
==== Front
JPRAS Open
JPRAS Open
JPRAS Open
2352-5878
Elsevier

S2352-5878(24)00096-2
10.1016/j.jpra.2024.06.011
Original Article
Abdominoplasty versus endoscopic approach to diastasis recti repair: A comparative study of outcomes
Medina J.P. a
Tambasco D. b
Albanese R. albaneseroberta16@gmail.com
bc⁎
Croceri R. a
Tomaselli F. b
Pirchi D.E. a
a Hospital Universitario Británico de Buenos Aires, Buenos Aires, Argentina
b Plastic Surgery Unit, San Carlo di Nancy Hospital, via Aurelia 275, Rome, Italy
c Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medical Area (DAME), University of Udine, Piazzale Santa Maria della Misericordia 15, 33100, Udine, Italy
⁎ Corresponding author at: Santa Maria Misericordia Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine UD, Italy. albaneseroberta16@gmail.com
09 7 2024
9 2024
09 7 2024
41 411419
27 4 2024
30 6 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Diastasis recti (DR) is characterized by the deviation of the abdominal rectus muscle due to widening of the linea alba and laxity of the abdominal wall musculature.1,2 This condition affects the quality of life, in terms of performance of activities of daily living and physical tasks.3-7 Several techniques have been described to correct DR.11 This prospective research aimed at comparing the traditional approaches vs endoscopic plication for DR repair in terms of safety, effectiveness and satisfaction of the patients based on patient-reported outcome measures via the BODY-Q abdomen scale.

Materials and Methods

We performed a retrospective multicenter study in 2 departments of aesthetic and plastic surgery, Department of Plastic Surgery, San Carlo of Nancy Hospital, Rome (group I) and Hospital Británico de Buenos Aires, Argentina group II). A total of 85 consecutive patients treated using abdominoplasty access (group I) and 85 consecutive patients treated using an endoscopic approach (group II) were enrolled in the study. The minimum follow-up was 12 months.

Results

Descriptive statistics were used to report the counts and frequencies for categorical data. Continuous normally and non-normally distributed data were described as means with standard deviations and medians with interquartile ranges as appropriate. All analyses were performed using the STATA/IC 16.0 software.

Conclusion

Our multicenter experience reveals that open and minimally invasive approaches are viable options. Identifying the optimal approach for DR repair should also rely on the patient's desired treatment outcome.

Keywords

Abdominoplasty
Diastasis recti
Laparoscopic approach
Body contouring
==== Body
pmcIntroduction

Diastasis recti (DR) is characterized by the deviation of the abdominal rectus muscle due to widening of the linea alba and laxity of the abdominal wall musculature.1,2

This condition affects the quality of life, in terms of performance of activities of daily living and physical tasks.3, 4, 5, 6, 7 DR may be associated with lower back pain, abdominal discomfort, and urinary incontinence.8, 9, 10 Several techniques have been described to correct DR.11

A median or abdominoplasty access (Pfannenstiel's approach, extended bilaterally toward the anterior-superior iliac spines) can be performed.12 Absorbable or nonabsorbable suture threads, or mesh, may be used to perform the recti plication.3

Endoscopic surgery is a viable option, but it requires surgical skills and specific considerations.7,13,14 Moreover, the risk of recurrence differs among all the described procedures.

The traditional approaches can simultaneously treat abdominal lipodystrophy with excellent results.15,16 Newer approaches include the endoscopic procedure, a minimally invasive technique with rapid postoperative rehabilitation.

This prospective research study was aimed at comparing the abdominoplasty approach to endoscopic plication for DR repair, in terms of safety (infection, seroma, hematoma, surgical wound dehiscence, hospital stay, and surgical time) and effectiveness (diastasis recti recurrence, detected through ultrasound sonography).

Materials and methods

We performed a retrospective multicenter study in 2 departments of aesthetic and plastic surgery, Department of Plastic Surgery, San Carlo of Nancy Hospital, Rome (group I) and Hospital Británico de Buenos Aires, Argentina (group II).

A total of 85 consecutive patients treated with abdominoplasty access (group I) and 85 consecutive patients treated with an endoscopic approach (group II) were enrolled in the study.

