Mesh suture repair of rectus diastasis with and without a concurrent ventral hernia

A retrospective cohort study was conducted and included all consecutive patients with and without hernias who had a full mesh suture RD plication from the xyphoid to the symphysis pubis and abdominoplasty by a single surgeon (G.A.D). The review included cases between January 2023 and January 2025. Patients were identified through institutional implant logs of mesh suture, and all were treated at a single urban, academic hospital. Inclusion criteria included: use of mesh suture for rectus muscle plication in conjunction with abdominoplasty. Exclusion criteria included: use of planar mesh and abdominoplasty without plication. Notably, patients with incisional, epigastric, trocar site, and umbilical hernias were included in the “with hernia” group for analysis. All patients paid a portion of the surgical fee “out of pocket” for the abdominoplasty.

Retrospective review of the electronic medical record (EMR) was performed to evaluate patient characteristics, surgical details, and outcomes. The primary outcome for this report was incidence of surgical site infection (SSI) which includes superficial, deep, and organ space infections. We also collected surgical site events (SSE) including seroma, hematoma, soft tissue breakdown, cellulitis, suture granuloma, chronic draining sinus, and enterocutaneous fistula per definitions by Majumder et al. [14] SSI, SSE, readmissions, and reoperations were recorded within one year of index surgery, however in cases where follow-up extended beyond 365 days, additional review of the medical record was performed to assess for any mesh-related late complications. Hernia formation after index surgery was recorded for longest follow up time available. Mean follow up was calculated from the index procedure to date of last documented review of the electronic medical record (EMR). Hernia recurrence was defined as documentation of a recurrent defect based on physical exam or cross-sectional imaging. The EMR was reviewed for documented follow-ups, including both the internal EMR and “Care-Everywhere,” which allows for a limited view of outside hospital encounters at participating hospitals. As mesh suture was used as part of standard clinical practice by the surgeon, patients did not give additional informed consent.

Statistical analysis was performed using IBM SPSS Statistics 29 (Armonk, NY: IBM Corp). Descriptive statistics were performed to summarize patient characteristics, surgical details, and outcomes. Univariate subgroup analyses were performed using Chi-square with post-hoc adjusted standardized residuals (cutoff for significance of \(\:\pm\:\) 1.96) for categorical variables. For continuous variables, independent sample T-test was performed. A value of p < 0.05 was considered statistically significant unless otherwise stated.

It is well known that standard suture has limitations in abdominal wall approximation. Burger demonstrated that for incisional hernias, a suture closure has higher failure rates than a mesh closure with a 60% failure rate at 10 years [17]. In laparotomy closure, even with the small bites technique, failures of tissue approximation occur and increase over the years [18]. Mesh suture plication of the midline is a unique technique distinct from the “small-bites” laparotomy closures that are performed to decrease hernia formation [19]. While the 4:1 concept is well accepted for a standard suture, each mesh suture has 18 filaments that cross the repair site, and it therefore can be considered an exaggerated small-bites technique despite the empirically established 8 mm travels between each suture passage. The capture of the anterior rectus fascia in each bite is also distinct from the passage of the suture only through the linea alba in “small-bites.” The needle of mesh suture has a larger diameter than the 2−0 suture of a slowly absorbable suture and this larger needle size has not been problematic to date in a large registry report of mesh suture [10]. Linea alba plication theoretically should not be different from full thickness abdominal wall closures, other than that the starting point is a compliant female abdomen typically that may be subjected to decreased tissue stresses. However, to achieve an aesthetic outcome, the surgeon may intentionally increase the tension on the repair to better narrow the waistline. Surgeons have described multiple suturing techniques to plicate the linea alba with durable results; many absorbable and nonabsorbable techniques for RD plication are reported in the literature including interrupted and continuous techniques, and multiple layered suture closures [3, 4, 20‐26]. While these techniques may be effective in decreasing the tension at the STI, they do require extra time and complexity. Mesh suture may be an alternative option to decrease pressure at the STI while keeping the running plication simple and efficient. Fibrovascular incorporation of the permanent filaments may also lead to a more lasting durable repair.

