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Diastasis recti abdominis (DRA) refers to the separation of the rectus abdominis muscles along the linea alba. Though traditionally viewed as a postpartum cosmetic issue, DRA has functional implications and affects both women and men.
Methods
A comprehensive literature review was conducted using PubMed, Web of Science, and Google Scholar, identifying 355 relevant publications over the past two decades. Priority was given to high-quality studies including randomized trials, observational studies, systematic reviews, and meta-analyses.
Results
DRA is highly prevalent in postpartum and menopausal women, and increasingly recognized in males with risk factors such as obesity and aging. Diagnostic tools have evolved from clinical assessment to imaging modalities such as ultrasound, CT, MRI, and elastography. Conservative management, especially core stabilization, improves function in mild cases. Severe DRA may require surgical repair, including open, laparoscopic, or robotic-assisted techniques, often with mesh reinforcement. Rehabilitation and biomaterials enhance surgical outcomes. However, consensus is lacking on treatment indications and long-term efficacy.
Conclusion
Advances in diagnostics, surgical techniques, and rehabilitation have improved DRA management. Future efforts should focus on standardizing treatment criteria, enhancing personalized care, and evaluating long-term outcomes.
Diastasis recti abdominis (DRA), defined by the atypical separation of the rectus abdominis muscles along the linea alba, is a common yet frequently neglected condition that encompasses both cosmetic and functional challenges (Fig. 1). Traditionally, DRA has been perceived as a postnatal issue predominantly affecting women. However, recent studies have highlighted its significant impact on men, particularly in the context of advanced age, obesity, smoking, or lack of physical exercise [1]. Epidemiological studies reveal a high prevalence of DRA among postpartum women, with incidence rates reported to range from approximately 21% to nearly 30% [2, 3], especially among those diagnosed with gestational diabetes mellitus (GDM) [4]. Furthermore, peri- and postmenopausal women also demonstrate a notable prevalence of DRA, often in conjunction with pelvic floor dysfunction (PFD) [5, 6], thereby expanding the clinical relevance of DRA across diverse demographic groups.
Fig. 1
Anatomical Illustration of Diastasis Rectus Abdominis
The pathophysiology of DRA is characterized by a multifaceted interplay of hormonal fluctuations, mechanical stressors, and alterations in muscular integrity. During pregnancy, hormonal changes lead to increased laxity of the connective tissue within the abdominal wall, which, when combined with the continuous mechanical stretching caused by the expanding uterus, facilitates the separation of the abdominal muscles [7]. Additionally, factors such as obesity, elevated intra-abdominal pressure, and certain exercise regimens further exacerbate DRA across diverse populations [8]. Therefore, a comprehensive understanding of the complex mechanisms underlying the development of DRA is crucial for the advancement of clinical management strategies.
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Historically, clinical awareness and research into DRA were limited, often relegating it to minor aesthetic relevance. However, recent advancements have catalyzed a paradigm shift toward recognizing its substantial clinical implications. Diagnostic techniques have evolved significantly from simple physical examinations to advanced imaging modalities such as ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI), offering improved accuracy and detailed assessment of muscular and fascial anatomy [9]. Additionally, innovative techniques, such as shear-wave elastography, provide quantitative evaluation of muscle tissue elasticity, further refining diagnostic precision [10, 11].
Treatment strategies have correspondingly evolved, progressing from conservative exercises primarily aimed at symptomatic relief to sophisticated surgical interventions designed for structural repair. Surgical management has experienced significant advancements, with minimally invasive techniques, including robotic-assisted procedures, emerging as effective alternatives to traditional open surgery [12]. Concurrently, the use of biomaterials, particularly biologic meshes, has improved surgical outcomes by enhancing durability and reducing recurrence rates [13]. Despite these advancements, considerable debate persists regarding optimal management protocols, treatment indications, and the long-term efficacy of various interventions. This review comprehensively synthesizes current knowledge on DRA, encompassing its epidemiology, diagnosis, management, and other pertinent aspects, addressing existing controversies, and outlining future directions to optimize clinical outcomes and patient quality of life.
Methods
This review conducted a comprehensive search of PubMed, Web of Science, and Google Scholar using the keywords"diastasis recti abdominis,""diastasis recti,"or"DRA,"to identify relevant studies published over the past 20 years. The initial search yielded 355 publications. Priority was given to randomized controlled trials (n = 25), observational study (n = 19), systematic reviews (n = 49), and meta-analyses (n = 11), from which key evidence and findings were extracted to inform clinical practice (Fig. 2).
