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Background Abdominal rectus diastasis can lead to functional disability. There is no consensus regarding treatment. This was a prospective study on patients randomized to surgery using either Quill self-retaining sutures or retromuscular mesh for abdominal rectus diastasis repair. The primary aim of the study was to compare long-term recurrence after surgery. Secondary aims were abdominal muscle strength, pain, and quality of life. Methods A total of 57 patients were eligible and 52 were investigated. A routine 1-year follow-up ruled out any patient with recurrence and this was followed up by clinical examination for recurrence and assessment of the secondary outcomes a median of 5 years (3.8–6.5 years) after surgery. Quality of life was assessed using the Short Form-36 questionnaire. Pain related to activity was evaluated using the Ventral Hernia Pain Questionnaire. Results No recurrence of abdominal rectus diastasis was found. Significant improvements were seen between index surgery and long-term follow-up in all domains of Short Form-36. There were no significant differences in quality of life or self-reported muscle strength between the two surgical groups. Long-term pain remained unchanged compared to that at the 1-year follow-up. “Pain this week” had decreased significantly at long-term follow-up compared to prior to surgery (mesh p = 0.009, Quill p = 0.003). Conclusion No recurrence of abdominal rectus diastasis appeared. There was no difference in quality of life or long-term pain between the two surgical groups. Implantation of retromuscular mesh entails more extensive surgery implying potentially higher risk for complications. This leads us to recommend reconstruction with double-row self-retaining sutures for the repair of abdominal rectus diastasis in patients with functional disability.
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Scandinavian Journal of Surgery
1 –7
© The Finnish Surgical Society 2020
Article reuse guidelines:
DOI: 10.1177/1457496920913677
E. Swedenhammar1, K. Strigård2, P. Emanuelsson1, U. Gunnarsson2, B. Stark1
1Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
2 Division of Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Karolinska
University Hospital, Umeå, Sweden
Background: Abdominal rectus diastasis can lead to functional disability. There is no
consensus regarding treatment. This was a prospective study on patients randomized to
surgery using either Quill self-retaining sutures or retromuscular mesh for abdominal
rectus diastasis repair. The primary aim of the study was to compare long-term recurrence
after surgery. Secondary aims were abdominal muscle strength, pain, and quality of life.
Methods: A total of 57 patients were eligible and 52 were investigated. A routine 1-year
follow-up ruled out any patient with recurrence and this was followed up by clinical
examination for recurrence and assessment of the secondary outcomes a median of 5 years (3.8–
6.5 years) after surgery. Quality of life was assessed using the Short Form-36 questionnaire.
Pain related to activity was evaluated using the Ventral Hernia Pain Questionnaire.
Results: No recurrence of abdominal rectus diastasis was found. Significant
improvements were seen between index surgery and long-term follow-up in all domains
of Short Form-36. There were no significant differences in quality of life or self-reported
muscle strength between the two surgical groups. Long-term pain remained unchanged
compared to that at the 1-year follow-up. “Pain this week” had decreased significantly at
long-term follow-up compared to prior to surgery (mesh p = 0.009, Quill p = 0.003).
Conclusion: No recurrence of abdominal rectus diastasis appeared. There was no
difference in quality of life or long-term pain between the two surgical groups. Implantation
of retromuscular mesh entails more extensive surgery implying potentially higher risk for
complications. This leads us to recommend reconstruction with double-row self-retaining
sutures for the repair of abdominal rectus diastasis in patients with functional disability.
Key words: Abdominal rectus diastasis; operation method; abdominoplasty; quality of life; recurrence;
long-term follow-up
Ebba Swedenhammar, M.D.
Department of Molecular Medicine and Surgery
Karolinska Institutet
Karolinska University Hospital
Solna (L1:00)
SE-171 76 Stockholm
913677SJS0010.1177/1457496920913677Long-term follow-up after repair of rectus diastasisE. Swedenhammar, et al.
Original Research Article
E. Swedenhammar, et al.2
Abdominal rectus diastasis (ARD) can be either a pri-
mary or a secondary condition following pregnancy,
massive weight loss, or previous abdominal surgery.
ARD affects both genders but is more frequent in
women, often related to hormonal variations in preg-
nancy (1–3). The incidence of ARD after delivery is not
known with certainty, with studies reporting a wide
range between 40% and 60% after 4 days to 1 year (4).
ARD is present when the linea alba width is more than
27 mm at umbilical level, or approximately more than
1 cm above or below the umbilicus depending on age
(2). Midline bulging of the anterior abdominal wall
can be perceived as discomfort, pain, or impaired core
stability. Difficulty in performing daily activities or
during physical activity has been reported (5, 6).
No consensus has been reached regarding the most
appropriate surgical method or associated benefits.
Different techniques for ARD repair have been
described in several small studies and they differ in
respect to the number of layers of sutures, suture
material used, positioning of the sutures, and if a mesh
was used (7, 8). A prospective randomized study by
our group (9) compared surgical repair with plication
using double-row Quill sutures, to retromuscular
mesh repair. A group allocated to dedicated exercises
served as controls at a 3-month follow-up. By the
1-year follow-up, the operated patients had increased
abdominal muscular strength measured by the Biodex
dynamometer, experienced less pain during daily
activities, and reported improved quality of life (QoL)
(10). Moreover, the double-row repair with Quill
sutures did not result in more postoperative complica-
tions or recurrence of ARD compared to the mesh
repair (9). The consistency of these findings needed to
be addressed in a long-term follow-up analysis.