Marangi et al. was the first to describe the use of mesh suture for RD plication in abdominoplasties, though the study excluded patients undergoing concomitant procedures and hernia repairs [27]. They compared mesh suture to standard 0-polypropylene suture plication and found no significant differences in complications between groups [27]. As compared to our study, we found similar rates of complications including infection (2.1% versus 0%), hematoma (2.1% versus 3.1%), and soft tissue breakdown (8.5% versus 6.2%). Notably we did have more seromas (8.5% versus 1.5%), however half of these were in the concurrent hernia repair group and are attributed to greater soft tissue dissection. It is reassuring that there were no chronic draining sinuses or fistulae in either study. A notable finding by Marangi et al. was that the mesh suture group had a faster plication time as compared to standard suture. This was in part attributed to different suturing techniques used; the mesh suture was used in a running fashion and 0-polypropylene suture was used as interrupted figure-of-eights [27]. The technique used for the 0-polypropylene was likely used due to its propensity for suture pull-through.

Our study is the first to examine the use of mesh suture for abdominoplasty with RD repair and concurrent hernia repair. We observed no significant differences in short-term complication rates between patients undergoing abdominoplasty alone and those undergoing simultaneous hernia repair, suggesting that mesh suture may be a feasible option in both settings. Prior studies have examined the risks and benefits of combining procedures during abdominoplasty, though many are limited by small sample sizes [4, 28‐30]. For example, Erfan et al. reported outcomes in 15 patients who underwent anterior component separation and midline hernia repair with absorbable suture and noted a 26.4% complication rate with no hernia recurrences [31]. Moreno-Egea et al. studied 111 patients undergoing concurrent incisional hernia repair with abdominoplasty and found no increase in morbidity compared to either procedure alone, with improvements in quality of life scores [32]. These findings highlight the potential value of integrating surgical approaches, though data remains limited.

Currently, the European Hernia Society recommends mesh reinforcement for umbilical or epigastric hernias > 1 cm in the setting of RD; however, this recommendation is based on low-quality evidence and carries only a weak strength of recommendation [8]. We diverged from these guidelines to explore the use of mesh suture in a patient cohort that may benefit from avoiding planar mesh due to its associated complexity, increased foreign body burden, or potential impact on aesthetic outcomes. Mesh suture, by combining elements of mesh reinforcement with the simplicity of suture placement, may represent a viable alternative for select low-risk patients undergoing aesthetic abdominoplasty with rectus diastasis repair. However, given the small sample size and heterogeneity of our series, particularly in hernia size and type, these findings should be interpreted as hypothesis-generating. Future studies should consider stratified, prospective enrollment, ideally randomized, based on hernia defect size (e.g. <1 cm, 1–2 cm, > 2 cm). Larger hernias may still warrant planar mesh, and repair selection should be guided by individual anatomy, risk profile, and surgical goals.

In our practice, mesh suture has become an alternative to planar mesh in patients with favorable anatomy, specifically those patients with RD but without significant rectus muscle widening. Previously, planar mesh was preferred for moderate to severe RD, but we now reserve it where rectus approximation would not appreciably narrow the semilunar lines due to excessive muscle width [33]. For others, mesh suture may represent a “sweet spot” between traditional suture and planar mesh repairs, balancing technical efficiency, tension mitigation, and aesthetic outcomes. In our practice, abdominal compliance is used as a clinical tool to guide surgical decision-making (Fig. 6). We define compliance based on the patient’s ability to engage the abdominal musculature and generate intra-abdominal pressure during physical examination, in combination with assessment of abdominal wall laxity intraoperatively. We stratify patients into three categories: excessive, moderate, and low compliance. Excessive compliance describes a soft, lax abdominal wall with minimal intrinsic tension or muscular tone, often seen in multiparous women who have had twin gestations or very large newborns. Simple approximation of the medial borders of the rectus muscle will leave a “floppy” non-aesthetic abdominal contour, as the muscles themselves have little to no tone, and thus, mesh abdominoplasty, defined as a retrorectus planar permanent mesh with mesh suture approximation of the rectus muscles, is preferred. Moderately compliant abdominal walls are pliable but with some inherent tone or resistance. In these patients, the mesh suture could meaningfully approximate the two hemi-abdomens and generate enough lasting tension to achieve an hourglass shape. Low compliance refers to a firm, non-pliable abdominal wall with high intrinsic tension, often due to well-developed rectus muscles and dense fascia. These patients may have difficulty achieving midline approximation without creating excessive tension across the closure. Male patients, especially those with athletic builds, frequently fall in this category. In this category, mesh abdominoplasty is preferred to provide durable reinforcement and optimize contour, as traditional mesh suture repair alone may not sufficiently counteract the high recoil forces of the abdominal wall. This compliance-based framework helps tailor repair strategy to the individual patient’s anatomy and physiology.