Fig. 2
Flow Diagram of Literature Screening and Selection. DRA, diastasis rectus abdominis; RCT, randomized controlled trials
DRA occurs in the general population and is particularly common in certain groups. Studies have shown that postpartum women are a high incidence group of DRA. For instance, in a study of 1,133 postpartum women found that the proportion of those diagnosed with DRA reached 53.8%. In that study, among 176 women diagnosed with GDM, the incidence of DRA was 29.0%, compared to 25.8% in those without GDM; although this difference was not statistically significant, it reflects the high occurrence of DRA in the postpartum population [14]. Another cross-sectional study of 460 primiparous women at 6–8 months postpartum found that 96 (20.9%) women reported a bulging along the abdominal midline, suggesting the possibility of DRA [15]. Additionally, age appears to be associated with DRA. In a study of 150 peri- and postmenopausal women, 37.3% were found to have supra-umbilical DRA, and 78.6% of those with DRA also had PFD, indicating that DRA is relatively common in older women and is closely related to PFD [5].
In men, although research is more limited, the incidence of DRA is not negligible. Some studies indicate that DRA in males may be related to certain body parameters, such as body length at birth and waist-to-hip ratio [16]. DRA in men may be associated with old age, high BMI, smoking, and lack of physical exercise [1].
Reported prevalence rates of DRA vary across studies, likely due to differences in measurement methods, measurement sites, and diagnostic criteria. For instance, in assessing DRA, some studies use ultrasound to measure the inter-rectus distance (IRD), while others have used calipers to measure the actual distance between the medial border of the rectus abdominis; different techniques can lead to variation in results. Likewise, the selection of measurement sites, such as above the umbilicus, below the umbilicus or at different distances, as well as the specific criteria for determining the presence of DRA, make the prevalence of DRA difficult to be uniform across studies. Nevertheless, it is clear from various studies that DRA is a relatively common condition, especially in postpartum and elderly women, which merits greater attention, including recognition of its impact in men. Further research on its accurate epidemiological characteristics is of great significance for formulating targeted prevention and treatment strategies [8].
Pathophysiology
The pathologic mechanism of DRA is complex and involves many factors, including anatomical structure, muscle function, and physiological changes. While DRA is more common in women, especially during pregnancy and the postpartum period, men may also be affected. Studies have indicated that DRA may be associated with a decrease in core muscle strength, which can in turn lead to issues such as low back pain [17]. From an anatomical perspective, hormonal changes during pregnancy are a crucial factor. Pregnancy-related hormonal fluctuations cause the connective tissues of the abdominal wall to relax, creating conditions that facilitate the development of DRA. A study of 171 pregnant women using ultrasound measurements found that as pregnancy progressed, the IRD at 37 weeks of gestation was significantly greater than at 12 weeks; at 6 weeks postpartum the IRD had decreased but remained higher than the 12-week measurement. Meanwhile, the rectus abdominis thickness and Young's modulus at 37 weeks were markedly reduced, and although they partially recovered by 6 weeks postpartum, they were still lower than at 12 weeks. These findings demonstrate that significant changes occur in the abdominal muscles and connective tissue during pregnancy [10].
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In men, the occurrence of DRA may be related to factors such as increased abdominal pressure, obesity, and improper exercise techniques. Obesity leads to accumulation of abdominal fat and elevated intra-abdominal pressure, which can promote the separation of the rectus abdominis. Additionally, certain high-intensity or inappropriate exercise routines might cause or exacerbate DRA [18]. It is important that postoperative rehabilitation and exercise regimens be carefully managed to avoid further separation of the abdominal muscles.
Moreover, mechanical factors should not be overlooked. During pregnancy, progressive uterine enlargement imposes sustained pressure on the abdominal wall, resulting in gradual elongation and thinning of the rectus abdominis muscles. In certain cases, an anteriorly positioned fetus concentrates tensile forces on the linea alba rather than allowing uniform stress distribution across the abdominal wall. This localized and prolonged mechanical strain contributes significantly to the separation of the rectus muscles. Some studies also indicate that individual predispositions such as multiparity, a higher body mass index (BMI), and diabetes can increase the risk of DRA. For example, women who have had multiple pregnancies experience repeated abdominal wall stretching, raising the likelihood of DRA. Individuals with a high BMI accumulate excess abdominal fat, adding burden to the abdominal wall and potentially precipitating DRA. Diabetes may affect muscle metabolism and structure, thereby impairing the normal function of the rectus abdominis and increasing the incidence of DRA [8].
