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Scandinavian Journal of Surgery
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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 etal. (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 etal.’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 etal. (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
etal. (18) and Rosen etal. (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 etal. 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. metall 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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Received: October 21, 2019
Accepted: February 19, 2020