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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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https://doi.org/10.1177/1457496920913677
Scandinavian Journal of Surgery
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© The Finnish Surgical Society 2020
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DOI: 10.1177/1457496920913677
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SCANDINAVIAN
JOURNAL OF SURGERY
SJS
LONG-TERM FOLLOW-UP AFTER SURGICAL REPAIR OF ABDOMINAL
RECTUS DIASTASIS: A PROSPECTIVE RANDOMIZED STUDY
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
ABSTRACT
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
Correspondence:
Ebba Swedenhammar, M.D.
Department of Molecular Medicine and Surgery
Karolinska Institutet
Karolinska University Hospital
Solna (L1:00)
SE-171 76 Stockholm
Sweden
Email: ebba.swedenhammar@ki.se
913677SJS0010.1177/1457496920913677Long-term follow-up after repair of rectus diastasisE. Swedenhammar, et al.
research-article2020
Original Research Article
E. Swedenhammar, et al.2
INTRODUCTION
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.
MATERIALS AND METHODS
STUDY DESIGN AND PARTICIPANTS
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 (D.nr 2009/227-31,
2011/1186-32, 2016/55-32) and was registered on
ClinicalTrial.gov with the number 2009/227-31/3/
PE/96. The Declaration of Helsinki principles of ethi-
cal standard were followed.
SELF-REPORTED QUESTIONNAIRES
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.
TABLE 1
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
tenderness
Immunosuppressive therapy
Wish to have abdominal wall
reconstruction
Smoking
For women: 1 pregnancy,
>1 year after childbirth
ARD: abdominal rectus diastasis.
Long-term follow-up after repair of rectus diastasis 3
CLINICAL INVESTIGATION
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
visit.
STATISTICS
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).
RESULTS
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.
TABLE 2
Demographics at long-term follow-up.
Mesh Quill p
Follow-up since operation
(years)
0.797
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
Age
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.
ABDOMINAL WALL PAIN
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.
CORE STABILITY AND OVERALL WELL-BEING
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.
SF-36
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).
PREGNANCY
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.
CLINICAL OUTCOME
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).
DISCUSSION
In a previous study of the same study cohort (10), we
showed that no recurrence of ARD had occurred at
TABLE 3
The VHPQ results for preoperative and long-term follow-up after repair.
Questionnaire Preoperative Long term Preoperative Long term
Mesh
(n = 29)
Mesh
(n = 28)
Quill
(n = 28)
Quill
(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
population.
PF: physical functioning; RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role-emotional;
MH: mental health.
TABLE 4
BMI and waist circumference preoperative measurements compared to long-term follow-up.
BMI
preoperative
BMI long term p Circumference
preoperative
Circumference
long term
p
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.
CONCLUSION
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
importance.
AUTHORS’ NOTE
The study was registered on ClinicalTrial.gov with the num-
ber 2009/227-31/3/PE/96.
AUTHORS CONTRIBUTIONS
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.
DECLARATION OF CONFLICTING INTERESTS
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
FUNDING
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).
ORCID ID
E. Swedenhammar https://orcid.org/0000-0001-9189-
9725
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... 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] 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 patientreported outcome measures via the BODY-Q abdomen scale. ...
... 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. ...
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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.
... It is more frequent in females and often related to hormonal changes during pregnancy [1][2][3]. When ARD is present, pain, discomfort, or impaired core stability during physical activity are often perceived [4][5][6]. ...
... They scored lower than the control group when asked about quality of life and self-perceived body image. ARD can have significant psychological and social repercussions, contributing to lower self-esteem, and an overall decrease in quality of life as seen both in previous work from our group [6,21] and Nielsen et al. [44] where patients scored lower in their quality-of-life variables compared to controls. ...