Clinical diagnostic techniques for DRA
Imaging-based diagnostic methods
Imaging evaluation is integral to the diagnosis and clinical management of DRA, offering precise assessment of rectus abdominis muscle separation and facilitating individualized treatment planning. Establishing normative reference values for the IRD and linea alba width is a critical prerequisite for accurate diagnosis [19, 20]. In a comprehensive review, Tung et al. (2021) described two widely recognized classification systems for DRA: the Rath and Nahas classifications. The Rath classification incorporates age-related variations, recognizing that the extent of pathological separation may increase with advancing age. Conversely, the Nahas classification is based on the etiological characteristics of fascial abnormalities, providing a framework for tailoring surgical interventions aimed at restoring abdominal wall integrity. Importantly, Tung emphasized that a separation of 2 cm or more should be deemed clinically significant, particularly in patients with concurrent hernias or those undergoing hernia repair [9]. This threshold has important implications for surgical decision-making and underscores the need for standardized diagnostic criteria in clinical practice.
Ultrasound is one of the most commonly used diagnostic modalities due to its convenience, noninvasiveness, and repeatability. Ultrasound allows clear visualization of the rectus abdominis muscles, the IRD, and muscle thickness. Shen et al. (2024) showed that a width-length classification based on ultrasound measurements can help guide the clinical treatment of DRA and has a high degree of accuracy in determining treatment strategies [21]. For example, in a study of postpartum women, ultrasound assessment found that 122 cases (85.31%) exhibited widening of the linea alba and 21 cases (14.68%) had discontinuity in the midline. Additionally, different ultrasound echo patterns were observed, which aided in accurately diagnosing DRA [22].
Aside from ultrasound, CT and MRI also play important roles in DRA evaluation. CT provides a detailed view of the abdominal wall anatomy and helps determine the degree of rectus abdominis separation and any associated abdominal wall changes [23]. MRI, with its superior soft tissue contrast, can better depict the rectus abdominis and surrounding tissues, thereby improving diagnostic accuracy [24]. However, due to its higher cost and longer examination time, MRI has certain limitations in routine clinical practice. In addition, some studies have explored the use of shear-wave elastography in combination with ultrasound to measure not only the morphological parameters of the rectus abdominis, but also to assess the muscle hardness. For example, in a study of 171 pregnant women, a significant change in the hardness of the rectus abdominis during pregnancy was found through this combined technique, providing more information for the diagnosis and assessment of DRA [1]. The ongoing development and refinement of imaging methods have greatly supported accurate DRA diagnosis and aided clinicians in formulating appropriate treatment plans.
In addition, imaging tests not only play a role in diagnosis, but also provide important information in postoperative evaluation. For example, the recovery of rectus abdominis separation can be monitored through postoperative ultrasound, ensuring the durability of the surgical results [25]. In summary, imaging is indispensable in the diagnosis and management of DRA. It helps physicians accurately assess the condition and provides a scientific basis for personalized treatment planning, thereby improving patient outcomes and quality of life[21, 23‐25].
Clinical evaluation criteria
Clinical evaluation is very important for accurately judging the separation of rectus abdominis and formulating reasonable treatment plan. Common evaluation methods include physical examination and the use of specific questionnaires. In physical examination, the presence of DRA is determined by measuring the IRD, for example, using digital nylon calipers at locations above, at, and below the umbilicus. Studies have shown that clinical examination correlates well with ultrasound measurements of rectus abdominis separation, making it a reliable method when imaging is not available [26]. In one study, postpartum women were evaluated using a specific finger width distance as a criterion to determine the presence and severity of DRA [15]. Physical examination can also help identify other issues associated with DRA, such as low back pain and stress urinary incontinence [17, 27].
In addition, several questionnaires are employed to assess the impact of DRA on patients’ quality of life. For example, the International Consultation on ICIQ-FLUTS is used to evaluate urinary symptoms, and the SF-36 questionnaire is used to quantify health-related quality of life. In a study of 51 patients who underwent rectus separation and correction surgery, these questionnaires were evaluated before and after surgery, and the mean scores obtained by analyzing the questionnaires showed significant improvement in urinary symptoms and quality of life after surgery, suggesting that these questionnaires can assist in evaluating the efficacy of DRA treatment to some extent [28]. In addition, it can also be combined with the symptoms of patients, such as co-existing low back pain or PFD, to comprehensively assess DRA’s impact and develop corresponding treatment strategies.