While this three-point classification of abdominal wall compliance has proven useful in guiding intraoperative decision-making and optimizing aesthetic outcomes, its clinical application remains largely qualitative and subject to surgeon interpretation. To better standardize this approach, future studies should incorporate CT imaging-based morphological assessment to evaluate parameters including rectus muscle thickness, width of diastasis, and lateral abdominal wall quality. Objective correlation between imaging findings and surgeon compliance assessments would allow for greater reproducibility and potentially enhance preoperative planning. Validation of this framework through prospective morphometric studies would further strengthen its clinical utility and support its integration into procedural algorithms.

In our study, there was a single hernia recurrence, identified 165 days postoperatively in a patient with a prior biologic mesh hernia repair and recurrent defect measuring 5 cm in transverse width, substantially larger than the cohort mean of 2.8 cm and exceeding the typical indication for mesh suture repair in this context. Upon review, we recognize that the size of this patient’s defect falls outside of the clinical scope of this series and while inclusion of this case reflected real-world surgical decision-making at the time, it introduces heterogeneity. Current principles of abdominal wall reconstruction support the use of planar mesh for larger or more complex defects, particularly those involving prior failed repairs. Before mesh suture can be considered in such contexts, its safety, efficacy, and durability must first be validated in smaller, lower risk defects. The presence of this outlier reinforces the need for clear anatomic and clinical criteria to guide patient selection and highlights the importance of future prospectively studies that stratify outcomes by defect size and complexity to optimize device selection.

Importantly, this series reflects an aesthetic surgical population undergoing elective, self-pay, abdominoplasty, rather than reconstructive procedures such as panniculectomy, which are typically performed in higher BMI patients or those with massive weight loss [34]. These differences influence surgical planning, particularly with respect to the extent of dissection, use of liposuction, application of rectus diastasis plication and expectations for contouring and these differences must be considered when interpreting outcomes. As such, findings from this study may not be generalizable to higher-risk populations, further underscoring the need for careful patient selection and context-specific interpretation of results.

Beyond patient selection, the safety and tolerability of nonabsorbable materials are also critical considerations in assessing feasibility. Concerns have been raised in the literature regarding the potential for chronic pain or foreign body sensation due to the chronic inflammatory response elicited by permanent materials [35]. In this study, no patients reported chronic pain or palpability related to mesh suture, as documented in the EMR. This favorable profile may reflect both the surgical technique (all knots were buried within the plication) and the device’s structural characteristics; under tension, mesh suture flattens to a ribbon-like configuration that conforms closely to tissue. Lastly, the mean operative time was approximately three hours, comparable to the senior author’s typical duration for abdominoplasty without mesh suture. Given that this time includes many concurrent procedures, the use of mesh suture did not appear to prolong operative time meaningfully and may offer a technically efficient solution in appropriate cases.

This was a single-center, retrospective study and therefore limited by its design. It is important to note that the mean BMI of this cohort was 26.6, reflective of a generally health population seeking aesthetic improvement. As such, findings may not be generalizable to higher-risk or higher-BMI populations commonly seen in the ventral hernia literature. All surgeries were performed by a single surgeon experienced with mesh suture; while this supports technical consistency, it may limit generalizability and introduces the possibility of expert bias. We acknowledge that a learning curve may exist for new users of mesh suture, though its handling is similar to standard suture. While 90-day SSI, SSE, readmission and reoperation rates were well-captured, the mean follow-up duration of less than one year is insufficient to fully assess long-term outcomes such as hernia recurrence or delayed mesh-related complications such as chronic infection. Notably recurrence often manifests beyond 18 months, and additional follow-up is needed to assess this outcome. Although not designed as a comparative study, this early experience provides feasibility and data to guide future prospective, ideally randomized trials comparing mesh suture to planar mesh or other standard techniques. Finally, we also recognize that some patients may seek care outside of the treating institution. To mitigate this, we utilized “Care Everywhere,” which provides visibility into external encounters for participating health systems; however, the scope is not universal. Longer-term follow up and larger studies will be required to more definitively evaluate the durability and broader application of mesh suture use in this study.