The aim of this study was to compare long-term
outcomes of ARD repair using double-row Quill self-
retaining suture with retromuscular mesh repair in
patients with functional disability due to ARD. The
primary endpoint was recurrence rate of diastasis
after the 1-year follow-up. Secondary endpoints were
QoL, self-reported abdominal muscle strength, and
pain in the abdominal wall.
Patients with the diagnosis ARD combined with dis-
comfort and/or abdominal pain, referred to either the
Department of Reconstructive Plastic Surgery or the
Centre for Surgical Gastroenterology at the Karolinska
University Hospital between December 2009 and
December 2012 were invited to take part in the study.
Inclusion and exclusion criteria for the primary study
by Emanuelsson etal. (9) are shown in Table 1. Patients
underwent computed tomography (CT) and were
measured clinically prior to the randomization. The
patients were referred to either site depending on the
patients’ proximity to the hospital sites. Eligible
patients were randomized prior to the operative pro-
cedure to either one of two surgical procedures: dou-
ble-row vertical suture repair with self-retaining
barbed sutures 2/0 PDO (Quill™SRS) (11) or rein-
forcement with lightweight polypropylene mesh
(BARD™ Soft Mesh) placed in the retromuscular
plane on the peritoneum, the mesh was not anchored
laterally with sutures. Then the anterior fascia was
closed with running sutures 2/0 PDS (polydioxanone).
For technical reasons, a wide dissection from the pubic
symphysis to the xiphoid was done to expose the rec-
tus muscles completely. Further details of the opera-
tive procedures have been described elsewhere (9). A
full abdominoplasty was performed if the patient had
surplus skin.
A consort diagram for the study is shown in Fig. 1.
For the calculated power (80%) in the primary study,
25 patients were needed in each arm. For every drop-
out, another three patients were included to maintain
this power. At the primary randomization, 57 patients
were randomized to surgery and 32 to training. The
surgical randomization took place when the patient
had been anesthetized in the operating theater. All
surgeries were executed by a colorectal surgeon with
special interest in abdominal wall surgery and a plas-
tic surgeon in collaboration. Patients were evaluated
between 26 October 2015 and 28 September 2016. The
median and mean long-term follow-up was 5 years
(range: 3.8–6.5 years, interquartile range (IQR): 1.2).
The study was approved by the Regional Ethics
Review Board in Stockholm ( 2009/227-31,
2011/1186-32, 2016/55-32) and was registered on with the number 2009/227-31/3/
PE/96. The Declaration of Helsinki principles of ethi-
cal standard were followed.
Aspects of QoL as well as pain and its effect on daily
activities were addressed using the Short Form-36 (SF-
36) questionnaire and the Ventral Hernia Pain
Questionnaire (VHPQ) (12). SF-36 is an instrument
designed to create health scores in eight different
dimensions. There are four mental and four physical
dimensions that can also be summarized in two com-
ponent scores (13). The VHPQ is a validated question-
naire to assess the patient’s own experience of pain
before and after surgery of the ventral abdominal wall
and relates to daily activities. Outcomes were com-
pared with preoperative and 1-year follow-up data.
Inclusion and exclusion criteria from the primary study as seen in
co-author Emanuelsson etal.’s (9) article.
Inclusion Exclusion
ARD 3 cm Ongoing pregnancy
>18 years old Ongoing breastfeeding
Abdominal wall discomfort or
Immunosuppressive therapy
Wish to have abdominal wall
For women: 1 pregnancy,
>1 year after childbirth
ARD: abdominal rectus diastasis.
Long-term follow-up after repair of rectus diastasis 3
At the long-term follow-up, all patients underwent
clinical assessment by a senior surgeon not previously
involved in any part of the study.
Recurrence of ARD was defined as separation of
the rectus abdominis muscles 3 cm, either above or
below the umbilicus. Measurements of ARD were
made using exactly the same method as in the exami-
nation prior to surgical repair (9). Any gap present
was measured halfway between the pubic symphysis
and the umbilicus or halfway between the xiphoid
process and the umbilicus. If recurrence was uncertain
in the clinical assessment, CT was performed.
The abdominal circumference was measured at the
level of the umbilicus. Potential soft-tissue irregulari-
ties covering the abdominal wall, as well as appear-
ance of the scar and position of the umbilicus were
noted. Details of medical events, smoking, or further
pregnancies since the 1-year follow-up were retrieved
from patient notes or taken at the long-term follow-up
Statistica version 13 was used for all statistical calcula-
tions. Patient demographics were presented with
min–max and IQR. When comparing continuous vari-
ables, the Mann–Whitney U test was used since non-
parametric outcomes were expected. Dichotomous
data were compared with the chi-square test and
Fischer’s exact test. The SF-36 results were evaluated
with paired and independent t tests. Collected data
were matched with reference data from an age-
matched Swedish population (13). The VHPQ was
evaluated using the Mann–Whitney U test and
dependent variables with Wilcoxon’s rank-sum test.
Power was originally calculated for the primary
endpoint in the original study, recurrence at the 1-year
follow-up, in our previous study on ARD repair. To
obtain a significance level of 95% for 80% power, each
surgical group required at least 25 patients (10) assum-
ing a recurrence rate of 30% in the Quill group and 5%
in the mesh group after 1 year. This presumption was
based on the results of previous studies on incisional
hernia repair with mesh or sutures (14, 15).
Of the 57 patients operated, 53 were available for long-
term follow-up (Fig. 1 and Table 2). One early recur-
rence in the Quill group was repaired with
retromuscular mesh within 6 weeks after index sur-
gery. This patient was excluded from further follow-
up within the frame of our research protocol. There
were no significant differences in demographic param-
eters between the groups (Table 2). Except for the early
recurrence before the 3-month follow-up, no ARD
recurrence was found in either group between the
1-year and long-term follow-up. Two patients (one in
each group) noted some bulging of the abdominal
wall and some diffuse abdominal pain, but no recur-
rence was confirmed either by clinical assessment or
Fig. 1. Flow chart: consort diagram.
