Rectus Abdominis Diastasis (RAD)

Hattori Taro Kanzaki, MD
The Operative Review of Surgery. 2023; 1:218-220.

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Table of Contents

Pathophysiology and Presentation
Diagnosis and Treatment

References

Pathophysiology and Presentation

Also Known as “Diastasis Recti”, “Diastasis of Rectus Abdominis Muscle (DRAM)”, “Abdominal Muscle Separation”, or “Divarication of the Rectus Abdominis”

Definition

  • Definition: Abnormally Wide Separation of the Rectus Abdominis Pillars 1
  • Fascia Remains Intact (Not a True Hernia)
  • Separation > 2 cm is Generally Considered Abnormal Although Clinically Evident RAD May Be Present with Smaller Distances 2,3
  • Can Be Congenital or Acquired

Risk Factors for Acquired Diastasis 4-7

  • Elevated Intraabdominal Pressures
    • Pregnancy
    • Obesity
  • Prior Abdominal Surgery
  • Connective Tissue Disorders
  • Diabetes
  • Abdominal Aortic Aneurysm (AAA)

Presentation 2

  • Many are Asymptomatic
  • Prominent Midline Ridge Extending from the Xiphoid to Umbilicus
    • Bulge Rises with Increased Intraabdominal Pressure (Sitting-Up or Head Lift)
  • Abdominal Pain
  • Not a Hernia – No Risk of Incarceration or Strangulation

Diastasis Recti 8

Diagnosis and Treatment

Diagnosis 9

  • Generally a Clinical Diagnosis Based on History and Physical Examination
  • May Be Confused with a Ventral Hernia
  • Imaging (US, CT, or MRI) Can Be Used if Diagnosis is Uncertain, to Aid in Classification or to Guide Surgical Planning
    • Imaging Can Also Evaluate for the Coexistence of True Hernias
    • US (Preferred) or CT Can Be Used if Diagnosis Uncertain
  • Multiple Classification Systems Have Been Proposed 10-12

Treatment 13,14

  • Primary Treatment: Weight Loss and Abdominal Wall Strengthening/Physiotherapy
  • Consider Surgical Repair for Large Symptomatic Diastasis that Fails Conservative Management

Surgical Repair 13-17

  • Primary Surgical Repair is Rectus Sheath Plication
  • Approaches:
    • Plications Can Be Single or Double Layer
    • May Consider Reinforcement with Mesh
    • Can Be Done Open or Minimally Invasive
  • Can Perform a Combined Abdominoplasty for Excess Skin
  • Surgical Repair Can Improve Both Pulmonary and Abdominal Wall Function
  • Low Recurrence Rates – Generally Reported as 0% at 6 Months

Rectus Sheath Plication 14

References

  1. Diastasis Recti. Cleveland Clinic. 2022.
  2. Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg Hand Surg. 2014 Jun;48(3):163-9.
  3. Keshwani N, Mathur S, McLean L. Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period. Phys Ther. 2018 Mar 1;98(3):182-190.
  4. Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg Hand Surg. 2014 Jun;48(3):163-9.
  5. Brauman D. Diastasis recti: clinical anatomy. Plast Reconstr Surg. 2008 Nov;122(5):1564-1569.
  6. McPhail I. Abdominal aortic aneurysm and diastasis recti. Angiology. 2008 Dec-2009 Jan;59(6):736-9.
  7. Cavalli M, Aiolfi A, Bruni PG, Manfredini L, Lombardo F, Bonfanti MT, Bona D, Campanelli G. Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia. 2021 Aug;25(4):883-890.
  8. Cheesborough JE, Dumanian GA. Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs. Plast Reconstr Surg. 2015 Jan;135(1):268-276. (License: CC BY-NC-ND 3.0)
  9. Tung RC, Towfigh S. Diagnostic techniques for diastasis recti. Hernia. 2021 Aug;25(4):915-919.
  10. Nahas FX. An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg. 2001 Nov;108(6):1787-95; discussion 1796-7.
  11. Keramidas E, Rodopoulou S, Gavala MI. A Proposed Classification and Treatment Algorithm for Rectus Diastasis: A Prospective Study. Aesthetic Plast Surg. 2022 Oct;46(5):2323-2332.
  12. Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, Kukleta J, Kuthe A, Lorenz R, Stechemesser B. Classification of Rectus Diastasis-A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front Surg. 2019 Jan 28;6:1.
  13. Mommers EHH, Ponten JEH, Al Omar AK, de Vries Reilingh TS, Bouvy ND, Nienhuijs SW. The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc. 2017 Dec;31(12):4934-4949.
  14. Jessen ML, Öberg S, Rosenberg J. Treatment Options for Abdominal Rectus Diastasis. Front Surg. 2019 Nov 19;6:65. (License: CC BY)
  15. Emanuelsson P, Gunnarsson U, Strigard K, Stark B. Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up. J Plast Reconstr Aesthetic Surg. (2014) 67:1082–8.
  16. Nahas FX, Augusto SM, Ghelfond C. Nylon versus polydioxanone in the correction of rectus diastasis. Plast Reconstr Surg. (2001) 107:700–6.
  17. Birdsell DC, Gavelin GE, Kemsley GM. “Staying power”–absorbable vs. nonabsorbable. Plast Reconstr Surg. (1981) 68:742–5.