Comparison of diagnostic methods
Various diagnostic modalities for DRA have distinct advantages and limitations. Ultrasound is easy to perform, highly repeatable, and free of radiation, allowing real-time observation of the rectus abdominis. It is well-suited for dynamic assessment of DRA, for example, tracking changes in the IRD during various stages of pregnancy and postpartum [1]. However, ultrasound results may be affected by operator experience and manipulation, and some fine structures may not be as clearly observed as MRI and CT.
CT can provide excellent anatomical detail and can clearly show the abdominal wall muscles, fascia structure, and IRD. It is also able to accurately and repeatably measure the width of the white line and the degree of rectus abdominis separation at multiple levels (supraumbilical, periumbilical, subumbilical). At the same time, the co-existing diseases such as abdominal wall hernia, muscle atrophy, fat infiltration or intra-abdominal lesions can be found. CT reconstruction technology allows for multi-plane and three-dimensional visualization that provides a comprehensive assessment of the integrity of the abdominal wall. But CT involves ionizing radiation, which mainly limits young patients, pregnant women, or those who need repeated tests. CT cannot assess muscle function or dynamic changes (e.g., during straining).
In terms of soft tissue contrast, MRI provides better soft tissue resolution than CT and ultrasound, and can show the rectus abdominis muscle, the white line, and the peripheral fascia in detail. Moreover, MRI uses magnetic fields instead of ionizing radiation, effectively avoids the risks associated with ionizing radiation, making it safer for younger patients, pregnant women, and patients with repeated tests. At the same time, advanced MRI techniques, such as cine-MRI, can assess abdominal wall movements, muscle contractions, or strain patterns to provide functional information. However, the cost is high, the scan time is long, and patients must meet certain physical requirements (e.g., no metal implants, ability to tolerate confinement in the scanner). These limitations make MRI unsuitable for some patients.
Furthermore, other diagnostic approaches like physical examination combined with patient questionnaires, though relatively simple, offer important insights into patient-reported symptoms and functional deficits. These methods complement imaging examinations, and together they can improve the accuracy of DRA diagnosis (Table 1).
Conservative management is an important component of DRA treatment and primarily includes exercise therapy and physical therapy. Exercise therapy is considered an effective method for improving functional deficits by activating the abdominal muscles [29]. Core stability training, in particular, has been shown to benefit patients with DRA. In a randomized controlled trial involving 40 postpartum women with DRA, one group performed an intensive core stability exercise program combined with traditional abdominal exercises, while the control group performed only traditional abdominal exercises. After 8 weeks, the group incorporating core stability training had a significantly greater reduction in IRD (P < 0.0001) and a marked improvement in quality of life (P < 0.0001) compared to controls, demonstrating the positive role of core stabilization exercises in DRA treatment [30]. Furthermore, another study demonstrated that curl-up exercises can increase abdominal muscle strength without worsening the IRD in postpartum women [31]. Early postpartum engagement in low-intensity exercise has also been associated with a reduction in the severity of pelvic girdle pain, suggesting additional benefits of timely postpartum exercise interventions [32].
Various physical therapy approaches have also been explored for DRA. In a study of 32 first-time mothers, one group used a belly band combined with targeted torso exercises. Positive effects on body image were observed after 6 months (Cohen's d = 0.2–0.5), suggesting that abdominal binders may have some adjunct value in the treatment of DRA [33]. Additionally, manual therapy techniques have been investigated. For example, albeit in a small case series, visceral manipulation therapy was applied in 3 women with DRA, and after a minimum of 4 treatment sessions, the IRD was reduced, pain scores decreased, and functional activities improved. This case series indicates that conservative treatments can achieve favorable outcomes in some patients with DRA, although individual results may vary [34]. Another study suggested that surface electromyography biofeedback-assisted core muscle strengthening exercises combined with Kinesio taping showed significant effects in reducing the IRD and improving physical function [35]. However, most existing studies on physical therapy for diastasis recti abdominis are concentrated between 6 and 12 months postpartum [33, 36, 37]。In the early postpartum period, the inter-rectus distance often decreases spontaneously due to hormonal influences [38‐40], potentially introducing bias into early rehabilitation studies and thereby limiting the validity of their conclusions.
Overall, conservative interventions (exercise and physical therapy) show promise for improving DRA-related functional deficits and quality of life. Further research (including larger trials) is still necessary to determine the best treatment options and techniques.