Patients eligible for intervention and follow-up.
Demographics at long-term follow-up.
Mesh Quill p
Follow-up since operation
Median 4.95 5.10
Min–max 4–6.5 3.8–6.3
IQR 1.05 1.3
BMI 0.700
Median 22.9 22.8
Min–max 18.1–30.2 18.8–36
IQR 3.85 4.95
Median 43 42 0.776
Min–max 29–63 30–62
IQR 6.5 11
Gender, n (%) 1
Female 27 (96.4) 23 (95.8)
Male 1 (3.6) 1 (4.2)
Smokers, n (%) 1 (3.6) 4 (16.7) 0.169
Postoperative pregnancy, n (%) 2 (6.7) 2 (8.3) 1
BMI: body mass index; IQR: interquartile range.
Significant levels are calculated with Mann–Whitney U test and for
dichotomous variables with chi-square test and Fischer’s exact test.
The five smokers found in long time follow-up began smoking
after surgery.
E. Swedenhammar, et al.4
by CT. Five patients had resumed smoking after the
last follow-up.
VHPQ questionnaire ratings are listed in Table 3. No
significant differences were seen between the two
groups. When comparing dependent data, “pain this
week” was significantly lower in both groups com-
pared to preoperative values (preoperative vs long-
term: mesh p = 0.009, Quill p = 0.003). There was not
enough material for statistical analysis in several of
the variables due to few symptoms at the long-term
follow-up. At the long-term follow-up, a few patients
mentioned the appearance of discomfort and diffuse
pain that was not revealed in the two questionnaires.
Twenty-five patients (89.3%) in the mesh group and
21 patients (87.5%) in the Quill group expressed no
difference in well-being compared to the improve-
ment reached at the 1-year follow-up (10). A similar
situation was the case for self-reported core stability.
Twenty-seven patients in the mesh group and 20 in
the Quill group were satisfied with functional out-
come, but only 11 versus 7 patients, respectively,
were satisfied with the aesthetic outcome. Excess
skin at the lateral borders of the lower abdominal
scar, irregularities of the fat layer covering the
abdominal wall, and a wider scar than expected were
the main complaints.
Prior to surgery, both groups scored significantly
lower in all domains compared to the Swedish
matched population (p < 0.001) (9). Furthermore, the
baseline preoperative physical and mental health
scores of patients in the Quill group were significantly
lower than those reported in the mesh group. All
domains were above the Swedish matched population
at the time of the long-term follow-up, except for vital-
ity (VT), social function (SF), and mental health (MH)
in the Quill group (Fig. 2).
When comparing mental component score (MCS)
between the two groups, a significantly higher score
was seen in the mesh group (p = 0.002). There was no
difference in physical component score (PCS) between
the groups (p = 0.867).
Two patients in each group became pregnant during
the period between the 1-year and long-term follow-
up. Interestingly, the two patients operated with Quill
suture plication described recurrence of ARD during
the second respective third trimester with return to
stability of the abdominal wall after delivery. The two
patients operated with retromuscular mesh suffered
from abdominal wall pain and discomfort in the sec-
ond respective third trimester. They experienced
intense rigidity of the anterior abdominal muscles
with more lateral than midline expansion of abdomi-
nal wall tissues.
The circumference of the waist was similar in both
groups. No significant difference was seen between
the two groups when comparing body mass index
(BMI) and circumference prior to surgery with values
at the long-term follow-up (Table 4).
In a previous study of the same study cohort (10), we
showed that no recurrence of ARD had occurred at
The VHPQ results for preoperative and long-term follow-up after repair.
Questionnaire Preoperative Long term Preoperative Long term
(n = 29)
(n = 28)
(n = 28)
(n = 24)
Pain right now 1 22 25 21 23
Pain right now >1 6 3 7 1
Pain last week >111 3 12 1
Difficulty rising from chair 2 0 7 0
Difficulty sitting 1 1 3 2
Difficulty standing 1 1 6 1
Difficulty climbing stairs 2 0 6 0
Difficulty driving a car 1 0 0 0
Difficulty performing sports and physical activity 11 5 14 3
VHPQ: Ventral Hernia Pain Questionnaire.
If patients graded their pain right now as 1, the pain was considered easily ignored. Scorings higher than 1 constituted pain not easily
ignored during everyday activities. They presented with symptoms, for example, swelling after eating or discomfort and weakness in
the abdominal trunk. Other reported symptoms were tactile discomfort, muscle cramps during exercise, less stamina during physical
exercise, and lower back pain.
“Pain last week” was significantly lower in both groups compared to preoperative values (preoperative vs long-term: mesh p = 0.009,
Quill p = 0.003).
Long-term follow-up after repair of rectus diastasis 5
1-year follow-up after the index operation. In the pre-
sent long-term follow-up, no further recurrences
occurred indicating that reconstructions of ARD with
either mesh or Quill double-row suture are stable over
time. Consequently, our hypothesis that there would
be a difference in ARD recurrence between Quill dou-
ble-row suture and retromuscular mesh repair (30%
and 5%, respectively) 1 year after surgery was rejected,
as well as throughout the long-term follow-up period
in this prospective randomized trial. Thus, no method
was overtly superior for ARD repair in this respect.
