Rectus Diastasis

The term rectus diastasis refers to a gap in the middle of the abdomen between the straight abdominal muscles, which occurs more frequently after pregnancies, weight training and obesity.

Please book an appointment for the rectus diastasis consultation under VISCERALCHIRURGIE

A gap between the straight abdominal muscles (rectus muscle) is called rectus diastasis. The midline (linea alba) between the two muscles consists of connective tissue and becomes thinner and thinner as it moves apart.

As a result, the thin layer loses strength and thus stability. Constantly increased pressure in the abdominal cavity, such as during pregnancy or recurrent pressing during weight training, further increases the bulging and weakness of the connective tissue. The abdominal wall becomes loose in the midline.

Diagnosis of rectus diastasis is simple. In most cases, a protrusion of the mid-abdomen is seen when the patient is standing. By definition, in Germany a gap in the midline (linea alba) of more than 20mm in width is considered pathological, although no symptoms need be present. However, this classification is very limited, so that in women after pregnancy a gap of up to 25mm can be considered quite normal.

In this context, there is often also a slight relaxation of the anterior abdominal wall muscles. The finger test in the lying position is well known. The gap is palpated with the fingers lying next to each other. If there is a gap of 2 or more fingers, a rectus diastasis is definitely present.

The more exact measurement of a rectus diastasis, however, is done with ultrasound about 2-3cm above the navel, in the navel area and, if necessary, below the navel in a relaxed state of the abdominal wall. Further diagnostics are not necessary.

During pregnancy, the expansion of the abdominal wall muscles is a natural process. After the birth of the child, the connective tissue becomes firmer again and, as part of the regression in the first 6 months after a delivery, the gap usually closes again.

For this purpose, special regression gymnastics is recommended, which should be started about 6-8 weeks after childbirth and last about 2-6 months. Exercises with weights on the hands and crunch exercises should be avoided at all costs. However, up to 33% of women still complain of insufficient involution 12 months after childbirth and thus of an existing diastasis.

However, in the current state of studies there is no recommendation for specific programs and no evidence that exercises will reduce rectus diastasis. It is rather the general muscle strengthening that leads to an improvement of the posture and thus the well-being.

Often this is an aesthetic problem. However, with larger diastases, there is an imbalance between the back and abdominal muscles.  Due to the separation of the anterior abdominal muscles, the muscle strength is no longer as effective, so that the back muscles are significantly more stressed and the patients complain of chronic back pain.

In terms of posture, there is an increased protrusion of the lumbar spine (hyperlordosis) with a resulting abdominal protrusion. The impression of a "pseudopregnancy" is created, often in combination with protruding skin.

The following problems may occur:

• Weakening of the anterior abdominal depression stability.
• Weakening of the abdominal press
• Back pain
• Pelvic instability
• Pelvic floor weakness with difficulty in defecation

The size of a rectus diastasis does not automatically lead to major problems. People are too different for that.

Previously, rectus diastasis was not considered a disease and was therefore poorly defined. A score of the so-called linea alba above 2cm was considered pathological and thus the diagnosis of a rectus diastasis was confirmed, without further therapy recommendation or differentiation. This inadequate definition has now been expanded for the first time in a current classification, so that the localization, extent of the width, skin structure and the number of pregnancies and abdominal wall hernias are also included.

In the new classification created by abdominal surgeons, the findings are important for eventual surgical planning.

Position

The locations describe the spread of the diastasis: these are referred to as M1-M5, where M1 refers to the area below the sternum, M2 refers to the upper abdominal area, M3 refers to the umbilical area, M4 refers to the lower abdominal area, and M5 refers to the area above the pubic bone. Thus, men often have an M1-M3 location and women have an M2-M4 spread of rectus diastasis.

Width

Measuring the maximum width in cm. Then, rectus diastasis is divided into W1 (less than 3cm), W2 (three to five cm) and W3 (over 5 cm width) based on the width. The ultrasound measurement point is 2-3cm above the navel.

The condition of the skin

The eventual expansion or even associated over-expansion of the abdominal skin, which is divided into 3 grades. S0 shows no skin laxity or skin folds, S1 shows minor skin laxity and minor folds and

S2 an extensive finding with extreme folds.

