Petrenko, Syplyviy, and Petrenko: Multidetector Computed Tomography Criteria of Operative Treatment of Diastasis Recti Abdominis



Problem statement and analysis of the recent research

Diastasis recti abdominis (DRA) is a widespread pathology. DRA is caused by congenital and acquired weakness of anterior abdominal wall followed by widening of linea alba, anterior abdominal wall muscles atrophy, formation of pendulous abdomen with internal organs dislocation syndrome [1, 3, 4, 5]. It is important to mention, that diastasis recti abdominis remains asymptomatic during long time. Moreover, diastasis is often accompanied by ventral hernias, especially umbilical and linea alba hernias. Usually, ventral hernias serve as a reason of surgeon’s consultation.

Nevertheless, despite DRA prevalence, there is no single opinion about indications to surgical treatment of DRA, terms and content of operative treatment. Classical types of operative treatment (Napalkov type, Voznesenksiy type, Askerhanov type, Kolesnikov type and other) are used in patients with III degree of DRA [1, 2]. All of them are enough difficult and traumatic. Therefore, we have found it rational to analyze the use of attenuated operative treatments at early stages (I and II degree) of DRA and use of mesh implants for III degree of DRA. The solutions of these questions are presented in our work.

The objective of the research was to develop objective criteria of diastasis recti abdominis with the use of MDCT for adequate operative correction of this pathology using modern technologies.

The objective of the research

This research is devoted to the structure, frequency and etiology of postoperative complications encountered during the treatment of ureteral calculi with the use of semi-rigid ureteroscope and ultrasonic lithotripsy.

Materials and methods

From 2005 to 2016 years there were 92 patients with RAD under our observation. They included 52 men (56.5 %) and 40 women (43.5 %). Mean age of patients constituted 56.7 years. All the patients were examined according to our designed standards, which included MDCT of anterior abdominal wall and organs of abdominal cavity. If necessary, we performed MDCT of thorax and small pelvis. MDCT was performed on scanner Aquilion 16 with use of standard scanning protocol, Valsalva’s maneuver and lateroposition. The following pathology was identified in patients during MDCT-examination (Table 1).

Table 1.

Comorbidity in patients with DRA

No Comorbidity Number of cases
Abs. %
1 Umbilical hernia 70 27.8
2 Groin hernia 15 5.9
3 Hernia of linea alba 12 4.7
4 Chronic calculous cholecystitis 19 7.5
5 Chronic non-calculous cholecystitis 8 3.2
6 Chronic pancreatitis 5 2.0
7 Liver cysts 3 1.5
8 Kidney cysts 2 0.8
9 Urolithiasis 4 1.6
10 Uterine fibroid 3 1.2
11 Ovarian cysts 1 0.4
11 Obesity 69 27.4
13 Pendulous abdomen 41 16.3
14 TOTAL 252 100.0

Consequently there were 252 cases of comorbidity in 92 patients with diastasis recti abdominis.

Having analyzed scientific works of VV Zhebrovskiy et al. [1], SA Kolesnikov [2], D Brauman [5], DH Petrenko et al. [4] we introduced criteria of degrees of DRA depicting maximal inter-rectal distance (MID): I degree – MID < 30 mm, II degree – MID = 30-50 mm, III degree – MID > 50 mm. Depending on the degree of diastasis patients were divided into 3 groups: I degree of DRA – 25 (27.2 %) patients, II degree – 40 (43.5 %) patients, III degree – 27 (29.3 %) patients. The examples can be seen in Fig. 1, Fig. 2, Fig. 3.

Fig. 1.

Axial MDCT-scans (a,b) and sagittal reconstruction (c) in the patient at the age of 48 with I degree of DRA, where 1 – marked maximal inter-rectal distance (28.9 mm), 2 – umbilical hernia.

gmj-23-gmj.2016.3.16-g1.jpg
Fig. 2.

Axial MDCT-scans (a,b) and sagittal reconstruction (c) in the patient at the age of 39 with II degree of DRA, where 1 – marked maximal inter-rectal distance (42.6 mm), 2 – umbilical hernia

gmj-23-gmj.2016.3.16-g2.jpg
Fig. 3.

Axial MDCT-scans (a,b) and sagittal reconstruction (c) in the patient at the age of 55 with III degree of DRA, where 1 – marked maximal inter-rectal distance (51.4 mm), 2 – linea alba hernia, 3 – simple cyst in posterior segment of left kidney

gmj-23-gmj.2016.3.16-g3.jpg

All the patients asked for surgical help because of ventral hernias. Diastasis recti abdominis was detected during their examination. On the basis of conducted examination by agreement with every patient (noted in informed patient’s consent – form No 003 – 6/0) the following operations were performed (Table 2).