Advances in surgical treatment
For patients with more severe DRA, surgical intervention is often an important option. A variety of surgical techniques have been utilized to repair DRA. Various open repair techniques are available, including direct suture repair, rectus abdominis muscle plication, and mesh reinforcement. These procedures typically involve approximation of the anterior rectus sheath or placement of a prosthetic mesh to restore abdominal wall integrity. In contrast, mesh-based repair has demonstrated lower recurrence and complication rates, particularly in patients with a DRA width of ≥ 10 cm, leading to superior long-term outcomes [41]. In patients with concurrent skin redundancy, subcutaneous fat accumulation, or pronounced aesthetic deformity, open repair is often combined with abdominoplasty. This approach allows for resection of excess cutaneous and subcutaneous tissues while simultaneously reinforcing the abdominal wall through rectus sheath plication or overlapping suture techniques. The goal is to achieve both functional restoration and aesthetic improvement [28].
Minimally invasive surgery is also increasingly applied in the treatment of DRA. a completely endoscopic subcutaneous repair (as detailed later in Technical Advances) has shown feasibility in correcting DRA with concurrent midline hernias, yielding significant aesthetic improvements [42]. Furthermore, robotic-assisted techniques have been introduced; for example, the robotic transabdominal retromuscular rectus diastasis (r-TARRD) repair offers a new minimally invasive option. In a series of 45 patients undergoing r-TARRD, the average operative time was 192 min and the average hospital stay was 4.2 days. At one month postoperatively, 1 patient (2.22%) had a mesh infection, and at one year 4 patients (8.88%) had a recurrence. These findings suggest that r-TARRD is generally safe and effective, though refinements and longer-term follow-up are still needed [43] (Table 2).
Table 2
Comparison between r-TARRD and Traditional Open Plication for Rectus Diastasis Repair
Parameter
r-TARRD
Traditional Open Plication
Surgical Approach
Laparoscopic access with robotic assistance
Open midline incision
Extent of Tissue Dissection
Confined to the retromuscular (posterior) space
Extensive subcutaneous flap elevation
Mesh Use
Optional (commonly used in moderate-to-severe cases)
Generally not used
Average Operative Time
180–240 min
Approximately 135 min
Length of Hospital Stay
1–3 days (some suitable for outpatient surgery)
Same-day or overnight
Postoperative Recovery
Faster, less pain, minimal scarring
More discomfort, slower recovery
Aesthetic Outcome
Superior (small, concealed incisions)
Prominent scar, especially with concurrent abdominoplasty
Recurrence Rate
Very low (especially with mesh use)
Relatively higher (10–20%)
Postoperative Complications
Rare (notably low infection rates)
More common (e.g., seroma, hematoma)
Patient Selection
Ideal for moderate-to-severe DRA, recurrent cases, poor tissue quality
Suitable for mild-to-moderate DRA, cost-sensitive patients
Moreover, repairing DRA (especially in conjunction with hernia repair) may reduce certain complications. For example, one study found that correcting rectus diastasis lowers the risk of postoperative abdominal wound dehiscence [44]. Another study on achieving long-term stability by using absorbable sutures to repair DRA has been confirmed, indicating that this method can maintain the stability of the abdominal wall after surgery [45]. Anterior compartment mobilisation (ACM), performed via a posterior dissection plane, has demonstrated favorable outcomes in the management of very severe DRA. The technique facilitates medial advancement of the rectus muscles and anterior rectus sheaths to restore midline integrity. In a cohort of 282 patients undergoing repair for large ventral or incisional hernias, ACM achieved complete fascial closure in all cases. At one-year follow-up, there were no recurrences or major complications, and only two patients (0.7%) experienced minor complications. These findings support the feasibility and effectiveness of ACM in treating complex midline defects, including severe DRA [46].
In summary, surgical treatment plays a vital role in the management of severe DRA. However, patient selection for surgery should be cautious, as discussed later, given ongoing debates about indications.