We included patients with DR ≥ 2 cm who underwent DR repair. The procedure was performed by the same operator (D.T. in group I; J.P.M. in group II). All patients were women with no previous abdominal procedures performed. Their baseline characteristics are listed in Table 1.Table 1 Patient demographics and surgical elements in groups I and II.

Table 1Patient characteristics and surgery		
	Group I (mean)	Group II (mean)	p-value	
Age (yr)	37.5	39	0.434	
Weight (kg)	65.5	71.4	0.276	
BMI (kg/m2)	26.2	27	0.437	
Previous pregnancies (%)	50	44	0.111	
Smoking	12.3	15.6	0.456	
Surgical time (min)	176 (145–201)	80 (55–105)	<0.05⁎	
Drains (d)	2.8	5.3	<0.05⁎	
Hospital stay (d)	2 (0.5–5)	1.5 (0.5–3)	0.565	
Follow-up (mo)	15.3	16.9	0.987	
⁎ p = 0.05

The minimum follow-up was 12 months. Clinical follow-up was at 15 days, 1 month, 3 months, 6 months, and 1 year. Ultrasound sonography was conducted at 1 month, 6 months, and 1 year.

Abdominoplasty approach (AT)- group I

Skin markings were made preoperatively while the patient was standing and were verified in prone position. Every surgical procedure was performed under general anesthesia.6

The resection was usually decided upon while the patient was in sitting position. The lower incision was placed between 4 and 9 cm from the labial commissure.17

It may vary according to individual factors, such as age, skin laxity, muscle tone, and risk factors. Lowering scar tension is mandatory to reduce abnormal healing.

The incision was extended to the anterior-superior iliac spines on both sides of the incision. Electrocautery with the “cut” function was used to dissect the rectus muscle sheath up to the xiphoid process.

The umbilicus was isolated using a cold blade. Any located hernia was reduced, and its breach was sutured with Vicryl 2/0.

DR was corrected with standard diastasis correction using single Vicryl 0 stitches, with the knot located on the inside. Only the median plication was used (Figure 1).Figure 1 A-B) A 46-year-old patient with a 6-cm DR at ultrasound control. A 360° lipo-abdominoplasty was performed. The application was performed using single stiches. C-D) Postoperative result 18 months after surgery. The abdominal convexity is completely resolved. The aesthetic result is satisfactory.

Figure 1

After skin tailoring, the umbilicus was transposed, thus recreating the normal umbilical adhesion area. Reintegration into the abdominal wall was performed through a horizontal incision. The 12-o'clock position of the newly formed aperture was identified, and the superficial fascia system at this point was anchored to the muscle fascia just above the umbilicus.18,19

Two drains were placed in the subcutaneous area. Depending on the amount of serum, the drains were removed 1 or 2 days after surgery. A layered suture with Vicryl 2/0, Vicryl 3/0, and Vicryl rapide 4/0 was used.

Immediately after the surgical procedure, a light compression garment was applied16 (Figure 2).Figure 2 A-B) A 37-year-old patient with a 4-cm DR in ultrasound control. A high definition lipo-abdominoplasty was performed. C-D) Postoperative result 24 months after surgery. An excellent aesthetic result, with a good high abdomen definition.

Figure 2

Endoscopic technique (ET) - group II

Under general anesthesia, the patient was placed in a supine position with both arms extended. The surgeon stood between the patient's legs, assistant stood on the surgeon's left, and scrub nurse stood on the right. The monitor was placed at the patient's head.

The patient was positioned slightly in the Trendelenburg position, to avoid expansion of the subcutaneous emphysema toward the chest wall (Figure 3).Figure 3 External margin of the defects is indicated using a line.

Figure 3

A line was drawn at the external margin of the defects, and 3 trocars were placed in the suprapubic region: a 10-mm optical trocar placed at the midline, and 2 accessory 5-mm trocars on the right and left sides (Figure 4).Figure 4 Positioning of surgical ports.

Figure 4

An incision was made at the suprapubic midline, and the subcutaneous cellular tissue was dissected until the aponeurosis was exposed. The 10-mm trocar was introduced and a space was created, aided by 10 mm Hg insufflation pressure. Under direct vision, both 5-mm lateral trocars were placed, one on each side of the optical trocar, separated by 5 cm.