The present data are contrary to previous reports
stating ARD recurrence rates between 30% and 40%
for suture repair. Van Uchelen et al. (16) reported a
40% recurrence rate after repair with a single-row ver-
tical plication using absorbable sutures. In contrast to
Gama etal. (17), we did not see a 30% recurrence rate
when using barbed sutures. This discrepancy in results
could be explained by the double-row longitudinal
suture technique used in this study, reducing horizon-
tal tension at the medial margins of the rectus muscles.
These results are also comparable to those from Nahas
etal. (18) and Rosen etal. (19) using a similar approach.
The risk for fascial rupture may thus be reduced com-
pared to using a single-row technique (17). Further
randomized studies evaluating different suturing
techniques are needed.
Our own observations had previously indicated a
significant improvement in all domains and parame-
ters 1 year after ARD repair (10). In this assessment,
the majority of patients experienced overall improved
QoL and diminished bodily pain in the SF-36 and
VHPQ. The consistency of results in the various SF-36
domains and VHPQ indicates that the outcome of sur-
gery is long-lasting and stable over time.
At long-term follow-up, all domain scores were
above the Swedish matched population, except for VT,
SF, and MH in the Quill group. Preoperatively patients
in the Quill group had a lower component score for self-
rated mental health than patients in the mesh group.
Furthermore, even though the demographics of the
patient groups appeared to be similar, we noted that
patients in the Quill group scored significantly lower
for specific SF-36 domains. Meningaud etal. showed in
Fig. 2. SF-36. Results from the two groups, before operation and at long-term follow-up after surgery, compared to a matched Swedish
PF: physical functioning; RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role-emotional;
MH: mental health.
BMI and waist circumference preoperative measurements compared to long-term follow-up.
BMI long term p Circumference
long term
Mesh 0.633 0.412
Median (min–max) 23 (18–30) 22.9 (18.1–30.2) 85.5 (71–102) 85 (71–102)
IQR 4 3.85 12 8
Quill 0.605 0.167
Median (min–max) 23 (18–31) 22.8 (18.8–36) 87 (72–116) 87.5 (60–113)
IQR 4 4.95 19 17.5
BMI: body mass index; IQR: interquartile range.
E. Swedenhammar, et al.6
their multicentre study that patients undergoing plastic
surgery might have a different psychological profile
compared to the general population. Using structured
interviews and three assessment scales, they found
more depression and anxiety among plastic surgery
patients (20). Nonetheless, the psychological profile of
our two groups differed somewhat after randomization
as shown in the preoperative SF-36 results.
The majority of patients in both groups were satis-
fied with their functional outcome (return from sick-
leave, running marathons, and possibility to play with
their children among others) but expressed dissatis-
faction regarding the aesthetic outcome. This empha-
sizes the importance of addressing the patient’s
expectations; aspects of functionality and aesthetics
should be clearly explained at the preoperative visit.
Further studies are needed to identify the patient
cohort most likely to benefit from ARD repair. In-depth
interviews in combination with assessment of abdom-
inal function and QoL could possibly help to establish
a score system for rating indication for surgery.
In the clinical examination, we found a median
waist circumference that was larger than expected, in
some cases the circumference was larger than prior to
index surgery despite no ARD recurrence or weight
gain. Up to our best knowledge verified by search in
PubMed and Web of Science, this observation has not
been described previously. Many patients had a low-
to-normal BMI, but their waist circumference was
larger than expected, the median in the mesh group
was 85 cm compared to 87.5 cm in the Quill group.
According to the World Health Organization (WHO),
women with a waist circumference larger than 88 cm
run a great risk for cardiovascular disease and an
increased risk if the waist is 80–88 cm (21). One could
argue that these patients might have had a general lax-
ity in the abdominal wall even though the repair was
intact. Could this laxity be an expression of a differ-
ence in the muscular biology and morphology of the
abdominal wall? This aspect will be addressed in fur-
ther morphological studies of the muscles and connec-
tive tissue of the abdominal wall.
Four patients became pregnant after the 1-year fol-
low-up at which time a few patients asked about
future pregnancy. Nahas published a case report of a
woman becoming pregnant 2.5 years later after
abdominoplasty including diastasis repair with plica-
tion. According to Nahas, despite no recurrence of the
diastasis, the patient’s waist had returned to normal
15 months after delivery. Nahas (22) suggested delay-
ing pregnancy at least 12 months after surgery to
assure formation of mature fibrotic tissue after repair.
There are few randomized prospective studies con-
cerning repair of rectus diastasis and even fewer with
long-term follow-up. The dropout rate in this study
was low and we were able to collect a wide range of
parameter values that could be compared with preop-
erative data. It would be valuable to identify specific
markers and symptoms that correspond to ARD and
changes over time after the index operation. There
was an obvious risk for bias when comparing the two
groups regarding self-reported mental health since
patients in the Quill group scored poorer mental
health even prior to surgery.
No recurrence of ARD developed between the 1-year
and a long-term follow-up after repair with double-
row barbed sutures or retromuscular mesh in this
prospective randomized study. Results of ARD
repair were stable during long-term follow-up also
regarding improvement in QoL. Included patients
had an ARD width of 3–7 cm with a median of 4 cm.
Implantation of retromuscular mesh entails more
extensive surgery than double-row suture repair,
thus having a higher potential risk for complica-
tions. This leads us to recommend using double-row
self-retaining suture for the repair of ARD. More
studies are needed, because for this group of patients
an improvement in QoL and less pain can be of great
The study was registered on with the num-
ber 2009/227-31/3/PE/96.
E.S., B.S., P.E., K.S., and U.G. all helped with the study
design. E.S. metall the patients and collected the data. E.S.
wrote the article with help and multiple revisions from all
the other authors. E.S. made the statistical analysis with
assistance from, especially, U.G. Interpretation of the result
was made mostly by E.S., U.G., B.S., and K.S. All authors
have approved the final version of this manuscript.