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Rehabilitation training programs
Rehabilitation is a crucial component of DRA management, focusing on strengthening the abdominal and pelvic floor muscles. Multiple studies have evaluated exercise-based programs. Studies have shown that standardized rehabilitation can significantly improve the condition of DRA in postpartum women and enhance their quality of life [47]. For instance, in one study of 70 women with DRA at 6–12 months postpartum, the intervention group underwent a standardized 12-week exercise regimen (including head lift, abdominal curl, and oblique abdominal curl exercises, 5 days per week). Although this exercise program did not significantly change the IRD, it led to increases in rectus abdominis thickness (MD 0.7 mm, 95% CI 0.1 to 1.3) and muscle strength (MD 9 Nm, 95% CI 3 to 16), indicating that targeted abdominal exercises can enhance abdominal muscle strength and thickness [31]. Another study investigated core stability training combined with transcutaneous electrical acupoint stimulation in postpartum women with DRA, and found that this combined approach significantly reduced the degree of DRA and also reduced waist circumference and improved quality of life [11]. These findings highlight the particular importance of core muscle training in DRA rehabilitation.
At the same time, integrating pelvic floor muscle training into the rehabilitation program is also of great significance. Early implementation of low-intensity combined pelvic floor and abdominal muscle exercises has been shown to have positive effects on postpartum recovery. In a longitudinal study of 504 postpartum women divided into different exercise groups, those in a low-intensity exercise group experienced relief of pelvic floor pain and a modest improvement in DRA within the first year postpartum, suggesting that early low-intensity combined rehabilitation training is of important value for postpartum recovery [32].
Additionally, emerging therapies such as electro-acupuncture combined with physical exercise have proven effective in improving DRA. In a randomized controlled trial, patients receiving electro-acupuncture therapy showed greater improvement in DRA compared to those performing exercise alone, and the beneficial effect remained significant at 26 weeks post-intervention [37]. Pilates, which has become popular in recent years, has also been shown to have a positive impact on DRA in postpartum women. Studies indicate that Pilates training can effectively reduce the IRD, decrease waist circumference, and improve abdominal muscle endurance [48].
In addition, The TOR (Training, Operation, and Rehabilitation) concept has emerged as a novel strategy for managing abdominal wall dysfunction and DRA. This multidisciplinary approach integrates preoperative symptom assessment, individualized core strengthening, tailored surgical repair, and structured postoperative rehabilitation. Preliminary evidence suggests that TOR may significantly improve physical function and quality of life in postpartum women [49].
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In summary, well-designed rehabilitation training programs are of great importance in the treatment of DRA. Such programs can improve the function of the rectus abdominis and enhance patients’ quality of life. Of note, rehabilitation protocols should be individualized according to each patient’s specific condition in order to achieve optimal outcomes.
Technical advances in DRA treatment
Minimally invasive surgical techniques
Minimally invasive surgical techniques have been increasingly applied in the treatment of DRA, offering the advantages of smaller incisions and faster recovery. For example, a totally endoscopic subcutaneous approach for repairing DRA associated with midline hernias has been reported. As noted earlier, Bellido Luque et al. demonstrated in 21 patients that a totally endoscopic subcutaneous approach for DRA with midline hernias is feasible and yields excellent mid-term results [42]. In addition to such endoscopic repairs, other minimally invasive methods have been applied to procedures related to DRA.
Minimally invasive methods have also been applied to procedures related to DRA in abdominal wall surgery. For instance, harvesting a rectus abdominis muscle flap (as used in complex pelvic reconstruction) traditionally requires a long incision in the rectus sheath, risking donor-site morbidity. A modified laparoscopic-assisted technique has been developed to avoid the long incision, thereby promoting faster recovery and improved cosmetic results [50]. The previously described robotic-assisted r-TARRD repair is an example, allowing precise midline reconstruction with mesh placement and achieving a high success rate with mostly minor complications [43]. Another emerging approach is the pre-aponeurotic endoscopic repair (REPA) for DRA; despite the minimally invasive nature of REPA, postoperative pain management remains a challenge. A recent study demonstrated that combining a transversus abdominis plane block with a rectus sheath block significantly reduced postoperative pain and opioid requirements for patients undergoing REPA, thus improving their postoperative recovery experience [51].
The ongoing development of minimally invasive surgical techniques provides DRA patients with treatment options that involve less trauma and faster recovery. These innovations are expected to further improve clinical outcomes and patient experiences.
Application of biomaterials
Biomaterials play an important role in the treatment of DRA, primarily by enhancing repair effectiveness and promoting tissue healing. Research indicates that biomaterials can promote wound healing by modulating cellular behavior and dynamically remodeling the extracellular matrix, thereby maximizing regenerative and reparative outcomes [52].