The supra-aponeurotic space was dissected in an upward direction until the insertion of the umbilicus was reached; the supra-aponeurotic space was subsequently released from the hernial sac and its contents were reintroduced into the intra-abdominal compartment.

If other supraumbilical abdominal wall defects were present, the dissection was performed as previously described. Finally, the dissection of the supra-aponeurotic space continued until the subxiphoid region was reached. After the dissection was completed, and the dermo-epidermal flap was released, the DR and associated aponeurotic defects were identified.

Repair of each defect was tailored to the particular characteristics of each case. The mesh was positioned in the preperitoneal space (inlay) or, most commonly, in the supra-aponeurotic space (onlay). In patients with associated large abdominal wall midline defects, the plication of both rectus muscles can be difficult. The anterior component separation technique with lateral relaxing incisions at the level of the aponeurosis of the external oblique abdominal muscle decreases wall tension at the time of closing the defect and enables better wound stability (Figure 5). Thus, better compliance of the anterior abdominal wall was achieved with correct approximation of the muscles to the midline. Relaxing incisions should be guided by the anatomy, and performed parallel to the lateral edge of the aponeurosis of the rectus abdominis muscle, thereby allowing for better approximation as high as 4–5 cm on each side.5Figure 5 Lateral relaxing incisions.

Figure 5

Midline closure: The plication of the recti muscles was performed with continuous absorbable (180 days) barbed sutures (V-LOC No. 0, Medtronic) from the subxiphoid to the suprapubic region. A second continuous non-absorbable monofilament suture was added to ensure greater stability. Closure included all midline defects (Figure 6).Figure 6 Midline suture.

Figure 6

Mesh placement: If the defect exceeded 4 cm, a polypropylene mesh was preferably used to complete the abdominal wall repair. The mesh was introduced in the preperitoneal or supra-aponeurotic space, and was fixed with polypropylene stitches, absorbable staples or both. Finally, the umbilicus was reinserted to its normal position with a single stitch of absorbable suture, and a silicone drain was placed in the surgical bed through one of the 5 mm trocars. Subsequently, a compressed bandage was placed to diminish the dead space between the aponeurosis and subcutaneous cellular tissue. An abdominal girdle was used for at least 1 month after surgery.

Statistical analysis

Descriptive statistics were used to report counts and frequencies for categorical data. Continuous normally and non-normally distributed data were described as means with standard deviations (SD) and medians with interquartile ranges (IQR) as appropriate.

All analyses were performed using the STATA/IC 16.0 software (StataCorp LLC; College Station, TX).

Results

Eighty-five consecutive patients who underwent AT (Group I) and 85 patients who underwent ET (Group II) were included in the final analysis. In the AT cohort (n = 85), mean age was 37.5 years (26–76 years) and the average weight was 65.5 kg with an average body mass index (BMI) of 26.2 kg/m2.

In 50 % of the cases, there was a history of pregnancy, and 12.3 % were smokers.

In the EP cohort (n = 85), mean age was 39 years (29–34 years), the average weight was 71.4 kg with an average BMI of 27 kg/m2. In 44 % of the cases, there was a history of pregnancy. Moreover, 15.6 % were smokers. There were no statistically significant differences between demographic characteristics (all p = 0.05).

Median operative time was different between the two cohorts (group I: 176 mins [145–201] vs group II: 80 mins [55–105]; p < 0.05) as was the mean maintenance period of the placed surgical drains (group I: 2.8 (0.8) days vs group II: 5.3 (0.8) days; p < 0.05). AT has been shown to be associated with longer operating times. The length of hospital stay (days) was similar in both groups (group I: 2 days vs group II: 1.5 days; p = 0.536).

Postoperative complications are analyzed in Table 2.Table 2 Complications in groups I and II.

