Letter to the Editor: Abdominal rectus diastasis: an ongoing debate about indication

In the paper “Long-term follow-up after surgical repair of abdominal rectus diastasis: A prospective randomized study,” Swedenhammar and colleagues reported the 5-year follow-up of a randomized trial comparing mesh and sutured repair of abdominal rectus diastasis. They concluded that no patients had recurrence, and most importantly that the patient-reported quality of life was significantly improved after surgery ¹ .

These results are interesting, as the indication for treatment of rectus diastasis is part of an ongoing debate, and to date most studies on both surgical and non-operative interventions are inconclusive ² . As abdominal rectus diastasis is a benign disease, most often affecting young women, the indication is of high importance when subjecting this patient group to operative treatment. The novel findings in the study by Swedenhammar et al. are that even 5 years after surgical repair, the patients reported satisfaction with the outcome. The improvements in quality of life lifted the included patients from the 36-Item Short Form Survey (SF-36) scores below the average scores of matched individuals in the normal population, to above this level. Thus, operative treatment improved the quality of life of patients with a benign disease, regardless of the type of repair.

These findings, in part, can be compared to the treatment of ventral or inguinal hernias; non-operative treatment seems safe, and surgical repair leads to improvements in quality of life. This potential improvement in quality of life of course must not be outweighed by the risk of complications to the operative repair ³ . More than 1/3 of the patients included in the original study of short-term complications after surgical repair of abdominal rectus diastatis encountered complications, however none severe ⁴ . A future change toward minimally invasive repair of abdominal rectus diastasis probably will reduce this risk of wound-related complications.

The European Hernia Society and Americas Hernia Society’s joint guidelines specifically mention the treatment of abdominal rectus diastasis when a concomitant ventral hernia is present, and recommend mesh repair in this setting, as the hernia recurrence rate in patients with abdominal rectus diastasis is increased, although the literature in this specific patient group indeed is also limited ⁵ . Whether or not a hernia repair concomitant to diastasis repair also leads to improvements in quality of life remains unknown.

If the findings of Swedenhammar et al. are confirmed in future studies with long-term follow-up, operative treatment of abdominal rectus diastasis maybe should be offered at a more aggressive rate.