In addition, existing abdominal wall hernias, such as an umbilical or upper abdominal hernia, and the number of pregnancies that have taken place are also recorded.

Since rectus diastasis is "only" a protrusion, there is usually no medical indication for surgery. Unlike a hernia (abdominal wall hernia), there is no risk of tissue incarceration here because there is no gap.

Therefore, the costs of the operation are usually not covered by the public or private health insurance, so that the patients then have to pay for it themselves. A rectus diastasis alone does not actually require surgery.

The situation is different if there is an upper abdominal or umbilical hernia. With these so-called hernias, there is always a gap in the abdominal wall that does not recede on its own, but only grows larger over the years. Since fat from the inside of the abdomen or even small intestine can become trapped in this gap, there is a medical necessity to close the gap.

Therefore, health insurance companies always cover the costs of hernia operations. Problems can only arise with the type of care, whether it can or must be performed on an outpatient or inpatient basis (with an overnight stay). The surgical treatment of hernias is usually performed by abdominal surgeons (visceral surgeons).

The simultaneous treatment of a rectus diastasis is not automatically included in this procedure, as this represents a significantly larger operation to date, which also results in a significantly larger skin incision and a more extensive wound area.

This considerable additional procedure is therefore not usually covered by health insurance. There must be a written confirmation from the insurance company that all costs will be covered. In our experience, however, this is not given (even for privately insured patients).

Since the cost of rectus diastasis surgery is not usually covered by health insurance, the corrections in Germany are traditionally performed by plastic aesthetic surgeons, who charge the patient for the entire operation as a self-pay service. In addition, besides a rectus diastasis, there is also a partly massive overstretching of the abdominal skin, which requires an abdominoplasty.

This should only be performed by very experienced plastic aesthetic surgeons, otherwise a very unsatisfactory cosmetic result may result. However, it should be emphasized that the treatment of a concomitant abdominal wall hernia in these operations often does not comply with the standards (guidelines) of abdominal surgeons, who insert plastic meshes in certain sizes of abdominal wall hernias to prevent recurrence (recurrence) of the hernia.

Therefore, hybrid surgeries should be considered for present hernias, in which an experienced abdominal surgeon (visceral surgeon) is responsible for abdominal wall reconstruction and a plastic surgeon is responsible for aesthetics.

We offer these operations through our expert in hernia surgery Dr. Sepe.

This question is not easy to answer because there is no standardized surgery. The main problem is the surgical access to the rectus diastasis. Obviously, large midline incisions, which would easily solve the problem, are unacceptable.

Minimally invasive via keyhole surgery, a diastasis can be sutured, but the sutures should not be inside the abdomen, i.e., not in direct contact with the bowel. A mesh placed in the abdomen for stabilization is not appropriate in otherwise healthy patients.

However, there have been a number of innovations in the surgical management of abdominal wall hernias in recent years, which are now being incorporated into rectus diastasis therapy in experienced centers, leading to healing and a good cosmetic result. 

This situation is the classic domain of plastic aesthetic surgeons.

If there is no abdominal wall hernia, there is no need to insert a mesh. Meshes would be more likely to prevent recurrence of rectus diastasis, but so far there are no comparative studies that we know of, so meshing is not recommended.

If an abdominal wall hernia (hernia) is present in addition to the rectus diastasis, a mesh should always be inserted, otherwise the risk of a new hernia (recurrence) is very high. Minimally invasive therapy procedures have become widely accepted. Minimally invasive refers to the length of the skin incision and not the technique.

• One option is minimally invasive tunneling of the subcutaneous fat from the pubic bone. In this procedure, gas is pumped into the abdominal wall, creating an artificial cavity. The rectus diastasis is dissected free with fine instruments and the straight abdominal wall muscles are sutured back together.  Finally, a plastic mesh is placed on the abdominal musculature and taped in place to secure it. This is an experimental method, the results of which have not been verified in studies. One variant is, for example, the TESLAR method.