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publication of
this article: The study was funded by the Swedish National
Cooperation for Medical Education and Research (ALF).
E. Swedenhammar
1. Brauman D: Diastasis recti: Clinical anatomy. Plast Reconstr
Surg 2008;122:1564–1569.
2. Rath AM, Attali P, Dumas JL etal: The abdominal linea alba: An
anatomo-radiologic and biomechanical study. Surg Radiol Anat
3. Lo T, Candido G, Janssen P. Diastasis of the recti abdominis
in pregnancy: Risk factors and treatment. Physiother Can
4. Mota P, Pascoal AG, Carita AI etal: Normal width of the inter-
recti distance in pregnant and postpartum primiparous women.
Musculoskelet Sci Pract 2018;35:34–37.
Long-term follow-up after repair of rectus diastasis 7
5. Doubkova L, Andel R, Palascakova-Springrova I etal: Diastasis
of rectus abdominis muscles in low back pain patients. J Back
Musculoskelet Rehabil 2018;31(1):107–112.
6. Parker MA, Millar LA, Dugan SA: Diastasis rectus abdominis
and lumbo—Pelvic pain and dysfunction—Are they related? J
Womens Health Phys Ther 2009;33:15–22.
7. Mommers EH, Ponten JH, Al Omar AK etal: The general sur-
geon’s perspective of rectus diastasis. A systematic review of
treatment options. Surg Endosc 2017;31(12):4934–4949.
8. Hickey F, Finch JG, Khanna A: A systematic review on
the outcomes of correction of diastasis of the recti. Hernia
9. Emanuelsson P, Gunnarsson U, Strigard K etal: Early complica-
tions, pain, and quality of life after reconstructive surgery for
abdominal rectus muscle diastasis: A 3-month follow-up. J Plast
Reconstr Aesthet Surg 2014;67(8):1082–1088.
10. Emanuelsson P, Gunnarsson U, Dahlstrand U etal: Operative
correction of abdominal rectus diastasis (ARD) reduces pain
and improves abdominal wall muscle strength: A randomized,
prospective trial comparing retromuscular mesh repair to
double-row, self-retaining sutures. Surgery 2016;160(5):
11. Quill™ Self-Retaining System (SRS) Comprised of Dyed PD0
(Polydioxanone) Synthetic Absorbable Surgical Suture Material
Instructions for Use. Angiotech, Reading, PA, 2007.
12. Clay L, Franneby U, Sandblom G etal: Validation of a ques-
tionnaire for the assessment of pain following ventral her-
nia repair—The VHPQ. Langenbecks Arch Surg 2012;397(8):
13. Sullivan M, Karlsson J, Ware JE Jr: The Swedish SF—36 Health
Survey—I. Evaluation of data quality, scaling assumptions,
reliability and construct validity across general populations in
Sweden. Soc Sci Med 1995;41(10):1349–1358.
14. Christoffersen MW, Helgstrand F, Rosenberg J etal: Long-term
recurrence and chronic pain after repair for small umbilical
or epigastric hernias: A regional cohort study. Am J Surg
15. Burger JW, Luijendijk RW, Hop WC etal: Long-term follow-up of
a randomized controlled trial of suture versus mesh repair of inci-
sional hernia. Ann Surg 2004;240(4):578–583; discussion 583–585.
16. Van Uchelen JH, Kon M, Werker PM: The long-term durability
of plication of the anterior rectus sheath assessed by ultrasonog-
raphy. Plast Reconstr Surg 2001;107(6):1578–1584.
17. Gama LJM, Barbosa MVJ, Czapkowski A etal: Single-layer pli-
cation for repair of diastasis recti: The most rapid and efficient
technique. Aesthet Surg J 2017;37:698–705.
18. Nahas FX, Augusto SM, Ghelfond C: Nylon versus polydiox-
anone in the correction of rectus diastasis. Plast Reconstr Surg
19. Rosen A, Hartman T: Repair of the midline fascial defect in
abdominoplasty with long-acting barbed and smooth absorb-
able sutures. Aesthet Surg J 2011;31(6):668–673.
20. Meningaud JP, Benadiba L, Servant JM et al: Depression,
anxiety and quality of life among scheduled cosmetic surgery
patients: Multicentre prospective study. J Craniomaxillofac
Surg 2001;29:177–180.
21. Guidelines on overweight and obesity: Electronic textbook.
According to waist circumference, https://www.nhlbi.nih.
22. Nahas FX: Pregnancy after abdominoplasty. Aesthetic Plast
Surg 2002;26:284–286.
Received: October 21, 2019
Accepted: February 19, 2020
... Of the included articles, four were randomized control trials (Level I) [10], one was a retrospective cohort study (Level III) and two were prospective case series (Level IV). Two of the included randomized trials were overlapping reports of the same cohort of patients, with varying follow-up periods and outcome measurements [10,20,21]. The mean MINORS score for the two non-comparative articles was 9.5/16 (SD 0.71, range 9-10), which represents a moderate risk of bias. ...
... Functional outcome measures were used in all seven studies; details of each study can be found in Table 4. The most consistent result was an improvement in the physical function subscale of SF-36 in all studies that used this instrument [6,10,21,23]. The next most commonly used scale, the DRI, showed improvement in one study [23] but no improvement in another [2]. ...
... However, a third study by Wilhelmsson et al. demonstrated no significant difference [2]. Regarding functional outcomes, the most consistent result was an improvement in the physical function subscale of SF-36 in all studies that used this instrument [6,10,21,23]. The DRI scale showed improvement in one study [23] but no improvement in another [2]. ...