Table 2Complications	
	Group I (mean%)	Group II (mean%)	p-value	
Infection	1 (1.17)	2 (2.35)	0.347	
Seroma	4 (4.7)	6 (7.05)	0.182	
Hematoma	4 (4.7)	5 (5.88)	0.876	
Wound dehiscence	3 (3.52)	2 (2.35)	0.794	
Oil cyst	0 (0)	0 (0)	>0.99	
Recurrence of diastasis recti	2 (2.35)	3 (3.52)	0.911	

Recurrence of DR was observed in 2 patients in group I; in 3 patients in group II. There were no statistically significant differences when evaluating concurrent procedures between the cohorts (all p > 0.05).

Discussion

Rectus diastasis results in the loss of intraabdominal wall integrity, potentially resulting in aesthetic dissatisfaction, functional impairment, and musculoskeletal pain.20 In addition, abdominal protrusion can lead to weakness and instability of the trunk and pelvic muscles, thereby increasing the risk of injury to the spine and pelvis.21 Furthermore, DR is known to strongly correlate with an overall negative body image. DR can become a permanent deformity and increase the chances of midline hernia if not treated.22

Chronic back pain results from an imbalance between the anterior and posterior postural muscles of the trunk. Some patients with DR have chronic discomfort at this level, which increases with abdominal movements. DR may be accompanied by other midline defects, such as hernias. The anatomically weak tissue, the damaged linea alba, can be corrected only when the hernia is surgically corrected due to a defect.

The probability of hernia recurrence may be high and the aesthetic results can be uncertain. Therefore, if DR is associated with other midline defects, the simultaneous correction of both conditions is recommended.23

When DR is associated with abdominal lipodystrophy, abdominoplasty is currently the treatment of choice. After the dermoepidermal flap is released and the subxiphoid region is reached, the DR is corrected with the plication of both superficial aponeurosis, covering any other associated defect. After all the skin on the abdomen is stretched downward, and excess skin and subcutaneous cellular tissue are removed, the umbilicus is reinserted to obtain an acceptable aesthetic result.24, 25, 26

Regardless of the size of DR, the use of sutures is sufficient to fill the defect.

Another option to correct DR is the laparoscopic approach. The correction is achieved by using continuous intracorporeal sutures or transfascial stitches associated with the placement of an intra-abdominal reinforced mesh.

The subcutaneous endoscopic approach provides a new therapeutic alternative. The indications for using mesh are based on the size of DR and/or the associated midline defects. Diastasis >5 cm or associated with other defects > 5 cm justifies the use of mesh in ET.

There were no significant differences in the recurrence of DR. No correlation between the recurrence rate and size of DR was observed. This indicates that if the surgery is performed by experienced surgeons, the success of the surgery is ensured regardless of the severity of the clinical condition.

This study confirmed that, when performed by experienced surgeons, both procedures are reliable and achieve adequate surgical results.

In both procedures, seroma was the most common complication.27, 28, 29, 30

Only a small number of patients required fine-needle aspiration in the outpatient clinic, owing to its size.

Seroma was associated with impaired aesthetic outcomes in group I and elevated incidence of prosthetic infections or fistula formation in group II. In both cases, ultrasound control was considered an effective tool.

The patients were satisfied with their aesthetic and functional results, and the procedure met their preoperative expectations.

The longer surgical time for group I was justified because of the removal of excess skin. Drainage removal time was reasonable for both procedures.

Limitations

The study faces a notable limitation owing to the different surgical techniques used to correct diastasis recti (DR), operated by different centers.

Future research endeavors should aim for controlled, multicenter studies to address this gap, allowing for a more robust comparison and validation of results across different methodologies and patient populations. Despite this limitation, our experiences offer a good starting point to discuss this technique.

ET is an interesting and predictable technique used by a few centers. The AT was historically used to solve multiple criticalities is a constantly evolving technique that increasingly aims to achieve a functional and aesthetic result that are difficult to achieve using other surgical techniques.

Conclusion

Both procedures, performed by experienced surgeons, were found to serve as excellent surgical tools. Patient selection was the key to success.

Both techniques were effective in the treatment of DR, and resulted in few complications, excellent recovery times, and satisfactory results.

Our study comparing two substantially different techniques indicated that both are reliable, reproducible, and can achieve surgical success.