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Purpose Patients with abdominal rectus diastasis (ARD) may have muscular functional impairments, but clinics lack appropriate objective assessment tools. The aim was to establish the relative and absolute reliability, and convergent validity, of muscular activity using Surface Electromyography (SEMG) during isometric abdominal muscle strength testing in patients with ARD and controls without ARD. Methods Twenty-six patients with ARD were matched for age, sex and BMI with controls without ARD. Participants were tested twice during isometric muscular contractions using SEMG located on six abdominal sites. Mean amplitude, fatigue, and recruitment order were analyzed. Relative reliability was evaluated with Intraclass Correlation Coefficients (ICC), while absolute reliability was estimated by calculating the Standard Error of Measurement and Minimal Detectable Change. Convergent validity was addressed in relation to participant characteristics, functional ability, and symptoms. Results Mean SEMG amplitude for all abdominal wall muscle contractions showed moderate to excellent relative test–retest reliability, with ICC values ranging from 0.46 to 0.97. In contrast, fatigue and recruitment order displayed poor to moderate relative reliability in both groups. Absolute reliability measures were generally high. A moderate to high convergent validity (ARD: rho-value 0.41–0.70; Controls: rho-value 0.41–0.75) was observed for mean amplitude in relation to a functional sit-to-stand test, abdominal circumference, BMI, back pain, and quality-of-life. Conclusions The results of applying SEMG during isometric abdominal muscle support practicing the method in clinics, although additional development is needed with further standardization and more functional testing. Furthermore, the method demonstrates construct validity in patients with ARD and in age- and sex-matched controls.
... Системні скарги, пов'язані з ДПМЖ, оцінено за спеціалізованим опитувальником VHPQ (Ventral Hernia Pain Questionnaire), який дав змогу встановити якість повсякденної діяльності [10]. Це -перевірений опитувальник для оцінювання власного досвіду пацієнта щодо болю до та після операції на передній черевній стінці, стосується повсякденної діяльності (табл.). ...
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Increased pressure on the muscles of the abdominal wall during pregnancy can often cause thinning and expansion of the white line of the abdomen, which is considered diastasis of the rectus abdominis muscles. Aim - evaluation of the functional consequences and influence of physical exercises on diastasis of rectus abdominis muscles. Materials and methods. We analyzed 54 patients who were diagnosed with diastasis recti during pregnancy and in the postpartum period. 26 women (the main group) after childbirth underwent a six-month rehabilitation program aimed at reducing diastasis (on average from the first to the seventh month after childbirth), 28 women (the control group) did not undergo a rehabilitation program after the birth of a child. Assessment of systemic complaints related to ventral hernia was carried out using a specialized questionnaire VHPQ (Ventral Hernia Pain Questionnaire), which allowed to assess the quality of daily activities. Statistical processing of the material was carried out using the Excel 11 program The results were considered probable when the probability ratio was less than or equal to 0.05. The odds ratio was estimated, the confidence interval was set at 95% and defined as ±1.96 standard error. Results. A statistically significant decrease in the width of the white line was observed in women of both groups 7-8 months after childbirth. Among patients of the main group, this was observed in 73.1% (19 people), and in the control group - in 64.3% (18 people), without a statistically significant difference between the groups. Conservative therapy of diastasis recti of the abdominal muscles made it possible to statistically significantly improve the quality of life of women after childbirth. Conclusions. In 64.3% of women in the postpartum period, diastasis of rectus abdominis muscles resolves itself within 7-8 months and does not require treatment. A course of six-month physical rehabilitation makes it possible to raise this indicator to 73.1% unreliably. Conservative therapy of diastasis recti of the abdominal muscles in women in the postpartum period allows a statistically significant improvement in the quality of life of patients. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. Informed consent of the women was obtained for the research. The authors declare no conflict of interest.
... Currently, there is no consensus on the advantages of isolated pleating and pleating with a grid [1]. In 2020, E. Swedenhammar and colleagues [14] reported on a randomised controlled clinical trial to compare double pleating of the anterior fascia of the rectus muscle with 2-0 slow-absorbable self-absorbable PFA sutures using Quill (a bi-directional thread with spikes that evenly distributes tension in the suture area) in 28 patients and retromuscular prolene mesh placement in 29 patients. After a three-month follow-up, the authors concluded that both techniques were equally reliable, although patients who received mesh reported better muscle strength. ...
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Objective. To compare the indicators of the early postoperative period in patients with diastasis of the rectus abdominis after suture plication and after mesh implantation. Materials and methods. The study included 120 patients with diastasis of the rectus abdominis muscles. In 60 patients (group 1), a suture was used to correct the diastasis, and in another 60 patients (group 2), a prolene mesh was used. Results. The regression of pain in patients of group 1 on the 1st and 3rd postoperative days was more dynamic than in patients of group 2: pain decreased by 3.0 and 2.5 times, respectively. Mesh placement increased the risk of hyperthermia by 61%. The number of patients with complications in the groups was not statistically significant (p=0.265), but the difference between the number of patients with several complications was statistically significant (p=0.018). The use of mesh increased the risk of seroma by 64% (p=0.046), haematoma by 19% (p=0.819), wound infection by 36% (p=0.741), and paresthesia by 64% (p=0.025). Conclusions. The correction of diastasis of the rectus abdominis muscles with a suture is more acceptable than the correction with the help of mesh placement.