Rectus diastasis plication performed during abdominoplasty aims to narrow the widened linea alba and return the rectus muscle bellies to their anatomic position. It is unclear whether plication improves abdominal strength and function. This systematic review summarizes the effect of rectus plication on abdominal strength, function, and postoperative complications. A comprehensive search of CINAHL, Embase, Medline and Web of Science was performed. Screening and data extraction were performed in duplicate. Data were extracted from the included articles, and outcomes were analyzed categorically. A total of 497 patients from seven articles were included. Mean age was 44.5 years (range 20.5-72) and 94.4% were female. Three articles reported abdominal strength measurements, with two showing significant improvement. Four articles used the SF-36 survey, all demonstrating improvement in physical function subscale postoperatively. An additional six instruments were used to assess functional outcomes, of which four demonstrated significant improvement. The overall complication rate was 17.0%. Rectus plication is commonly performed during abdominoplasty to improve abdominal form and function. While the literature to date is encouraging with respect to functional outcomes, improvements in abdominal strength are less consistent. Heterogeneity in patient population, outcome measures, and comparison groups limit the strength of our conclusions. Future research should include a large comparative study as well as a protocol for standardizing outcomes in this population.
... Although we did not include a standardized measure of postoperative pain, no patients in our sample had chronic pain or nerve pain. Emanuelsson in an RCT concluded that mesh has no advantages over a double row of suture plication, 19 but the degree or severity of rectus diastasis seemed less than in our study, where only the most severe cases of abdominal wall laxity were treated with mesh. ...
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Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication. Methods: Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last set of office photographs. Results: Surgical site occurrence rate was 0% of the 40 patients in the mesh group and 19% of the 37 patients in the standard group (P = 0.005); rates of soft-tissue revision were 23% in the mesh group and 27% in the standard group (P = 0.84). As to aesthetics, the mesh abdominoplasty patients had mean statistically lower preoperative scores in comparison with the standard plication group (65.8 ± 11.6 versus 70.3 ± 11.4, P = 0.0013). The mesh group had a statistical improvement to 75.9 ± 12.6 (P < 0.0001), whereas the standard plication group improved to 82.5 ± 11.4 (P < 0.0001). Conclusions: Retrorectus mesh placement in a cohort of patients with severe rectus diastasis had a complication rate lower than that seen in a cohort of patients with less severe rectus diastasis, therefore negating our original hypothesis. This was done without compromising aesthetic improvement.
... At the 1-year follow-up abdominal pain was evaluated with the Ventral Hernia Pain Questionnaire, abdominal wall muscle strength was evaluated with the Biodex System-4, Quality of Life was evaluated with the SF-36 questionnaire, patient perceived muscle strength was evaluated with a Visual Analog Scale. A long term follow-up has been presented by Swedenhammar et al [30], in 2020. At the 5-year follow-up, there were still no recurrencies, no difference between the two groups regarding Quality of Life (SF-36), or self-reported muscle strength (VAS). ...
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Introduction Over the last decade rectus diastasis has gained attention as a condition that may benefit from surgery. Numerous surgical techniques have been presented but scientifically proper studies reporting functional outcome are few and evidence is incomplete. The aim of this up-to-date review is to analyse the outcomes of rectus diastasis repair in recently published papers, focusing on functional changes following surgery. Method A comprehensive search in PubMed and Web of Science was performed. Suitable papers were selected using titles and abstracts with terms suggesting surgical treatment of rectus diastasis. All abstracts were scrutinised, and irrelevant studies excluded in four stages. Reports providing original data, including outcome assessment following surgery, were included. Result Ten papers with a total of 780 patients were found to fulfil the search criteria. Study design, surgical procedure, follow-up time, functional outcome and assessment instruments were compiled. All included studies reported improvements in a variety of functional aspects regardless of surgical method. The outcomes assessed include core stability, back pain, abdominal pain, posture, urinary incontinence, abdominal muscle strength and quality of life. Conclusion The results of this review show that surgical repair of rectus diastasis is a safe and effective treatment that improves functional disability. However, the absence of standardized instruments for assessing outcome makes it impossible to compare studies. Since indications for surgery are relative and related to core function, valid instruments for assessing indication and outcome are needed to ensure benefit of the procedure.
Background: Two main trends are described for treating diastasis recti: plication versus midline mesh reinforcement. Indications for these procedures have not been clearly described. This study reviewed the outcomes on treatment of rectus diastasis with plication versus mesh by assessing durability, complications and patient reported outcomes. Materials and methods: A systematic review of literature on treatment of diastasis recti was performed searching through Pubmed, Embase, Web of Science and Cochrane databases. This resulted in 53 eligible articles and predefined inclusion criteria led to the selection of 24 articles. Primary outcomes included recurrence and perioperative complications and secondary outcomes were defined as patient satisfaction, chronic pain and quality of life. Results: 931 patients were surgically treated for rectus divarication (age range 18 - 70 years). The most frequent noted comorbidity was obesity and 10.6 percent were smokers. Recurrence was reported in 5 percent. The most frequent complication was seroma (7 percent), followed by abdominal hypoesthesia (6 percent) and surgical site infection (2 percent). Chronic pain was reported in 4 percent. Satisfaction was assessed subjectively in the majority of patients and was generally rated as high. Follow-up period ranged from 3 weeks to 20 years. Conclusions: Durability, safety and high patient satisfaction supports surgical correction of rectus diastasis and could not favor a treatment method. Inter-rectus distance could not be identified as indicator for technique which emphasizes that other factors might add to the entity of abdominal wall protrusion more than previously thought.