Declaration of competing interest

J.P. Medina, R.Albanese, R.Croceri, F. Tomaselli, D.E. Pirchi no conflict of interests to disclose. Dr. Tambasco is currently a consultant in Solta Medical and Apyx Medical.

Ethical approval

This article does not contain any studies involving human participants or animals performed by any of the authors. For this type of study (retrospective), informed consent is not required.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
==== Refs
References

1 Lockwood T Rectus muscle diastasis in males: Primary indication for endoscopically assisted abdominoplasty Plast Reconstr Surg 101 1998 1685 1691 discussion 1692–1694 9583506
2 Sperstad J.B. Tennfjord M.K. Hilde G. Ellström-Engh M. Bø K Diastasis recti abdominis during pregnancy and 12 months after childbirth: Prevalence, risk factors and report of lumbopelvic pain Br J Sports Med 50 2016 1092 1096 27324871
3 Swedenhammar E. Strigård K. Emanuelsson P. Gunnarsson U. Stark B Long-term follow-up after surgical repair of abdominal rectus diastasis: A prospective randomized study Scand J Surg 110 2021 283 289 10.1177/1457496920913677 32299300
4 Lo T. Candido G. Janssen P Diastasis of the recti abdominis in pregnancy: Risk 5 factors and treatment Physiother Can 51 1999 32 37
5 Doubkova L. Andel R. Palascakova-Springrova I. Kolar P. Kriz J. Kobesova A 2 Diastasis of rectus abdominis muscles in low back pain patients J Back Musculoskelet Rehabil 31 2018 107 112 10.3233/BMR-169687 28946525
6 Brauman D Diastasis recti: Clinical anatomy Plast Reconstr Surg 122 2008 1564 1569 10.1097/PRS.0b013e3181882493 1569 18971741
7 Bracaglia R. Tambasco D. Gentileschi S. D'Ettorre M L-shaped lipothighplasty Ann Plast Surg 75 2015 261 265 10.1097/SAP.0000000000000075 PMID:24374390 24374390
8 Fuentes Aparicio L. Rejano-Campo M. Donnelly G.M. Vicente-Campos V Self-reported symptoms in women with diastasis rectus abdominis: A systematic review J Gynecol Obstet Hum Reprod 50 2021 101995 10.1016/j.jogoh.2020.101995
9 Sokunbi G. Camino-Willhuber G. Paschal P.K. Is diastasis recti abdominis 12 associated with low back pain? A systematic review World Neurosurg 174 2023 10.1016/j.wneu.2023.03.01 119–113
10 Tambasco D. D'Ettorre M. Gentileschi S. Colletti R. Mingrone G. Bracaglia R Postabdominoplasty wound dehiscence in bariatric patients: Biliopancreatic diversion versus gastric bypass: A preliminary study Ann Plast Surg 75 2015 588 590 10.1097/SAP.0000000000000195 PMID:25180957 25180957
11 Blankensteijn L.L. Hockx M. Mullender M. Bouman M.B. Melenhorst W.B.W.H Clinical significance of diastasis recti: Literature review and awareness amongst health care professionals J Plast Reconstr Aesthet Surg 84 2023 439 446 10.1016/j.bjps.2023.06.005 Epub 2023 Jun 9PMID:37413736 37413736
12 Cuccurullo D. Guerriero L. Mazzoni G. Sandoval M. Tartaglia E Innovations in 20 surgical treatment of rectus abdominis diastasis: A review of mini-invasive techniques Minerva Chir 75 2020 305 312 10.23736/S0026-4733.20.08461-8 33210526
13 Chang C.J Endoscopic-assisted abdominoplasty Clin Plast Surg 50 2023 163 170 10.1016/j.cps.2022.08.008 36396255
14 ElHawary H. Chartier C. Alam P. Janis J.E Open versus laparoscopic surgical management of rectus diastasis: Systematic review and pooled analysis of complications and recurrence rates World J Surg 46 2022 1878 1885 10.1007/s00268-022-06550-4 35430646
15 Tambasco D. Albanese R. Tomaselli F Reply to “Lipoabdominoplasty: Comparing UAL versus UAL/PAL techniques on complication profile and patient safety” Aesthet Plast Surg 2024 10.1007/s00266-023-03813-1 Epub ahead of print. PMID:38216791
