Techniques for diastasis recti: introduction and categories
Introduction
Surgeries aimed at treating diastasis recti are aimed at reconstructing linea alba thus bringing the rectus muscles closer together.
Numerous approaches have been proposed in the various historical periods, considering not only the anatomical ideal but also the available instrumentation and technical possibilities of the time.
Therefore, to classify the various reconstructions, it is necessary to describe them:
1) the structural features (how it is made and how the reconstruction works)
2) the anatomical working plane (the working layer where materials are placed)
3) the access route (large or small external incisions)
4)The tools/materials used.
The patient must have a true understanding of the subject before deciding about a possible intervention. Therefore, it is important to be able to classify the various types of interventions by fully understanding their characteristics.
All current techniques for example rely on muscle approach sutures and reinforcement mesh, but it is very different in the end result depending on where those sutures and nets are placed.
Therefore, it is not enough to know whether there is or is not a net, we need to know exactly in which layer of the abdominal part it will be placed with its advantages or not.
The concept then of mini-invasiveness, which is often publicized, must address not only small access routes of the surgery, but more importantly the reconstruction as a whole, its relationship to the surrounding anatomical structures , and its behavior once in place.
Reconstructive techniques by category
OUR REFERENCE TECHNIQUE
Robotic reconstruction Dr. Darecchio by transabdominal pre-peritoneal access.
The robotic technique by trans-abdominal pre-peritoneal (R-TAPP) is the one we prefer because of its results. It is performed using robotic instrumentation, through small access routes and is placed in a layer of the abdominal wall called thepre-peritoneum.
Robotics is used to access this particular workspace, which protects the reconstruction and prevents its contact with both viscera and surface tissues.
Through the pre-peritoneal plane, an anatomical alignment of the rectus muscles is achieved, which are kept level by a suture without eversion or introflexion, thus preserving their natural arrangement and dynamics of functioning.
If based on the characteristics of the tissues, there is an indication to place a mesh, it will always be placed in the preperitoneal plane, resulting in a safe area that prevents its contact with the viscera and does not interfere with the definition of the abdominals from an aesthetic point of view.
Due to the particular area of mesh placement, no traumatic fixation device is required; ultralight, partially resorbable, self-fixing nets are used.
Due to the articulatability of robotic instruments, one works in very thin spaces with minimal insufflation pressures .
The technique does not require extensive dissections and consequently no Drenage tubes are needed.
The surgery is performed under general anesthesia, exactly like all other techniques.
Reconstruction can be combined with removal of any excess skin and liposculpture if needed.
The postoperative stay is a few days, followed by a convalescence phase after which any kind of sports activity can be resumed.
OTHER TECHNIQUES.
Posterior INTRAPERITONEAL Techniques (Laparoscopy Minilaparoscopy)
As a type of instrumentation, laparoscopy is the distant ancestor of robotics.
However, the surgeries it allows on diastasis, apart from small access routes, are completely different internally.
The main critical point of all laparoscopic intraperitoneal reconstructions is that they result in direct contact with the viscera once in place.For this precise reason these techniques are not of our preference and we will describe them for didactic purposes only.
These techniques are performed using laparoscopic or minilaparoscopic instrumentation (identical to the former but slightly thinner).
Such instrumentations are the distant progenitors of robotic ones without, however, having the characteristic of articulability.
Because they are rigid, nonarticulating instrumentation , they allow work only within the abdominal cavity (Intraperitoneal) in the treatment of diastasis.
The approach of the rectus muscles is performed with a suture that is of necessity on the posterior side (posterior plication) of the abdominal wall and includes within it not only the necessary muscle-tendon fibers, but also the parietal peritoneum and pre-peritoneal fat (which, however, are tissues foreign to the reconstruction).
A mesh is finally placedintraperitoneal,that is, placed inside the abdominal cavity.
Such netting, in order not to be completely "free in the abdominal cavity," must of necessity be secured with special anchors or screws or spirals called "Tacker."
When the work is completed, boththe netand the Tackers, result in direct contact with the viscera.
The movements of laparoscopic and minilaparoscopic instruments are made possible by the creation of a temporary carbon dioxide layer called the Pneumoperitoneum, just as is done in all other "indoor" techniques.
Due to the non-articulability of the instruments, one works in rather large spaces withstandard insufflation pressures .
Therefore, there is no possibility in real clinical practice to perform these procedures without CO2 (as sometimes advertised).
There are also no "light or soft" or "multimodal without intubation" forms of anesthesia (sometimes advertised as different from general anesthesia) in actual clinical practice.
In fact, all laparoscopic and minilaparoscopic diastasis surgeries require general anesthesia in any of their variations, as do all other techniques.