Table 2.

Performed operations in patients with DRA

No Operation Number of cases
Abs. %
1 Hernioplasty with mesh implant + suturing of diastasis with the use of U-shaped sutures. 33 35.9
2 Hernioplasty with mesh implant + suturing of diastasis with the use of interrupted sutures + plasty of diastasis with mesh implant 21 22.9
3 Hernioplasty of umbilical hernia according to Sapezhko + suturing of diastasis with the use of interrupted sutures + groin hernia hernioplasty according to Lichtenstein 15 16.3
4 Laparoscopic cholecystectomy + Hernioplasy of umbilical hernia by Sapezhko + suturing of diastasis with the use of interrupted sutures 12 13.0
5 Hernioplasty + Plasty of diastasis recti abdominis according to our type 7 7.6
6 Dissection of diastasis recti abdominis + Hernioplasty and plasty with mesh implant 4 4.3
7 TOTAL 92 100.0

Surgical correction was performed according to the stage of DRA. Suturing of only 1/3 of linea alba length over umbilicus was enough in case of I degree. II degree of DRA was sutured with use of U-shaped sutures of 2/3 linea alba over umbilicus. In case of III degree of DRA we obligatory performed additional strengthening with mesh implant at the whole level of diastasis recti abdominis.

Results of the research and their discussion

Analysis of our clinical material shows that diastasis recti abdominis can be with expressed symptoms during long time. For a long term the progress of diastasis leads to abdominal wall muscle atrophy, growth of pendulous abdomen and as a consequence to syndrome of internal organs dislocations, especially in patients with large and giant ventral hernias (DH Petrenko [3]). Usually patients ask for a surgical help because of umbilical, groin hernia or hernia of linea alba, on rare occasions because of pendulous abdomen. Thereby, more than a half of patients, namely 69 (75.0 %) cases, had obesity of different stage. Naturally, palpation in these patients can rarely let DRA to be distinguished even with use of Valsalva’s maneuver. We used sonography as a screening and cheap method. Our experience shows that nowadays MDCT is the most informative method for diagnostics of anterior abdominal wall state and of organs of abdominal cavity. With high level of informative content, MDCT provides an opportunity to estimate the state of muscles and fascia of anterior abdominal wall, the degree of DRA, get a full characteristic of ventral hernias and to detect comorbidity of abdominal cavity organs. On the basis of this data we planned the content of operative correction of the detected surgical pathology.

Our experience indicates that surgical correction of diastasis recti abdominis should be performed in all of the identified cases taking under consideration the progress of this pathology. There were no lethal cases. We monitored the long-term results during the period from 1 to 10 years. DRA recurrences were not observed.

Conclusions

  • Diastasis recti abdominis is a widespread pathology that can gradually progress with appearance of anterior abdominal wall muscles atrophy, pendulous abdomen and internal organs dislocations syndrome.

  • Nowadays MDCT is the most informative method of examination of this group of patients and can not only objectively estimate the degree of DRA, but also verify surgical pathology of organs of abdominal cavity.

  • Operative treatment of diastasis recti abdominis should be performed depending on the degree of DRA with the use of modern technologies.

  • Operative correction in case of I degree and II degree of DRA is less traumatic, provides an opportunity to avoid severe anatomic and functional disorders in anterior abdominal wall, appearance of pendulous abdomen, syndrome of internal organs dislocations, allows to achieve good long-term results.

Prospects for further research

Further research of anatomic and functional disorders of rectus abdominis diastasis with pendulous abdomen formation and its operative correction is prospective.

References

1 

VV Zhebrovky, Tom Elbashir Mohamed. Surgery of abdominal hernias and eventrations. Simferopol: Business-Inform; 2002. 440 p.

2 

SA Kolesnikov, DV Volkov, YuA Kosovkiy, et al. Herniology: practical guide. Belgorod: Belgorodskaya oblastnaya tipographia; 20142014. 276 p.

3 

DH Petrenko, VA Syplyviy, HD Petrenko, et al. Syndrome of internal organs dislocations in patients with large and giant ventral hernias. Visnyk Ukr Med Stomat Acad. 2007;1-2 (7):154-156.

4 

D Petrenko, O Sharmazanova, N Bortnuy. MSCT in diagnostics of rectus abdominis diastasis. EPOS (Electronic Presentation Online System). 2016:1-9. doi:10.1594/ecr2016/C-0021.

5 

D Brauman. Diastasis recti: Clinical anatomy. Plastic and reconstructive surgery. 2008;122(5):1564-1569.



Copyright (c) 2017 G. Petrenko, V. Syplyviy, D. Petrenko

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