16 Tambasco D. Albanese R. Tomaselli F. Parodi P.C Reply: “Intra-abdominal pressure increases perioperatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient” J Plast Reconstr Aesthet Surg 89 2024 72 73 10.1016/j.bjps.2023.12.012 Epub 2023 Dec 13. PMID:38159473 38159473
17 Carlstedt A. Bringman S. Egberth M. Management of diastasis of the rectus 10 abdominis muscles: Recommendations for Swedish national guidelines Scand J Surg 110 2021 452 459 10.1177/1457496920961000 11 32988320
18 Tambasco D. Tomaselli F. Albanese R. Nele G. Parodi P.C REPLY: Modified diamond-shaped umbilicoplasty in abdominoplasty J Plast Reconstr Aesthet Surg 88 2024 328 329 10.1016/j.bjps.2023.11.026 Epub 2023 Nov 23. PMID:38061256 38061256
19 Tambasco D. Albanese R. Tomaselli F. Parodi P.C Reply: “Indications, outcomes, and complications of neoumbilical reconstruction: A systematic review” J Plast Reconstr Aesthet Surg 89 2024 53 54 10.1016/j.bjps.2023.12.005 Epub 2023 Dec 12. PMID:38142621 38142621
20 Thabet A.A. Alshehri M.A Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: A randomised controlled trial J Musculoskelet Neuronal Interact 19 2019 62 68 30839304
21 Spitznagle T.M. Leong F.C. Van Dillen L.R Prevalence of diastasis recti abdominis in a urogynecological patient population Int Urogynecol J Pelvic Floor Dysfunct 18 2007 321 328 16868659
22 Keshwani N. Mathur S. McLean L Relationship between interrectus distance and symptom severity in women with diastasis recti abdominis in the early postpartum period Phys Ther 98 2018 182 190 29228344
23 Al-Qattan M.M Abdominoplasty in multiparous women with severe musculoaponeurotic laxity Br J Plast Surg 50 1997 450 455 9326149
24 Cannistrà C. Lori E. Arapis K. Abdominoplasty after massive weight loss. Safety preservation fascia technique and clinical outcomes in a large single series-comparative study Front Surg 11 2024 1337948 10.3389/fsurg.2024.1337948 PMID:38333373; PMCID: PMC10850307
25 Jessen M.L. Öberg S. Rosenberg J Treatment options for abdominal rectus diastasis Front Surg 6 2019 65 10.3389/fsurg.2019.00065 PMID:31803753; PMCID: PMC6877697 31803753
26 Kulacoglu H Umbilical hernia repair and pregnancy: Before, during, after… Front Surg 5 2018 1 10.3389/fsurg.2018.00001 PMID:29435451; PMCID: PMC5796887 29435451
27 Wiessner R. Vorwerk T. Tolla-Jensen C. Gehring A Continuous laparoscopic closure of the linea alba with barbed sutures combined with laparoscopic mesh implantation (IPOM Plus Repair) as a new technique for treatment of abdominal hernias Front Surg 4 2017 62 10.3389/fsurg.2017.00062 PMID:29164131; PMCID: PMC5676438 29164131
28 Köckerling F. Botsinis M.D. Rohde C. Reinpold W Endoscopic-assisted linea alba reconstruction plus mesh augmentation for treatment of umbilical and/or epigastric hernias and rectus abdominis diastasis - Early results Front Surg 3 2016 27 10.3389/fsurg.2016.00027 PMID:27243016; PMCID: PMC4865488 27243016
29 Salari N. Fatahi B. Bartina Y. The global prevalence of seroma after abdominoplasty: A systematic review and meta-analysis Aesthet Plast Surg 45 2021 2821 2836 10.1007/s00266-021-02365-6 Epub 2021 Jun 2. PMID:34080041
30 Marouf A. Mortada H Complications of body contouring surgery in postbariatric patients: A systematic review and meta-analysis Aesthetic Plast Surg 45 6 2021 2810 2820 10.1007/s00266-021-02315-2 Epub 2021 May 20. Erratum in: Aesthetic Plast Surg. 2021 Dec 6; PMID:34018015 34018015
