|Year : 2019 | Volume
| Issue : 4 | Page : 142-148
Case series of a novel open plication supported by mesh (PSUM) - technique for symptomatic abdominal rectus diastasis repair with or without concomitant midline hernia: Early results and a review of the literature
Reetta Tuominen1, Jaana Vironen2, Tiina Jahkola1
1 Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
2 Abdominal Center, Helsinki University Hospital, Helsinki, Finland
|Date of Submission||12-Jul-2019|
|Date of Decision||04-Aug-2019|
|Date of Acceptance||14-Aug-2019|
|Date of Web Publication||22-Oct-2019|
Dr. Reetta Tuominen
Department of Plastic Surgery, Helsinki University Hospital, PL 266, 00029 HUS, Helsinki
Source of Support: None, Conflict of Interest: None
BACKGROUND: Abdominal rectus diastasis (ARD), sometimes combined with abdominal wall midline hernia, is a common complaint in women after childbirth. To some individuals, ARD causes functional disability. Convincing data of the long-term results of ARD repair are lacking, especially when ARD is severe, and the optimal technique is undefined. In plastic surgery, the repair is often done with suture alone, but if a concomitant hernia exists, using a mesh is mandatory. This paper reports a novel surgical technique aimed at a reliable and minimally traumatic repair of ARD with or without midline hernia and a review of the literature of ARD repair.
PATIENTS AND METHODS: During June 2013–April 2018, 37 consecutive patients with symptomatic ARD with or without concomitant midline hernia were operated on by using a narrow piece of a self-gripping mesh (n = 32) or the tails of the ventral patch (n = 5). The mesh was placed in between the plicated linea alba. The outcome and patient satisfaction in this pilot study were analyzed.
RESULTS: A significant subjective improvement in body balance after surgery was reported by 34 patients (92%). During the mean follow-up of 13 months, there was only one partial recurrence of ARD. The complication rate was low, and patient satisfaction was good.
CONCLUSION: According to the present study, selected patients with severe lack of muscle control and/or back pain benefit from ARD repair. The minimally traumatic PSUM mesh augmentation seems a promising method for the repair of ARD.
Keywords: Abdominal rectus diastasis, abdominoplasty, mesh augmentation, umbilical hernia
|How to cite this article:|
Tuominen R, Vironen J, Jahkola T. Case series of a novel open plication supported by mesh (PSUM) - technique for symptomatic abdominal rectus diastasis repair with or without concomitant midline hernia: Early results and a review of the literature. Int J Abdom Wall Hernia Surg 2019;2:142-8
|How to cite this URL:|
Tuominen R, Vironen J, Jahkola T. Case series of a novel open plication supported by mesh (PSUM) - technique for symptomatic abdominal rectus diastasis repair with or without concomitant midline hernia: Early results and a review of the literature. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2021 Apr 20];2:142-8. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/4/142/269728
| Introduction|| |
Abdominal wall midline hernia is a common issue. In fertile aged women, the midline hernia often occurs after childbirth,, and it is relatively often combined with abdominal rectus diastasis. ARD alone can also lead to bulging of the abdomen with protruding umbilicus mimicking umbilical hernia. According to Beer classification, the normal width of linea alba in nulliparous women is up to 2.2 cm measured 3 cm above the umbilicus. Acquired ARD persists approximately one-third of women after pregnancy., Anterior abdominal wall biomechanically influences the movements and stability of the lumbar spine.,,, It has been suggested that abdominal rectus diastasis contributes to back pain.,
Conventionally, plain ARD has been managed conservatively often with moderate results. There is some evidence that after ARD repair lower back pain is reduced.,, Consequently, the operative repair of ARD has gained new interest and an increasing number of women are seeking surgical help for their ARD with or without midline hernia. In general, patients are referred to a surgeon based on another primary concern than ARD and bulging: in the case of excess skin-subcutis, the person is referred to a plastic and reconstructive surgeon for abdominoplasty and in the case of midline hernia, to a general surgeon. General surgeons are not always familiar with ARD repair techniques. Even if there is no consensus on whether ARD is a condition requiring operative treatment, in patients with concomitant hernias, the treatment results may be suboptimal if the symptomatic ARD is not addressed. Treating the hernia alone leads to poor results both cosmetically and functionally.