PRE-APONEUROTIC anterior techniques (anterior plications during abdominoplasty (tummytuck) or endoscopy)
These are the techniques that approach the abdominal wall anteriorly, that is, between the panniculus adiposus and the anterior sheath of the rectus muscles.
Their main point of criticism is that the mesh may be very close to the skin (especially in individuals with thin panniculus adiposus). There is therefore a risk that it may be perceived by touch and/or may interfere with the definition of the abdominals from an aesthetic point of view.For this reason, such techniques are not of our preference and we will describe them for didactic purposes only.
They can be performed manually during abdominoplasty (tummytuck), or "indoors," with small access routes, in endoscopy.
In both cases , however, extensive dissection of the panniculus adiposus down to the xiphoid, with disconnection of the umbilicus, to expose the anterior sheath of the rectus muscles.
A muscle approach suture (anterior plication) is then performed manually or endoscopically.
A reinforcing mesh is then placed and must be secured with sutures traditionally or with anchors called Tucks se (the procedure is performed endoscopically).
This mesh is placed in a rather superficial plane and close to the skin with the risk of being perceptible to the touch and/or interfering with externally visible abdominal muscle definition.
They also require Drenervation tubes to be maintained for a variable period, and convalescence is not always short because of the extensive dissection.
These techniques require in all casesgeneral anesthesia.
RETROMUSCULAR-PREFASCIAL techniques (with mechanical suturers)
These techniques make use of mechanical sutures (manual or laparoscopic devices) that suture tissues using metal staples and cut at the end of the suture.
The main critical point is the anatomical subversion of the midline and muscle slimming to accommodate the mesh.For this reason, such techniques are not of our preference and we will describe them for didactic purposes only.
Sutures are devices designed for viscera surgery and not for the abdominal wall. Their use is therefore considered "of label" on the abdominal wall and presents a number of technical issues.
The suture instead of wire is in metal agraphes, which are calibrated to grip tissues other than the abdominal wall.
The midline, rather than reconstructed, is found to be centrally dissected by the suture cutter , resulting in unnatural communication between the two rectus muscles (which would normally be sealed individually).
A cavity is finally created by slimming the muscle fibers of the rectus from their posterior sheath, and a mesh is housed in this space.
This network therefore results in direct contact with the muscle contractile fibers, with obvious similarities to the traditional Rives technique (progenitor of the retromuscular-prefascial techniques).
Tubes of Drenervation may be required to be maintained for a variable period in the postoperative period.
Like all other techniques, these are also performed under general anesthesia.
PREFASCIAL RETROMUSCULAR techniques (with endoscopic anterior access).
The main critical points are the wide dissection on multiple anatomical planes, with the opening of the rectus muscle sheath.
The mesh results in direct contact with the muscle contractile fibers, and linea alba is knocked down posteriorly.
Initially designed for the treatment of ventral hernias and laparoceles , their use in diastasis recti has been proposed by some.
These techniques involve the extensive subcutaneous dislocations of traditional/endoscopic surgery in addition to the slimming of the rectus muscles with the opening of their tendon sheath, similar to techniques of the past (Rives-Stoppa) or related revisits (THT).
linea alba is knocked down on the back plane and a 'single concameration is created in direct contact with the contractile fibers to accommodate the mesh.
A net is finally placed, which will inevitably result in direct contact with the muscle contractile fibers .
These techniques make use of classic endoscopy/laparoscopy instruments and optics.
General anesthesia is provided as for all other techniques
The timing of the postoperative course and convalescence is secondary to tissue healing from the dissections. There are usually one or more Drenervation tubes to be removed with varying timing in the postoperative period.
Considering the reconstructive structure, it makes little sense to combine retromuscular-pre-fascial techniques with endoscopic access with removal of excess skin, which unfortunately, frequently occurs in diastasis recti.
PREFASCIAL RETROMUSCULAR techniques (with robotic posterior access).
The main critical point is the opening and dissection of the posterior sheath of the rectus muscles.
Therefore even if they are performed with laparoscopic or robotic instrumentation(Tarup or r-Tarup) they inherit the muscle dissection part from the traditional techniques of Rives and the like.
The mesh results in direct contact with the contractile fibers, and the midline is sutured only anteriorly since the posterior fascia is interrupted and abandoned.
These of techniques while they can be performed robotically are not part of our preference because of the reconstructive structure and dissection they involve.
From the patient 's perspective, it is important to fully understand the reconstructive structure of the surgery and not just dwell on the instrumentation used:
"the robot is just a tool with which different techniques can be made, with different reconstructive structure and different characteristics."
