Methods
Search strategy
((((((((((((diastasis[All Fields] AND recti[All Fields]) OR (rectus[All Fields] AND diastasis[All Fields])) OR (diastasis[All Fields] AND (“rectus abdominis”[MeSH Terms] OR (“rectus”[All Fields] AND “abdominis”[All Fields]) OR “rectus abdominis”[All Fields]))) OR (diastasis[All Fields] AND recti[All Fields])) OR ((“abdomen”[MeSH Terms] OR “abdomen”[All Fields] OR “abdominal”[All Fields]) AND diastasis[All Fields])) OR ((“abdomen”[MeSH Terms] OR “abdomen”[All Fields] OR “abdominal”[All Fields]) AND (“divorce”[MeSH Terms] OR “divorce”[All Fields] OR “separation”[All Fields]))) OR (diastasis[All Fields] AND recti[All Fields] AND abdominis[All Fields])) OR ((“divorce”[MeSH Terms] OR “divorce”[All Fields] OR “separation”[All Fields]) AND recti[All Fields])) OR ((“divorce”[MeSH Terms] OR “divorce”[All Fields] OR “separation”[All Fields]) AND (“rectus abdominis”[MeSH Terms] OR (“rectus”[All Fields] AND “abdominis”[All Fields]) OR “rectus abdominis”[All Fields]))) OR (diastasis[All Fields] AND rectus[All Fields] AND abdominus[All Fields])) OR (divarication[All Fields] AND recti[All Fields])) OR (divarication[All Fields] AND rectus[All Fields] AND abdominus[All Fields])) OR (divarication[All Fields] AND (“rectus abdominis”[MeSH Terms] OR (“rectus”[All Fields] AND “abdominis”[All Fields]) OR “rectus abdominis”[All Fields]))) |
Outcome definition and study selection criteria
Quality assessment
Data abstraction
Results
Surgery
Plication techniques
Author (year of publication) | Study period | Type of study | Population | Intervention | Primary and secondary outcome | Complications and/or results | Follow-up period (Method) | Recurrence rate % | Study quality | |||
---|---|---|---|---|---|---|---|---|---|---|---|---|
N = … | Age (years) | BMI (Kg/m2) | Type of DRAM* | |||||||||
Plication | ||||||||||||
Shirah, B.H. (2016) | 2004–2013 | Case series | 216 | 40.9 | 26.4 | NR (mean IRD 10 cm) |
Open repair with plication of posterior rectus fascia and sublay polypropylene mesh (n = 179).
Laparoscopic repair with midline plication with continuous suture and intra-abdominal polypropylene mesh (n = 37). | Recurrence rate, postop. complications, abdominal wall function, cosmetic outcome |
Open:
Wound infection (n = 11) 6.1% Seroma (n = 9) 5% Hematoma (n = 5) 2.8% Cosmetic (exc/good 95,6%, unsatis. 4,4%)
Laparoscopic:
Pain (n = 4) 10.8% Cosmetic (exc/good 91,2%, unsatis. 8,1%)) | 24 months (CT+ clinical examination) | 0% | 7/16 |
Sahoo, M.R. (2014) | NR | Case series | 3 | 35–45 | NR | A, B | Laparoscopic midline plication with interrupted sutures and intra-abdominal mesh reinforcement. | Recurrence rate, postop. complications | Pain and tightness of abdomen observed (no specification), which decreased during follow-up. | 12 months (NR_ | 0% | 5/16 |
Siddiky, A.H. (2010) | NR | Case report | 1 | 38 | NR | B | Laparoscopic midline plication with interrupted mattress sutures without mesh reinforcement. | Recurrence rate, postop. Complications | Postoperative pain and ileus described, delayed discharge after 5 days. | 8 weeks (NR) | 0% | 4/16 |
Palanivelu, C. (2009) | 1998–2007 | Case series | 18 | 42 | 28.2 | A, B, D | Laparoscopic midline plication with interrupted venetian blinds sutures and mesh reinforcement. | Recurrence rate, postop. complications | Pain (n = 2) 11.1% Pneumonia (n = 1) 5.5% Chronic pain(n = 2) 11.1% | 6–48 months (CT) | 0% | 7/16 |
Nahas, F.X. (2004) | NR | Case report | 2 | 38 & 59 | NR | C | Open midline plication of the posterior rectus sheath with interrupted sutures, and anchoring of the anterior rectus fascia to the posterior rectus fascia in the midline. | Recurrence rate, postop. complications | Uneventful recovery and satisfactory cosmetic results. | Case 1: 30 months (CT) Case 2: 6 months (CT) | 0% | 4/16 |
Deryugina, M.S. (2001) | NR | Case series | 73 | 45.9 | NR | NR | Open repair with midline plication of the linea alba using interrupted sutures mesh sublay reinforcement fine-pored woven Lavsan tape. | Recurrence rate | Missing | 1–11 years (NR) | 4% (n = 3) | 4/16 |
Modified hernia repair method | ||||||||||||
Angio, L.G. (2007) | NR | Case series | 12 | 43 | NR | NR | Open modified Chevrel technique without entering the abdominal cavity. Midline plasty with onlay mesh reinforcement. | Recurrence rate, cosmetic result, postop. complications | Seroma (n = 3) 7.0% | 24 months (12 months = CT, 18 and 24 months = clinical examination) | 0% | 8/16 |
Gireev, G.I. (1983, 1994, 1997)!