There is evidence that after suture repair of primary hernia, the concomitant ARD predisposes to midline hernia recurrence and therefore, mesh augmented repair is recommended. Mesh augmentation is a surgical technique long known in the literature for its good outcome for incisional and midline hernia repair. The implantation of the mesh, however, is a traumatic procedure with a risk of mesh-related complications, especially if a large mesh is being used. In combination with abdominoplasty, the suture plication of the superficial aponeurosis of recti muscles is the most commonly used reconstructive technique. There is a wide variety of plication procedures. Plastic and reconstructive surgical data implies that plication of linea alba alone is reliable in ARD repair, but the data are mostly concerning narrow ARD. Convincing data of the long-term results of ARD repair are lacking, especially when ARD is severe. Recurrence rates as high as 40% have been reported.
In our unit, during recent years, postpartum, normal weight, symptomatic ARD patients with or without hernia have been operated in collaboration with a general/abdominal surgeon and a plastic surgeon. To avoid over or under treatment, we have developed a method where a narrow strip of self-gripping mesh or the tails of ventral patch mesh are buried inside the plicated linea alba to give tensile strength to the midline plication. The preliminary results of our patient series are presented with a review of the literature of ARD repair.
| Patients and Methods|| |
In this prospective, single-center case series postpartum females who were operated on for severe ARD symptoms (with or without a concomitant hernia) between June 2013 and April 2018 were included in the study. The symptoms the women presented caused by ARD were lower back pain and/or they were unable to attend their previous physical activities that require abdominal muscle control (riding, yoga, downhill skiing, standing long periods, etc.). Altogether 19 patients in this cohort had a concomitant hernia. An umbilical hernia of one patient had been previously repaired, but there was a relapse of the hernia, an obvious ARD and unsolved lower back pain. In another patient, her previous umbilical hernia repair was successful, but the symptomatic ARD remained and was operated in this study setup. Smoking was contraindication, and postpartum period was >12 months. Our patients were all nahas type a: the ARD was caused by pregnancy and no additional laxity of the abdominal wall was seen.
Procedure and follow-up
In addition to ARD correction, a standard abdominoplasty was performed in 14 cases and modified abdominoplasty (four-aisle-star figure of skin de-epithelized around the navel) in 11 cases. Altogether there were 25 patients (seven with hernias) in abdominoplasty group. In 12 patients, the hernia repair was performed without abdominoplasty (patch group). Patient satisfaction and the effect of surgery on symptoms were evaluated at 1 month and 1 year after surgery. Here represented work has been reported in line with the process criteria. Approval by an ethics committee was not necessary as abdominoplasty is a common procedure, and the mesh used is widely utilized in hernia surgery.
PSUM-operative technique and postoperative care
A classic abdominoplasty was performed with suprapubic incision above the pubic hairline. Skin flaps were raised at the fascia level up to processus xiphoideus. In patients with modified abdominoplasty, a stellar skin opening was performed around umbilicus and the excess skin de-epithelized ensuring unilateral blood circulation to the umbilicus from the subdermal plexus. The incision was reached down to linea alba on one side of the navel and undermining around the navel was performed on the fascia level as in standard abdominoplasty. In case of hernia, the hernia sac content was either repositioned into the peritoneal cavity or resected. The repair of the ARD was done with monofilament nonabsorbable sutures of medial borders the anterior rectus sheath. A partly absorbent, self-gripping polypropene mesh (Progrip ®, Covidien) was tailored into a narrow 2 cm slice, over which the suture was done [Figure 1]. The mesh thus stays in a tunnel formed by linea alba plication. Every other suture was reached through the mesh. At the base of the umbilicus stalk, the mesh was split into two to encircle the stalk. In a similar fashion another slice of mesh was placed in the caudal end of ARD plication below the umbilicus. After ARD repair, umbilical repositioning, resection of excess skin-subcutis, and layered closure with absorbable sutures were performed. On patch group, the tails of preperitoneally or intraperitoneally placed ventral patch were buried inside the plicated linea alba in a similar PSUM fashion using a small incision above the navel. The extensive raising of the skin flaps was not done in these cases, where in general the ARD was significant only close to the umbilical area.
|Figure 1: In PSUM method, the medial borders of rectus sheath are plicated by nylon running suture. A narrow, partly absorbent, self-gripping polypropene mesh is placed in the midline. The mesh thus stays in a tunnel formed by linea alba plication and it offers stability to the plication|
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Postoperatively, patients stayed at the hospital for 1–3 days, and the drains were removed when there was <50 ml exudate/24 h. Abdominoplasty patients were instructed to wear an elastic belt for 4 weeks and avoid heavy lifting for 4–5 weeks.
| Results|| |
Altogether 37 consecutive patients were included in the study. Patient demographics are shown in [Table 1]. The mean follow-up period was 13 months (1–34 months). Three patients in patch group could not be contacted and were not available for follow-up.
