Key results and interpretation
According to results, PPAWI is a combination of morphological changes with the inclusion of back pain and social functioning disorders affecting a significant proportion of women after pregnancy. Sperstad in a large study of Norwegian women found that mild diastasis (2–3 fingers, ca. 5–6 cm) was found in 31% of women one year after delivery, and in 1%, the diastasis was moderate or severe (over 3 fingers) [
26]. Interestingly, in that study, none of the studied factors describing the pregnancy (age, height, weight and weight gain, baby’s birth weight or delivery mode) influenced the prevalence of RD. Other previous studies have shown similar results [
27]. Surgical treatment of RD does not have a consensus and options varies from simple suture plication to endoscopic or robot-assisted procedures and no approach shows superiority over others [
11,
28,
29]. Only double plication of diastasis has showed lower complication rate, still not increasing recurrence rate. The guidelines of the European and Americas Hernia Society for patients with RD and small concomitant umbilical or epigastric hernia recommended mesh placement instead of suture repair based on the high risk of recurrence in the sutured group [
30]. This recommendation has been given; however, it was not focused on PPAWI, and the quality of evidence is low. Although the Guidelines do not provide the solution to the questions, it is very important remark there is no consensus about treatment of RD and tailored approach and shared-decision process between patient and surgeon must be done [
31].
The choice of the technique in our study was based on various assumptions, which includes the fact that the subject of this non-life saving procedure are women with a long life expectancy. It forces to leave peritoneal cavity intact to prevent possible adhesions and not having negative impact on the function of the trunk. Prior IPOM publications showed the opposite, therefore IPOM procedure was abandoned [
32,
33].
The sublay technique requires opening the rectus sheath and involves a posterior layer of the rectus muscle in the inflammatory process of mesh ingrowth. In the past, onlay mesh was associated with seroma formation, but recently published data with the use of macroporous monofilament meshes did not confirm these findings [
30]. Knowing that thinning and stretching of the linea alba is an important risk factor for actual development of midline hernias (umbilical, epigastric, trocar, incisional hernia) due to the deterioration of the connective tissue and the pulling of the abdominal muscles [
16] and to compare the procedure with other surgical techniques, the mesh is used for the prevention of future RD recurrences and hernia formation.
In this paper, the authors assessed the value of the onlay mesh approach with full abdominoplasty and its impact on physical functioning and social and sexual life, as well as on the self-esteem of the treated women. We demonstrated that simultaneous single midline plication with onlay mesh and abdominoplasty is a safe, feasible, fast, and in our opinion, less tissue damaging method for PPAWI treatment. It should be recognized that there are no long-term results comparing onlay and retromuscular mesh in women with PPAWI or IPOM or endoscopic techniques versus open ones. On the other hand, the follow-up protocols are concentrated on widely accepted end points of the studies, including short-term complications such as seroma or infection and long-term recurrence. The authors believe that tailored approach should be considered when non life-saving procedures in women after pregnancy are proposed to improve their shape and quality of life.
We did find only few previously published papers describing psychological, sexual and social problems in the context of belly deformation or about the possible impact of the operation on these aspects of life, although they were focused on the impact of RD of various origin alone [
1,
3‐
9]. Olsson showed significant improvement in the SF-36 questionnaire one year after surgery and Temel showed that operation reduces significantly depression signs assed with BDI scores [
6,
9].
Limitations and strength of this study
This study has limitations. The inclusion criteria were restricted to symptomatic PPAWI and patients looking for surgical intervention, so the results may not be applicable to all PPAWI cases. The patients were qualified for surgery a minimum of 6 months after delivery, but it was not checked in the protocol if they had had sufficient physiotherapy before the surgery, simply accepting the patient statement. The protocol assessed only a few areas of human well-being because it was based on interviews with PPAWI patients. That is why other potentially important areas of mental health could be missing in this study. The protocol is also not validated to the general population of women after delivery. It is based on authors experience and does not have any similar ones in the literature. We have decided to apply this protocol in the study to show the importance of psycho-sexual factors on the well-being of described women population. We found that protocols validated for measuring impact of RD or hernia operations does not fully apply in this specific situation. That is why authors believe that creating and conducting fresh questionnaire for newly described phenomena is a strong element of this study.
On the other hand, this study was performed by an experienced team, and the surgical procedure was performed by one surgeon with over 20 years of experience in large ventral hernia repair. Compared to the other published studies on this topic, it is based on a relatively large heterogeneous group of patients, which makes its findings more valuable. It has also been proven that there is no necessity for the presence of plastic surgeons during the operation. In our opinion personal training in the procedure showed to be sufficient for general surgeon. The study team included female secretaries, and the anaesthesiologists were also women, which possibly bridges the divide in the interview touching on personal areas of the patient. To our knowledge, this is the first study assessing the impact of surgery on chosen behavioural areas in women’s lives. In light of this study, it must be pointed out that PPAWI is a complex pathology not expected as a consequence of pregnancy but resulting in long-lasting deformation. Struggling to raise a child while suffering from a loss of self-esteem leads to a decreased quality of life and social problems. Findings from this study shows that morphological changes (extended skin with panniculus and/or visible striae gravidarum) and coexisting small hernia (umbilical or linea albae) are also key problem in women after pregnancy. In the questionnaire for psychological assessment, most of the women reported a strong influence of PPAWI on back pain, social functioning, self-esteem and sexual life (Table
3). In the descriptive assessment (collected as comments), the most frequently noted problems were at the beach or swimming pool, the necessity of changing the style of dressing (can only wear sac-like clothing), being treated as pregnant again (e.g., on public transport or in the office) and stress during sexual activity independent of the type of partner (in a long-term relationship or a brand new one). Another conclusion coming from this study shows that umbilical hernia is present in most cases and should also be included in the description of PPAWI. This also revalidate what Kohler et al. previously stated [
34].
Generalizability
PPAWI is not only a morphological pathology but also or even mainly a psychological disorder leading to social exclusion. It must also be noted that in many countries (including the authors’ country of origin), asking for treatment for PPAWI is shamed and thought of as a whim. Describing the psychological and social consequences of PPAWI should lead the surgical societies to propose a definition of a new disease called PPAWIS (post-partum abdominal wall insufficiency syndrome). Further study should be conducted with the participation of psychologists and sexologists to gain more extended knowledge about the phenomena. Changing the definition (from PPAWI to PPAWIS) can also lead to different perceptions of the problem. We should appreciate how much a simple and safe procedure can change the life of thousands of patients. In the majority of the human population, discussions about the need for treatment can make it easier for women, while science will deliver arguments for it.