Long-term follow-up after surgical repair of abdominal rectus diastasis: A Prospective Randomized Study.

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). CONCLUSIONS: 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.

Management of diastasis of the rectus abdominis muscles: recommendations for swedish national guidelines.

BACKGROUND: Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike. METHODS: The consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience. RESULTS: The proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient's symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior. DISCUSSION: The level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.

Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures.

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.

Influence of acidic pH on keratinocyte function and re-epithelialisation of human in vitro wounds.

BACKGROUND: Chronic wounds are one of the greatest challenges for the healthcare system. Today, a plethora of dressings are used in the treatment of these wounds, each with specific influence on the wound environment. Due to differences in the permeability of the dressings the use will result in differences in the pH balance in the wound bed. However, little is known about how changes in the pH in the wound environment affect the different phases of the healing process. AIM: The aim of the present study was to investigate the effects of acidic pH on the regeneration phase by studying keratinocyte function in vitro and re-epithelialisation in an in vitro model of human skin. RESULTS: In vitro assays showed reduced viability and migration rates in human keratinocytes when pH was lowered. Real time PCR revealed differential expression of genes related to wound healing and environmental impairment. Tissue culture showed no re-epithelialisation of wounds subjected to pH 5.0 and moderate re-epithelialisation at pH 6.0, compared to controls at pH 7.4. CONCLUSION: The results indicate that lowering pH down to pH 5.0 in wounds is counterproductive in aspect of keratinocyte function which is crucial for successful wound healing.

Validation of Biodex system 4 for measuring the strength of muscles in patients with rectus diastasis.

To investigate the validity and reliability of the Biodex system 4 in the assessment of abdominal strength in patients with rectus diastasis, we studied 10 healthy volunteers and 10 patients with rectus diastasis of more than 3 cm. We assessed test-retest reliability at 30(o) and 60(o) of extension/flexion spinal angles, respectively, and isometric muscle strength with and without the abdominal girdle. Reliability was calculated using the interclass correlation coefficient (ICC). Validity was evaluated by correlation with the International Physical Activity Questionnaire (IPAQ) and a visual analogue scale (VAS) for self-assessment of abdominal muscular strength. The Kendall-Tau and Spearman tests were used. Reliability was excellent with ICC values ranging between 0.77 and 0.97. There was no significant difference in muscular strength for tests with or without a girdle except with 60(o) extension. The internal validity assessed as the correlation between VAS and isometric strength (p = 0.008) was excellent, whereas there was no correlation with IPAQ. The Biodex system 4 is a valuable and reliable instrument to measure abdominal wall strength in patients with rectus diastasis. The internal validity is excellent. The incongruence between abdominal muscle strength, as measured using the Biodex system 4, and IPAQ indicates that there is no relation between general physical activity (IPAQ) and muscular strength in patients with rectus diastasis.