Overall, patient satisfaction was high at 1 month and 1 year after surgery; cosmetic and especially functional results were good [Figure 2]. Most of the patients reported that muscle control was gained back, back pain was reduced or gone and the ones incapable of attending their previous sport activities were able to ski and do yoga again [Figure 3].
|Figure 2: Patient satisfaction on functional and esthetic result in abdominoplasty (n = 25) and hernia repair groups (n = 12)|
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|Figure 3: The effect of surgery per symptoms as reported by patients ARD repair|
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The stability of ARD repair was controlled manually postoperatively. An ultrasound was performed when recurrence was suspected. During the follow-up time, there was one patient whose ARD repair did not last. With this patient also the ARD related symptoms, back pain and weakness in the abdominal muscles relapsed 18 months postoperatively. The preoperative body mass index (BMI) of the patient was over 33 and ARD was 9.0 cm. Postoperatively, the patient gained weight, and 26 months postoperatively BMI was 35 and ARD 4.0 cm measured with ultrasound.
One PSUM with abdominoplasty operated patient got pregnant 2 years after surgery and a cesarean section was performed at gestational week 38. ARD repair was stabile 10 months after pregnancy measured with ultrasound, and the patient reported no recurrence of low back pain.
Postoperative complications were minor: two hematomas after abdominoplasty required reoperation (Clavien-Dindo IIIb), there were two superficial wound infections treated with per oral antibiotic (Clavien-Dindo II) and one seroma not requiring an intervention (Clavien-Dindo I). Minor dog ear removals were performed under local anesthesia for four of the abdominoplasty patients. In patch group, four out of twelve patients were unsatisfied with the esthetic result as surplus of skin was clustered in the midline. Abdominoplasty was performed afterward on two of these patients.
Review of the literature
In Pitanguy technique described in 1967, the fascia is plicated in the midline using nonabsorbable sutures. Ever since the plication of the anterior rectus sheath has been the most commonly used technique for repair of diastasis recti when abdominoplasty is performed. Various plication techniques have been described thereafter: using absorbable and nonabsorbable sutures, interrupted sutures, continuous sutures, barbed sutures, and all these in different combinations depending to the amount of suture layers and whether anterior, posterior, or both layers of rectus sheath are plicated. Barbed suture materials minimize the risk of sutures to cut through the tissue. The absorbable suture has gained interest as in thin patients the suture material is less palpable and theoretically, there is less formation of suture granulomas and less extrusion and infections. Polydioxanone (PDS) suture retains approximately 50% of its tensile strength at 4 weeks after implantation and 25% of its tensile strength at 6 weeks. In small case series, PDS has been a promising suture material. Tensile strength of collagen in a wound increases up to 3 months.
The available evidence suggests that after plication the recurrence rate for diastasis is low. An exception among publications is a retrospective study by van Uchelen et al. where 40% of the patients had residual or recurrent diastasis. van Uchelen plicated linea alba beyond medial borders of the rectus sheath generating more tension and used several suture materials even polyglycolic acid that is a relatively rapidly resorbing material-tensile strength of braided polyglycolic acid is 50% in 3 weeks. In a randomized controlled trial, Emanuelsson et al. compared retro muscular Stoppa style 30 cm × 30 cm mesh to Quill™ (SRS, self-locking technology, PDO 2/0, Angiotech) barbed double-row suture. There was no statistical difference between the study groups (n = 27 and 29). However, the sample size was based on the assumption of significant difference between recurrences in suture and mesh groups (30% in the suture group and 5% in the mesh group) at the 1-year follow-up. The sample size is too small to show smaller differences.