Biologic meshes are used in abdominal wall reconstruction to provide both structural reinforcement and support for tissue integration. Clinical data suggest they may reduce postoperative complication rates in specific contexts [13]. Their biodegradable properties enable gradual replacement by native tissue, facilitating repair of abdominal wall defects [53]. Preliminary studies have reported that biologic meshes may enable early closure of contaminated or potentially contaminated defects, particularly when primary skin closure is not feasible, by promoting granulation tissue formation and secondary healing [54]. However, these benefits remain subject to debate. A systematic review by Köckerling et al. assessed outcomes from multiple studies and found no consistent evidence supporting the superiority of biologic or biosynthetic meshes over synthetic alternatives in contaminated fields [55]. Similarly, other reviews have emphasized the limited quantity and quality of existing data, which do not substantiate claims that biologic meshes are less susceptible to infection or associated with lower explantation rates [56, 57].Further well-designed prospective studies are essential to clarify the role of biologic meshes in contaminated abdominal wall repair and to validate their purported advantages over synthetic materials.
Additionally, some absorbable materials have increasingly been used in DRA repair. In a study of 51 patients, absorbable sutures were used for rectus sheath plication, and postoperative ultrasound examination found no significant difference in IRD at long-term follow-up compared to traditional permanent sutures [45]. This finding suggests that absorbable sutures appear to reliably maintain long-term abdominal wall stability, offering a new material option for DRA treatment (Table 3).
Table 3
Comparison of Biomaterial Types Used in the Surgical Treatment of DRA
Material Type
Main Application
Advantages
Limitations
Biologic Meshes
Abdominal wall reconstruction and closure of contaminated or potentially contaminated defects
Biodegradable, promotes tissue integration, may support healing in contaminated fields
Controversial efficacy in contaminated environments, higher cost, limited high-quality evidence
Synthetic Meshes
Abdominal wall reinforcement, especially in clean surgical settings
Durable, widely available, lower cost
Higher risk of infection and foreign body reactions in contaminated fields
Limited long-term data, potential decrease in tensile strength over time
DRA, Diastasis Recti Abdominis
In summary, the application of biomaterials in DRA treatment not only enhances repair outcomes but also promotes tissue healing, providing more possibilities for effective management of DRA. With ongoing advances in materials science, it is anticipated that new biomaterials will be developed to further improve DRA treatment outcomes.
Discussion
Historical evolution and research progress
The understanding and study of DRA have evolved continuously over time. In the early medical literature, DRA received relatively little attention. As research advanced, it became increasingly recognized that DRA is prevalent among postpartum women and other specific populations, and that it can have potential health implications. In terms of diagnosis, approaches have progressed from simple initial physical examinations to the use of multiple advanced imaging techniques such as ultrasound and MRI, which have improved diagnostic accuracy. For example, ultrasound technology not only clearly displays the morphology of the rectus abdominis and the extent of its separation, but also provides quantitative metrics (such as measuring IRD) to support clinical diagnosis [10].
With respect to treatment, early management of DRA relied primarily on conservative measures, such as basic abdominal exercises to alleviate the separation of the rectus abdominis muscles. Surgical management of DRA has progressed significantly with medical advances. In 1967, Pitanguy introduced an abdominoplasty technique combining excision of excess tissue with rectus muscle plication, marking an early integration of functional and aesthetic repair [58]. This laid the groundwork for traditional open repairs, which later incorporated mesh reinforcement in severe cases [41]. Recently, ACM has demonstrated its feasibility and effectiveness in treating complex midline defects, including severe diastasis recti [46], reflecting the shift toward comprehensive reconstruction with improved functional and cosmetic outcomes. At the same time, rehabilitation training programs have been continually refined, evolving from single exercises to comprehensive regimens integrating multiple methods to improve outcomes. In recent years, research on DRA has paid more attention to the comprehensive consideration of various factors, such as combining individual differences of patients, lifestyle and other factors, to develop more personalized treatment plans, which will be a key future direction for DRA research and treatment.
Controversies and challenges
Controversies in treatment indications
There is ongoing debate regarding the indications for treating DRA. On one hand, opinions differ on whether active intervention is necessary for mild cases of DRA. Some experts argue that mild DRA may improve through the body’s natural recovery mechanisms or with simple conservative therapy, and that excessive intervention could introduce unnecessary risks and burdens for the patient [59]. However, others contend that even mild DRA should be treated proactively if it is accompanied by related symptoms such as low back pain or PFD, in order to prevent progression of the condition and improve the patient’s quality of life [17].