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Background: The majority of scientific reports pertaining to rectus diastasis (RD) cover the post-gestational form. Publications focusing on male RD are rare and non-specific. The RD of both genders is different in etiology, symptomatology, indication to therapy, and appropriate technique of repair. Current discussion: The midline abdominal wall hernias associated with RD have significantly higher recurrence rate if only the hernia is repaired. The gender-specific details of RD are evaluated and separately analyzed. It begins with the anatomy, collagen composition and its turnover, etiology, lifestyle, different phases of life, and impact on quality of life and culminates in different indications to active therapy. Despite the numerous techniques described, there is no consensus on the most effective one. Conclusion: The obvious differences in masculine and feminine RD mandate individual result analysis of both sexes to create a solid basis for therapeutic decision making. Outlook: There is an urgent need to standardize the data necessary to measure the quality of outcomes. RD-specific questionnaire of patient-reported outcome measures could help to validate the outcomes in terms of patient’s quality of life improvements.
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АННОТАЦИЯ Введение. До настоящего времени не достигнуто консенсуса относительно наиболее подходящего хирургического метода лечения диастаза прямых мышц живота в сочетании со срединными грыжами. Цель. Изучение результатов трех оригинальных методик оперативного лечения пациентов с диастазом прямых мышц живота в сочетании со срединными грыжами. Материалы и методы. Проведен анализ результатов лечения 74 пациентов. Пациенты разделены на три сопоставимые группы: в первой (n = 25) выполнялась пластика местными тканями с формированием апоневротической дупликатуры, во второй (n = 24)-использовался аутодермальный деэпителизированный трансплантат, в третьей (n = 25)-сетчатые импланты sub-lay. Оценивали: длительность наркотической аналгезии в послеоперационном периоде, сроки активизации больных, сроки стационарного лечения и результаты шкал Clavien-Dindo и EuraHSQoL. Длительность наблюдения-от 1 до 10 лет после операции. Результаты. Длительность применения наркотических аналгетиков в послеоперационном периоде в первой группе составила 1,08 ± 0,38 суток, во второй-0,98 ± 0,33 суток, в третьей-2,13 ± 0,93 суток. Срок активизации в первой группе был 3,00 ± 1,53 суток, во второй-0,89 ± 0,36 суток, в третьей-1,5 ± 0,48 суток; продолжительность стационарного лечения-9,24 ± 1,88 койко-дней, 6,34 ± 3,04 койко-дней и 8,36 ± 2,14 койко-дней соответственно. Послеоперационные осложнения в первой группе-6 класса CDI, 3 класса CDII, во второй группе-1 класса СDI, в третьей группе-6 класса CDI, 3 класса CDII. Через 12 месяцев после операции по шкале EuraHSQoL во второй группе болевые ощущения и функциональный дискомфорт отсутствовали, в первой и третьей группах присутствовали ограничения физической активности (р ≤ 0,05; различия между первой и третьей группами статистически незначимы, p ≥ 0,05). Статистических значимых различий между группами в косметическом дискомфорте не зарегистрировано (p ≥ 0,05). Заключение. Более безопасным и эффективным методом пластики передней брюшной стенки у больных с диастазом прямых мышц живота в сочетании со срединными грыжами является пластика с применением деэпителизированного аутодермального трансплантата. Ключевые слова: диастаз прямых мышц живота; грыжи средней линии живота; хирургическое лечение; осложнения; хирургическая операция
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Introduction. Diastasis rectus abdominis is the widening of the abdominal midline gap between the two rectus abdominis muscle bellies. The 2021 guidelines of the European Hernia Society indicate that there is limited evidence regarding the precise definition of diastasis; however, an extension up to 2 cm can be considered physiologically normal. Materials and methods. We conducted a clinical examination and surgical treatment of 120 patients with diastasis rectus abdominis. There were 92 females (76.7 %) and 28 males (23.3 %). Results and discussion. There was no significant difference in basic demographic indicators among individuals of young, mature, and elderly age groups. Among females, the majority were young individuals (up to 45 years), while among males, they were predominantly mature and elderly. When assessing the correlation between the history of diastasis rectus abdominis and age, we found that in males, the history of diastasis tended to be longer with increasing age. No such pattern was observed in female patients. Risk factors in males included mature and elderly age, playing wind instruments, significant physical activity, sarcopenia, and diabetes. In females, risk factors included asthenic body type, low body mass index, tendency to bruising, three or more pregnancies, multiple pregnancies, natural childbirth, or cesarean section, and preterm labor. Conclusions. The average age of females with diastasis rectus abdominis was likely (p<0.05) lower (44.03±11.95; median 41.0) than that of males (62.28±4.65; median 63.0). The duration of diastasis history was likely (p<0.05) shorter in females (2.89±1.21 years, median 3.0). Perspective research should focus on developing surgical tactics in patients with diastasis rectus abdominis, taking into account the gender-specific characteristics of this pathology.