Of note is that fascia heals poorly, and primary closure of ventral abdominal wall hernias is accompanied with high recurrence rates. The overall incidence of incisional hernia after laparotomy is approximately 10%. In hernia repair, mesh augmentation is an evidence-based technique to ensure a strong and reliable abdominal wall closure. In ARD repair Rives-Stoppa style, retro muscular mesh and other modifications have been used with good results. Laparoscopic techniques where mesh is placed intraperitoneally have been used in ARD repair as well. The downside of the laparoscopic method is the surplus of soft tissue clustered at the midline as a result of the ARD plication – the wider the ARD is, the more extensive the excess skin., Furthermore, the use of intraperitoneal mesh carries a small risk of severe bowel complications. Recently, new minimally invasive techniques have been published for repair of midline hernias combined with an additional rectus diastasis. In endoscopic mini/less open sublay (EMILOS)-technique a large mesh is placed in the retromuscular plane endoscopically, and the hernia sac is repositioned into the peritoneal cavity through small incision. Totally endoscopic sublay (TES)-technique is based on EMILOS-technique, but avoids any large skin incisions. Rectus muscles can be repositioned in the midline in the association of both of these techniques, minimizing the risk of bulging postoperatively. As with the laparoscopic technique, TES and EMILOS are less preferable when there is excess skins-subcutis, as these minimally invasive techniques do not reduce tissue from the abdominal wall.
There are three review articles on ARD repair. According to them, both plication-based methods and hernia repair methods are used with no difference in postoperative complications or recurrence. Most evidence, however, is of low quality and to find out long-term results requires more studies. To compare the width of the ARD and results of surgery, we collected the parameters of ARD in one randomized trial comparing two operative techniques and the original articles that were included in the review articles ,,,,,,,,,,,,,,,,,,,,,,,,,,, [Table 2]. The outcome results regarding the ARD repair stability are relatively good, but the crucial information of preoperative ARD severity is lacking in most of the studies. The more ARD there is, the more there is tension after correction and theoretically the probability of a recurrence rises.
|Table 2: Summary of the studies (with more than four patients and available in English) that were included in review articles and the only RCT on ARD repair: the width of the ARD pre- and post-operatively|
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| Discussion|| |
To some individuals, wide ARD causes disabilities that affect the quality of life: low back pain and difficulties in movement control. If extensive physiotherapy does not offer satisfactory improvement in symptoms, surgery can be considered. The preoperative planning of a normal weight postpartum female who has symptomatic ARD with or without midline hernia or skin-subcutis surplus must be performed thoroughly. The elimination of ARD also eliminates the underlying cause of abdominal wall defects. It restores anterior abdominal wall firmness and stabilizes the trunk when rectus muscles are repositioned adjacent to the new narrow linea alba. The amount of intraperitoneal content should be small-if there is a considerable amount of intraperitoneal fat, the ARD is natural, and should not be corrected. In this study, the patients were sportive and normal weight or skinny except one patient, whose diastasis repair relapsed. She was obese before the operation and gained weight postoperatively.
The present literature is scarce on the reliability of wide ARD repair and there is discrepancy in general and reconstructive surgical studies. General surgeons tend to use large meshes and plastic surgeons often repair the midline with suture alone. Theoretically, additional mesh augmentation offers stabilization of the linea alba reconstruction. Based on this, we have developed a novel PSUM – method. PSUM causes limited trauma to abdominal wall and aims at the reliable reconstruction of a wide and weakened linea alba. In this preliminary series, the patients reported good relief on their symptoms.
While functional results in our series have been promising, it is important to consider also the esthetic outcome. In our unit, collaboration of plastic and general surgeons when treating this patient group has been beneficial. Plication of ARD generates excess skin-subcutis in the midline that does not always dissolve postoperatively even if wide-undermining is performed. In our series, two patients had abdominoplasty as a second operation to correct this deformity.
Our current approach in the presence of a symptomatic ARD not responding to conservative therapy depends on the evaluation of the overall situation of the abdominal wall. In the case excess skin, the ARD repair is performed by the means of abdominoplasty and PSUM mesh is implanted in the midline. In the case of low-quality skin and lack of subcutaneous fat in the midline, the skin around navel is de-epithelized. A midline incision offers easy working field for PSUM-method. If there is no surplus of skin-subcutis and there is a concomitant umbilical or epigastric hernia preperitoneal ventral patch mesh is implanted, the tails of the mesh are used to plicate the ARD in PSUM-fashion, and the abdominal subcutis is undermined until the skin folds appropriately.
| Conclusion|| |
PSUM method is a promising operative technique for ARD repair in symptomatic patients with back pain and difficulties in movement control. However, further studies with a greater number of patients and longer follow-up are needed before the final assessment of this surgical technique can be made. Based on findings in this preliminary series, our study group is recruiting patients for randomized trial where PSUM method is used as one intervention and plication as another (ClinicalTrials.gov Identifier: NCT03509376).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]