMI), and smoking are used to estimate the postoperative risk of complications. It has been hypothesized that the hernia volume is directly related to postoperative complications because the volume of the hernia sac is reduced into the abdominal cavity, creating tension on the abdominal wall and the diaphragm, thus increasing the risk for wound and pulmonary complications. The primary aim of this study was to analyze the relationship between hernia volume and postoperative complications, the secondary aim was to validate a mathematical formula for calculating hernia volume.