Minimal access technique should be the gold standard and should be offered to patients when possible.One of the important issues in hernia surgery is Recti Diverication.Majority of patient are having advice of conservative measures like exercise,weight reduction,etc.Surgery is rarely suggested .
In the era of modern surgery,an acceptable and realistic solution is expected to be offered to these patients.
Case series here and there ,but no solid opinion is reflected in current literatures.
Excellent question Dr. Hussain. Indeed, laparoscopic repair should be offered for recti divarication even if asymptomatic. We have published our technique & results, please read:
Palanivelu C, Rangarajan M, et al. Laparoscopic repair of diastasis recti using the 'Venetian blinds' technique of plication with prosthetic reinforcement: a retrospective study. Hernia 2009;13(3):287-92.
http://www.ncbi.nlm.nih.gov/pubmed/19214651
We should consider firstly is the need for surgery.
Divarication is essentially a cosmetic issue and very different from a hernia. The clinical indication for surgery are really very few apart from cosmetic appearance which is most pronounced on attempts to sit up from a lying position. it is essentially a low risk condition.
Agreed, Dr. Budhoo, that this is not a hernia per se & mostly a cosmetic procedure. But one must consider the fact that these patients will have difficulty in physical activities due to 'loss of domain' of abdominal musculature, which can be remedied by surgery.
I would not treat this as this is not a hernia... agree it is more of a cosmetic issue.
I agree with Misra Budhoo and Mansoor Khan. In most cases there is no indication for surgery. And that is the reason why we are not having much experience with laparoscopic repair of divarication recti.
Interesting debate. I have to agree with the majority, I donot offer surgery for divarication of Recti. I am interested in the technique though, there are a subgroup of patients with moderate sized incisional hernia but a large divarication and can this technique be adopted for these patients? Conventional Lap incisional hernias dont address this adequately. Dr Muthukumaran Rangarajan have you got any links of videos from your operation you could share with us?
many thanks
I have experience with open and laparoscopic repair of recti diverication.
Majority of these patients had associated umbilical or paraumbilical hernia.The operation will address both conditions.
The main issue is the post-operative pain. Both techniques will cause significant post-operative pain ,however it may be less with laparoscopic repair.PCA is of great help in my patients.Hospitalization can be up to 5 days,it can be shorter up to 2 days with laparoscopic approach.
Patient satisfaction is great especially for young slim women who had previous pregnancy.I agree with my colleague that recti diverication does not fit the entire definition of the hernia but it is a musckoloskeletal problem that need to be considered for correction.Not offering a solution simply because it is not a hernia,just like saying to to the patient who has been diagnosed with cholecystitis [without stone/acalculous cholecystits] I don't operate because you don't have stone.
Selection of the patient for surgery is the corner stone.Not all recti diverications need surgery.Obese patients,patients with ASA3 and more to be avoided.
Laparoscopic or open technique will be tailored to the specific case and whther or not patients had previous laparotomy. .
Dear Dr.Hussain,
That was nicely put, I totally agree with your comments
Gentlemen, what an eye opener. Thank you for the insights and the wonderful article from dr. Rangarajan
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