• Another form of repair with a small incision in the umbilical region is the ELAR technique (Endoscopic Linea Alba Reconstruction) with mesh reinforcement. Here, a small incision of about 3-5cm is made at the belly button and the hernia and rectus diastasis are operated on under endoscopic control. The ELAR technique offers the advantage of fewer wound complications compared to the classic open technique. The mesh has no contact with the inside of the abdomen and therefore there are no adhesions with the intestine. Large rectus diastases may cause protrusion of the midline, so this technique is only suitable for smaller diastases with skin that is not overstretched.

• Currently, the most commonly used technique in abdominal surgery is MILOS surgery (Minimally Invasive Less Open Surgery). This operation consists of a small skin incision in the navel area or directly above the hernia and a plastic mesh is placed under the straight abdominal muscle on the connective tissue through this small skin incision (sublay technique). The plastic mesh, which does not dissolve, lies outside the abdominal cavity, which is why no adhesions of organs or the intestine can occur. The rectus diastasis can be closed with a suture and there is rarely pain or wound water formation (seroma), because the meshes do not have to be fixed in this technique. Depending on the technique, the version is also possible as eMILOS. In this case, gas is then injected and the mesh is placed under camera vision.

If patients have skin overstretching or skin folds, removal of these folds is always recommended, otherwise there may be a very unsatisfactory cosmetic result.

It has been shown that the combination of an abdominal surgeon and plastic surgeon is useful in the management of major rectus diastases with abdominal wall hernia and excess skin. This ensures sound reconstruction of the abdominal wall along with a cosmetically superior result for patients. This surgery can also be described as a "hybrid surgery".

Here, the plastic surgeon begins with mobilization of the skin and subcutaneous fat. The incision is usually made in the area of the pubic bone on the so-called "bikini line". In order to cleanly remove the excess skin without bulges on the sides, the incision must be made quite wide. The entire skin of the abdominal wall is mobilized over the navel to the breastbone.

Now the abdominal surgeon takes over the operation and opens the firm enveloping skin (fascia) of the straight abdominal muscles. A plastic mesh about 25cm long and about 12cm wide is inserted into the layer under the straight abdominal muscle (sublay position) without fixing the mesh by suture or glue. Afterwards, the rectus diastasis, which is completely closed, is sutured with a non-dissolving suture. Optionally, an ELAR operation can be performed instead, in which a mesh is also inserted.

Finally, the plastic surgeon takes over again and the visually appealing abdominoplasty is performed in order to obtain a taut abdominal wall again. The navel can be cut out in a circle and sewn in again, as this would otherwise be too deep due to the skin tightening, which is visually unacceptable. Alternatively, the umbilicus can also be removed in the case of larger hernias and reattached in the same session (neonabel). Cosmetically, there is often no difference to a real umbilicus and no umbilical hernias can occur afterwards.

It is important to be aware that these are all very extensive and stressful operations, which can also lead to long-term complaints such as chronic pain. For this reason, we sometimes do not recommend surgery for very small findings, especially if a subsequent pregnancy cannot be ruled out with certainty.

Therefore, on the basis of our experience, the following therapy recommendation can be derived from the new rectus diastasis classification.

Grade 1:

Findings: width of rectus diastasis < 3cm (W1); no or little skin overstretching (S0-S1).

Recommendation: rather no surgery, support by physiotherapy.

Grade 2:

Findings: width 3-5cm (W2); minor skin overstretching (S1), possibly small abdominal wall hernias.

Recommendation: minimally invasive surgery such as MILOS, e-Milos, ELAR with mesh and suture of rectus diastasis. 

Grade 3:

Findings: width 3-5 or > 5cm (W2-W3); severe skin overstretching (S2), possibly small abdominal wall hernias.

Recommendation: abdominoplasty with mesh insertion.

MILOS (Minimally Invasive or Less Open Surgery); ELAR (Endoscopic assisted Linea Alba Reconstruction)

We will be happy to advise you and, of course, take care of your abdomen after the operation.

• Classification of Rectus Diastasis - A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS)
• The General Surgeon`s Perspective of the rectus diastasis. A Systematic Review of Treatment Options.

You are welcome to book an appointment online in our appointment calendar DOCTOLIB under the specialty "Visceral surgeon and proctologist" with our doctors. We are looking forward to it.