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Background Diastasis of the rectus abdominis muscles (DRAM) is characterised by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This causes the midline to “bulge” when intra-abdominal pressure is increased. Plastic surgery treatment for DRAM has been thoroughly evaluated, though general surgical treatments and the efficacy of physiotherapy remain elusive. The aim of this systematic literature review is to evaluate both general surgical and physiotherapeutic treatment options for restoring DRAM in terms of postoperative complications, patient satisfaction, and recurrence rates. Method MEDLINE®, Embase, PubMed, PubMed Central®, The cochrane central registry of controlled trials (CENTRAL), Google Scholar, and the Physiotherapy Evidence Database (PEDro) were searched using the following terms: ‘rectus diastasis’, ‘diastasis recti’, ‘midline’, and ‘abdominal wall’. All clinical studies concerning general surgical or physiotherapeutic treatment of DRAM were eligible for inclusion. Result Twenty articles describing 1.691 patients (1.591 surgery/100 physiotherapy) were included. Surgical interventions were classified as plication techniques (313 patients; 254 open/59 laparoscopic), modified hernia repair techniques (68 patients, all open), and combined hernia & DRAM techniques (1.210 patients; 1.149 open/40 hybrid). The overall methodological quality was low. Plication techniques with interrupted sutures and mesh reinforcement were applied most frequently for DRAM repair. Open repairs were performed in 85% of patients. There was no difference in postoperative complications or recurrence rate after laparoscopic or open procedures, or between plication and modified hernia repair techniques. Physiotherapy programmes were unable to reduce IRD in a relaxed state. Though reduction of IRD during muscle contraction was described. Conclusion Both plication-based methods and hernia repair methods are used for DRAM repair. Based on the current literature, no clear distinction in recurrence rate, postoperative complications, or patient reported outcomes can be made. Complete resolution of DRAM, measured in a relaxed state, following a physiotherapy training programme is not described in current literature. Physiotherapy can achieve a limited reduction in IRD during muscle contraction, though the impact of this finding on patient satisfaction, cosmesis, or function outcome is unclear.
Study design: Longitudinal descriptive exploratory study. Objectives: Evaluate the normal width of the linea alba in first-time pregnant women during pregnancy and postpartum. Background: There are normative values on the width of the linea alba for nulliparous women, but limited knowledge about the normal width of the inter-rectus distance (IRD) in pregnant and postpartum women. Methods: Ultrasound images were recorded in 84 primiparous women, at 3 locations on the linea alba (2 cm below the umbilicus, and 2 and 5 cm above the umbilicus) and at 4 time points (gestational weeks 35-41 and 6th to 8th, 12th to 14th, and 24th to 26th weeks postpartum). The 20th and 80th percentiles were used to define the normal width of the linea alba. Results: During pregnancy, the 20th and the 80thpercentile corresponded to 49-79 mm below the umbilicus, 54-86 mm at 2 cm above the umbilicus and 44-79 mm at 5 cm above the umbilicus. At 6 months postpartum, the 20th and the 80thpercentile corresponded to 9-21 mm at 2 cm below the umbilicus, from 17 to 28 mm at 2 cm above the umbilicus and from 12 to 24 mm at 5 cm above the umbilicus. Conclusion: Different normative values for the width of the linea alba were found at different locations of the anterior abdominal wall. In primiparous women, the IRD may be considered "normal" up to values wider than in nulliparous.
Background: Abdominal muscles are important spinal stabilizers and its poor coordination, as seen in diastasis of rectus abdominis (DRA), may contribute to chronic low back pain (LBP). However, this has not yet been studied directly. Objectives: To conduct a pilot study to examine the association between DRA and LBP. Methods: Using a digital caliper, standard clinical DRA measurement was performed in 55 participants with and 54 without chronic LBP. Results: Participants were on average 55 years old, 69 (63%) were women. Among the 16 participants with DRA, 11 (69%) had chronic LBP; among the 93 participants without DRA, 44 (47%) had LBP. Among men, 7 of 9 (77%) with DRA had LBP and 14 of 31 (45%) without DRA had LBP. Among women, 4 of 7 (57%) with DRA had LBP and 30 of 62 (48%) without DRA had LBP. BMI was the strongest correlate of DRA and may explain the relation between DRA and chronic LBP. Conclusions: DRA and LBP may be interrelated, especially among men. This may be a function of greater BMI in individuals with chronic LBP. Understanding the association between DRA, LBP, and BMI may have important implications for treatment of LBP and for intervention.
