Rectus diastasis (RD) is frequently confused with a ventral hernia by patients and their relatives. Although an RD can be associated with a hernia, many times there is no hernia, which poses controversies regarding its best treatment. RD can cause several signs and symptoms like constipation, urinary incontinence, inability to lift objects and execute daily activities, and lumbar and pelvic pain. The European Hernia Society tried to give us guidelines to help us decide how to treat a patient with an RD. One primary recommendation is to share the decision-making process with the patient. Treatment must be tailored to each patient, and we should not apply the same rules to all patients. One treatment can be suitable for one but not the best option for another. That is why it is important that surgeons be able to perform different surgical techniques to treat the same disease.
A summary of the “European Hernia Society guidelines on the management of rectus diastasis” is available in BJS since 2021. The main drawback of these guidelines is the low-quality literature available, which led to weak recommendations. The first recommendation is to define “RD as a separation between rectus muscles wider than 2 cm”. The authors also propose a classification including type, inter-rectus distance, and concomitant umbilical and/or epigastric hernia (see the article). In my opinion, the inter-rectus distance is very important because if we have a separation wider than 5 cm, surgery is necessary. Clinical examination and ultrasonography can make the diagnosis, but a CT scan is crucial for hernia diagnosis and surgery planning. One interesting idea the guidelines give us is that we cannot surely associate symptoms with the width of the diastasis. So, a wider distance may not be the most symptomatic case, and surgery must not be offered only depending on symptoms, I think.
Some doctors talk about non-operative treatment options. Are these options good? Should we recommend a specific non-operative treatment? Well, according to the European Hernia Society there is limited evidence about these options, and ”no specific regimen can be recommended”. What do you think? Do you advise those treatments to your patients? On which scientific basis? Is surgery avoidable? Think about this...
Controversies aside, the European Hernia Society states that RD without hernia can be treated with linea alba plication with or without prosthesis reinforcement both by open or laparoscopic surgery. If a hernia is associated with the RD, a mesh is recommended, unless the hernia is <1 cm in which case linea alba plication can eventually be enough. According to the guidelines, the most reported technique is plication and onlay mesh. This is interesting because onlay mesh has a higher recurrence rate than sublay mesh. Another point the guidelines talk about is the use of abdominal binders during the postoperative period. Apparently, they do not impair pulmonary function as was told in the past. Additionally, seroma formation is not decreased with their use. However, abdominal binders seem to help mobilization, reduce postoperative pain, and give the patient a feeling of security.
As all guidelines, these are only ideas from a group of surgeons, based on some literature, and serve to help us in the decision-making process. Guidelines do not substitute intensive study and updates by doctors. If you do differently from the guidelines, it does not mean you are doing wrong. On the contrary, if you follow the guidelines “by the book”, it does not mean you are for sure offering a specific patient the best treatment option.
Link to the summary of the guidelines (base of this post):
Link to full guidelines:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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