“The rectus abdominal muscles tend to move away during contraction as they are medially released. Diastasis therefore gets progressively worse with training”
-Dott. Antonio Darecchio-
The diastasis of the recti abdominal muscles consists in the progressive – and unluckily irreversible – removal of the two rectus abdominal muscles and the concomitant thinning of the white line.
During this pathophysiological process, aggravation or new formation of umbilical or midline hernias is very frequent. The reasons for this pathology are to be found in the excessive increase in endoabdominal volume that occurs in cases of pregnancy or visceral obesity.
The disease is completely benign and usually slowly evolving, but contrary to what many may think it is almost irreversible and muscle strengthening exercises are not effective or counterproductive. In fact, diastasis recti is not a proper disease of the rectus-abdominal muscle but of the tendon sheath that surrounds it: a substantial difference, which makes training useless because of a tendon-aponeurotic tissue that, once fatigued by the disease, can no longer return to its original form.
The self-diagnosis of the diastasis of the rectus abdominal muscles is very simple, but it is necessary to pay attention to various other pathologies that can be a confounding element.
In the simplest case, with a normal bodyweight patient, during the movement of raising the head while lying down or, even more, bending the bust forward with the classic abdominal crunch, there will be visual evidence of an elongated and oval deformation located between the lower part of the sternum and the navel. Once back in the rest position, the deformation will disappear or become less evident, but by placing a hand in the region concerned you will clearly perceive a weakness of the tissues compared to the surrounding areas.
Diastasis recti is not a hernia but is often associated with midline hernias.
The therapy is surgical, specific and dedicated.
As with the inguinal hernia and the crural hernia, robotic surgery is the last frontier of minimally invasive surgery and allows the real and stable approach of a recti abdominal muscle to the contralateral through small access routes for camera and operating instruments.
The surgeon, therefore, through a three-dimensional camera and with the help of precise instruments, can achieve a full-thickness suture, stable and durable. This suture restores the medial margins of the tendon sheath of the rect abdominal muscles. This restores the white line, allowing the approach of the abdominal muscles and the closure of the wall defect without changing the original anatomy, but reconstructing it.
Thanks to this great advantage over open surgery, diastasis recti can now be treated in a minimally invasive manner without leaving showy scars or permanent foreign prosthetic elements. I often visit and operate patients who for many years have postponed an open-air surgery and who instead find the best solution with the minimally invasive robotics method.
This paragraph is the most important of the diastasis recti study as here I would like to speak to readers through concrete examples.
The typical case: patient with two recent pregnancies and diastasis recti highlighted after the second birth associated with small umbilical hernia.
Often from the first phone call I understand that the patient has consulted other doctors and perhaps received conflicting answers … Nothing easier because the real specialists in the field are very few.
A first visit is scheduled, which can be carried out in the clinics in Milan or Rome, depending on your preference.
The first visit shall always include a high-frequency ultrasound examination of the surface, even under stress. This test allows me to measure the defect precisely and confirm the diagnosis.
The other very important part of the visit is the in-depth interview on the aesthetic expectation. Often, in fact, we are faced with caesarean results with unpleasant scars or with an excess of dermo-adipose that we would like to eliminate.
As the aesthetic argument is raised, I point out the importance of reconstructing the anatomy of the muscles and the fact that this will be the first step in the repair of the diastasis recti. Everything that concerns the aesthetics, the skin, the shape of previous scars is possible and justified, but it is essential to have repaired in a solid and optimal way the musculature, the midline and the possible small associated hernia.
We all see what’s outside, but in order for the “outside” to be better, we need to consolidate the deeper layers of the abdominal wall.
On the other hand, robotic surgery today allows precisely this part of the surgery and no showy incisions of the past.
Patients who have already undergone multiple consultations often come from two markedly different pathways, which, however, have not yet led to a decision by the patient.
Let’s see why. Patients who come from the national health system and have been visited by the general surgeon of the National Health Service, have often been directed towards a surgical path with the prospect of an open intervention as is the case for large hernias and laparocelis. Often the suggestion of placing a “mesh” during the open-air surgery has completely overlooked the aesthetic aspect, which for obvious reasons is not reimbursed by national healthcare. The other group of patients I receive are patients who come from exclusively aesthetic surgical consultations to whom the possibility of performing an abdominoplasty (which in any case involves scars) has been proposed, an important surgical procedure and acts only on the superficial layers of the abdominal wall. With these perspectives it is natural to take time and wait, considering that the pathology is slowly evolving.
As an over-specialized general surgeon in abdominal wall robotics I know I can resolve cases of diastasis recti and give an answer to those who have not had it up to that moment.
Once the pre-operative procedure is completed, the intervention is organised in such a way as to optimise the logistical aspects: the operating session takes place in the morning, the average time is one and a half hours; the patient wakes up with 4 small medications on the left side, the general anaesthesia with latest generation drugs allows immediate recovery and there is no nausea or other undesirable effects linked to it.
It is possible to walk independently from the day after the intervention, when on average the discharge takes place.
The family member or carer may remain in the facility for the entire duration of the stay. As there are no medications or extended incisions, an almost normal life is immediately possible, but it is necessary to wait at least 10 days to regain the maximum physical efforts (including picking up the children), because even if there are no external surgical wounds, the tissues must heal and consolidate internally.
I usually monitor my patients postoperatively for diastasis recti 10 days after surgery and one year later. The only recommendation is to try to keep weight under control over time.
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