On the other hand, there is ongoing controversy regarding the indications for surgical treatment of DRA. For instance, in patients with DRA combined with other conditions (e.g., ventral hernias), surgical decision-making is not standardized. Some studies suggest tailoring the surgical plan based on factors such as hernia type/size and DRA severity. However, specific quantitative criteria and algorithms for these decisions have yet to be defined [60, 61]. Patient factors such as age and overall health further complicate the decision, underscoring the need for more research to guide either conservative or surgical intervention in various scenarios.
To date, there is no global consensus guideline for DRA management. Although Germany [61] and Sweden [62] have put forward suggestions for national guidelines, the surgical thresholds therein have not yet been unified, and thus there are differences in practice. This controversy highlights the balance between avoiding unnecessary surgeries and ensuring timely intervention for those in need.
Long-term efficacy evaluation
DRA is a common abdominal wall problem, particularly among postpartum women. Evaluating the long-term efficacy of its treatment is important not only for improving patient quality of life but also for guiding clinical management. However, research in this area remains relatively limited; many studies focus only on short-term outcomes and neglect the importance of extended follow-up.
With regard to conservative treatment, although some short-term studies demonstrate that exercise therapy and physical therapy have beneficial effects, it is unclear whether these improvements are maintained in the long term. For example, some patients show a reduction in their degree of rectus separation after a period of rehabilitation. However, it is uncertain whether the separation might recur after exercises are stopped. It is also unclear what long-term impact untreated DRA may have on quality of life. These questions highlight the need for further long-term follow-up studies to confirm the durability of benefits achieved through conservative management [33].
In surgical treatment, despite some short- and intermediate-term studies indicating that surgery can effectively repair DRA, the long-term outcomes still require further observation. Certain surgical techniques may yield excellent results in the early postoperative period, but as time passes there is the potential for recurrence of the diastasis or other late complications.
In summary, although progress has been made in the treatment of DRA, there remains a significant lack of data on long-term outcomes. We recommend that future research should place greater emphasis on prolonged follow-up in order to fully evaluate the sustained efficacy of different treatments, and to provide more reliable evidence for clinical practice.
Future outlook of DRA
Current research emphasizes genetic and molecular mechanisms to identify biomarkers for early diagnosis and individual risk prediction. Minimally invasive surgeries (robotic and endoscopic) are advancing, reducing patient trauma and expediting recovery. Personalized rehabilitation programs integrating smart technologies and big data are being developed to improve patient-specific outcomes. In addition, enhanced multidisciplinary collaboration among obstetricians, surgeons, rehabilitation specialists, and radiologists is providing more comprehensive, patient-centered care.
Future directions focus on personalized medicine. For instance, leveraging genetic testing and artificial intelligence to tailor treatments, predict healing potential, and optimize strategies. Such approaches could transform DRA management, enabling truly individualized therapy and improved long-term patient outcomes.
Conclusion
In conclusion, significant advancements have enhanced the understanding, diagnosis, and management of DRA. Current diagnostic techniques combining imaging modalities and clinical evaluations offer improved accuracy, facilitating tailored therapeutic approaches. Conservative therapies, minimally invasive surgery, and novel biomaterials have all demonstrated promising results in DRA management. However, debates continue regarding optimal treatment indications and the long-term efficacy of various approaches. Future research should emphasize multidisciplinary collaboration, personalized medicine, and longitudinal studies in order to refine clinical strategies, improve patient outcomes, and enhance quality of life for individuals affected by DRA.
Declarations
Competing interest
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Ein chirurgischer Eingriff kann für Patienten mit primärem Hyperparathyreoidismus gegenüber dem konservativen Management metabolisch von Vorteil sein. Denn wie eine Studie zeigt, senkt die Operation das Diabetesrisiko.
Beim Ernährungsmanagement vor und nach einer Krebs-Op. im Gastrointestinaltrakt klafft offenbar eine große Lücke zwischen Leitlinienempfehlungen und klinischer Praxis. Darauf deuten die Ergebnisse einer Umfrage in 263 deutschen Zentren hin.
Seit etwa 20 Jahren ist die Ballonsinuplastik als Option für die Therapie der chronischen Rhinosinusitis verfügbar. Zwei Studien haben sich nun mit der Frage beschäftigt, ob das Verfahren adäquat angewendet wird.
Patientinnen und Patienten, die schon früh am Tag auf dem OP-Tisch zu liegen kommen, haben bessere Überlebenschancen als am Nachmittag operierte. Allerdings sind die im Zuge einer Studie ermittelten Mortalitätsraten insgesamt niedrig und die Differenzen gering – wenngleich signifikant.