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Introduction. While for a long time rectus abdominis diastasis was largely associated with cosmetic issues, modern research increasingly demonstrates a spectrum of clinical symptoms that are clearly linked to the presence of rectus abdominis diastasis in patients: back and lower abdominal pain, urinary and fecal incontinence, pelvic organ prolapse, and fixation. Materials and Methods. We conducted a clinical examination of 120 patients with rectus abdominis diastasis. Among the examined patients, there were 92 females (76.7%) and 28 males (23.3%). Type A according to Keramidas was present in 39 patients (32.5%), type B in 60 (50.0%), type C in 15 (12.5%), and type D in 6 (5.0%). The assessment of patients’ daily activity was conducted using the specialized Ventral Hernia Pain Questionnaire (VHPQ). Results. Problems with rising from a chair were reported by 36 patients (30.0%) (p=0.001; χ2=36.82). Discomfort while sitting on a chair was complained of by 23 patients (19.2%) (p=0.001; χ2=88.82). Problems with prolonged standing were present in 41 patients (34.2%) (p=0.001; χ2=22.82). Climbing stairs was difficult for 38 patients (31.7%) (p=0.001; χ2=30.82). Difficulties in driving a car were experienced by 6 patients (5.0%) (p=0.001; χ2=190.82). The majority of patients (62, 51.7%) experienced difficulties in performing sports or physical activities (p=0.698; χ2=0.15). Conclusions. Among patients with rectus abdominis diastasis, impairment of daily life quality and activities was observed in 69.2% of cases. Only 30.8% of patients perceived diastasis exclusively as a cosmetic problem. The frequency of manifestations depended on the severity of rectus abdominis diastasis.
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Background Duramesh is a new suturing concept, combining the principles of meshes with the precision, flexibility and versatility of a suture, suitable also for Abdominal Rectus Diastasis correction. Objectives This prospective research aimed at comparing this mesh usage versus the polypropylene standard suture plication for Rectus Diastasis repair in terms of safety (infection, seroma, hematoma, surgical wound dehiscence and fistula rates and hospital stay), effectiveness (ARD recurrence evidenced through Ultrasound Sonography, palpability of the muscular suture, surgical time and postoperative pain evaluation) and satisfaction of the patients based on PROMs (BODY-Q). Methods 65 of the initial 70 patients, undergoing rectus diastasis repair, with a 6 months FU, were randomly divided in two groups: 1 composed of 33 patients treated with Duramesh and 2 of 32 patients treated with standard polypropylene 0 suture plication. Data regarding infection, seroma, hematoma, surgical wound dehiscence and fistula rates, hospital stay, ARD recurrence, palpability of the muscular suture, surgical time, postoperative pain evaluation (VAS) and PROMs (BODY-Q) were analyzed by Prism9. Results No significant differences were reported between the two groups in terms of: infection, seroma, hematoma, surgical wound dehiscence and fistula rates and hospital stay. The mesh usage decreases the time required to perform plication compared with standard polypropylene detached stitches suture. No statistically significant differences were found out regarding VAS and BODY-Q data. Conclusions Duramesh 0 application for Rectus Diastasis repair is safe and effective without compromising aesthetic improvement, as compared to standard polypropylene 0 plication.
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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.
Article
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.
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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.
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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:
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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.
Article
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. ClinicalTrial.gov: 2009/227-31/3/PE/96.
Article
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.