Background: Plication of the anterior rectus sheath is the most commonly used technique for repair of diastasis recti, but is also a time-consuming procedure. Objectives: The aim of this study was to compare the efficacy and time required to repair diastasis recti using different plication techniques. Methods: Thirty women with similar abdominal deformities, who had had at least one pregnancy, were randomized into three groups to undergo abdominoplasty. Plication of the anterior rectus sheath was performed in two layers with 2-0 monofilament nylon suture (control group) or in a single layer with either a continuous 2-0 monofilament nylon suture (group I) or using a continuous barbed suture (group II). Operative time was recorded. All patients underwent ultrasound examination preoperatively and at 3 weeks and 6 months postoperatively to monitor for diastasis recurrence. The force required to bring the anterior rectus sheath to the midline was measured at the supraumbilical and infraumbilical levels. Results: Patient age ranged from 26 to 50 years and body mass index from 20.56 to 29.17 kg/m2. A significant difference in mean operative time was found between the control and study groups (control group, 35 min:22 s; group I, 14 min:22 s; group II, 15 min:23 s; P < 0.001). Three patients in group II had recurrence of diastasis. There were no significant within- and between-group differences in tensile force on the aponeurosis. Conclusions: Plication of the anterior rectus sheath in a single-layer with a continuous suture showed to be an efficient and rapid technique for repair of diastasis recti. Level of evidence 1:
Background: The primary aim of this prospective, randomized, clinical, 2-armed trial was to evaluate the risk for recurrence using 2 different operative techniques for repair of abdominal rectus diastasis. Secondary aims were comparison of pain, abdominal muscle strength, and quality of life and to compare those outcomes to a control group receiving physical training only. Methods: Eighty-six patients were enrolled. Twenty-nine patients were allocated to retromuscular polypropylene mesh and 27 to double-row plication with Quill technology. Thirty-two patients participated in a 3-month training program. Diastasis was evaluated with computed tomography scan and clinically. Pain was assessed using the ventral hernia pain questionnaire, a quality-of-life survey, SF-36, and abdominal muscle strength using the Biodex System-4. Results: One early recurrence occurred in the Quill group, 2 encapsulated seromas in the mesh group, and 3 in the suture group. Significant improvements in perceived pain, the ventral hernia pain questionnaire, and quality of life appeared at the 1-year follow-up with no difference between the 2 operative groups. Significant muscular improvement was obtained in all groups (Biodex System-4). Patient perceived gain in muscle strength assessed with a visual analog scale improved similarly in both operative groups. This improvement was significantly greater than that seen in the training group. Patients in the training group still experienced bodily pain at follow-up. Conclusion: There was no difference between the Quill technique and retromuscular mesh in the effect on abdominal wall stability, with a similar complication rate 1 year after operation. An operation improves functional ability and quality of life. Training strengthens the abdominal muscles, but patients still experience discomfort and pain.
Conference Paper
Objective: The objective of this study was to determine the best treatment of incisional hernia, taking into account recurrence, complications, discomfort, cosmetic result, and patient satisfaction. Background: Long-term results of incisional hernia repair are lacking. Retrospective studies and the midterm results of this study indicate that mesh repair is superior to suture repair. However, many surgeons are still performing suture repair. Methods: Between 1992 and 1998, a multicenter trial was performed, in which 181 eligible patients with a primary or first-time recurrent midline incisional hernia were randomly assigned to suture or mesh repair. In 2003, follow-up was updated. Results: Median follow-up was 75 months for suture repair and 81 months for mesh repair patients. The 10-year cumulative rate of recurrence was 63% for suture repair and 32% for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound infection (P < 0.02) were identified as independent risk factors for recurrence. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). One hundred twenty-six patients completed long-term follow-up (median follow-up 98 months). In the mesh repair group, 17% suffered a complication, compared with 8% in the suture repair group (P = 0.17). Abdominal pain was more frequent in suture repair patients (P = 0.01), but there was no difference in scar pain, cosmetic result, and patient satisfaction. Conclusions: Mesh repair results in a lower recurrence rate and less abdominal pain and does not result in more complications than suture repair. Suture repair of incisional hernia should be abandoned.
Aim: The aim of this study was to evaluate early complications following retromuscular mesh repair with those after dual layer suture of the anterior rectus sheath in a randomised controlled clinical trial for abdominal rectus muscle diastasis (ARD). Methods: Patients with an ARD wider than 3 cm and clinical symptoms related to the ARD were included in a prospective randomised study. They were assigned to either retromuscular inset of a lightweight polypropylene mesh or to dual closure of the anterior rectus fascia using Quill self-locking technology. All patients completed a validated questionnaire for pain assessment (Ventral Hernia Pain Questionnaire, VHPQ) and for quality of life (SF36) prior to and 3 months after surgery. Results: The most frequently seen adverse event was minor wound infection. Of the patients, 14/57 had a superficial wound infection; five related to Quill and nine to mesh repair. No deep wound infections were reported. Patient rating for subjective muscular improvement postoperatively was better in the mesh technique group with a mean of 6.9 (range 0-10) compared to a mean of 4.8 (range 0-10) in the Quill group (p=0.01). The pre- and post-operative SF36 scores improved in both groups. Conclusions: There was no significant difference between the two surgical techniques in terms of early complications and perceived pain at the 3-month follow-up. Both techniques may be considered equally reliable for ARD repair in terms of adverse outcomes during the early postoperative phase, even though patients operated with a mesh experienced better improvement in muscular strength. 2009/227-31/3/PE/96.
We document the applicability of the SF-36 Health Survey, which was translated into Swedish using methods later adopted by the International Quality of Life Assessment (IQOLA) Project procedures. To test its appropriateness for use in Sweden, it was administered through mail-out/mail-back questionnaires in seven general population studies with an average response rate of 68%. The 8930 respondents varied by gender (48.2% men), age (range 15–93 years, mean age 42.7), marital status, education, socio-economic status, and geographical area. Psychometric methods used in the evaluation of the SF-36 in the U.S. were replicated. Over 90 % of respondents had complete items for each of the eight SF-36 scales, although more missing data were observed for subjects 75 years and over. Scale scores could be computed for the vast majority of respondents (95% and over); slightly fewer in the oldest subgroup. Item-internal consistency was consistently high across socio-demographic subgroups and the eight scales. Most reliability estimates exceeded the 0.80 level. The highest reliability was observed for the Bodily Pain Scale where all subgroups met the 0.90 level recommended for individual comparisons; coefficients at or above 0.90 were also observed in most subgroups for the Physical Functioning Scale. Tests of scaling assumptions including hypothesized item groupings, which reflect the construct validity of scales, were consistently favorable across subgroups, although lower rates were noted in the oldest age group. In conclusion, these studies have yielded empirical evidence supporting the feasibility of a non-English language reproduction of the SF-36 Health Survey. The Swedish SF-36 is ready for further evaluation.