| 1980–1989 | Case series | 56 | NR | NR | NR | Open modified Rives–Stoppa repair without mesh reinforcement. | Recurrence rate, work impairment, pain | 9 short-term complications, no work impairment 71.4%, moderate impairment 16%, and severe impairment 0%. | 24 months (NR) | 0% | 3/16 |
Combined (hernia and DRAM) | ||||||||||||
Privett, B.J. (2016) | 2013-2015 | Case series | 58 | NR | NR | NR (hernia <4 cm) | Open repair of DRAM with small umbilical hernia. Small umbilical incision and preperitoneal placement of self-adhesive mesh. | Recurrence rate, postop. complications | No postop. complications | NR (NR) | 1.7% (n = 1) | 3/16 |
Köckerling, F. (2016) | 2015-2016 | Case series | 40 | 53.6 | 32.6 | NR | ELAR plus for DRAM with umbilical or epigastric hernia. Endoscopic-assisted anterior rectus fascia turn over with mesh augmentation resembles a hybrid version of the modified Chevrel technique with only a small umbilical incision. | Postop. complications | Umbilical necrosis (n = 1) 2.5% Impaired wound healing (n = 1) 2.5% Seroma (n = 1) 2.5% Intermittent pain on exertion (n = 3) 7.5% | NA | NA | 4/16 |
Bellido L.A. (2015) | 2011-2012 | Prospective cohort study | 21 | 37.6 | 27.4 | A, B, C, D (hernia ≥2 cm) | DRAM with umbilical or epigastric hernia ≥2 cm. Endoscopic, subcutaneous, midline plication with V-lock suture, and onlay mesh reinforcement. | Recurrence rate, postop. complications, cosmetic appearance, pain (VAS) | Seroma in suprapubic area (n = 5) 23% Subcutaneous emphysema (n = 2) 9% | 20 months (US + clinical examination) | 0% | 11/16 |
Matei, O.A. (2014) | 2010–2012 | Case series | 44 | 60.2 | 31.2 | NR | Open repair with small umbilical hernia with Rives–Stoppa repair combined with sublay mesh placement. | Postop. complications | Minimal umbilical necrosis (n = 1) | NR | NA | 3/16 |
Yurasov, A.V. (2014) | 2006–2013 | Case series | 374 degree I: n = 174 degree II: n = 162 degree III: n = 38 | NR | NR | NR | Open Rives–Stoppa like repair for DRAM with umbilical hernia with sublay mesh placement continuous suturing of the posterior and anterior rectus fascia. The abdominal cavity is not opened. | Postop. complications |
group I: complication rate 2.5% (Hematoma of subcutaneous fat n = 1(1.2%) Ileus n = 1 (1.2%))
group II: complication rate 5.4%(Wound infection n = 1 (1.3%) Hematoma of subcutaneous fat n = 2 (2.7%) Ileus n = 1 (1.3%))
group III: complication rate 5% (Hematoma of subcutaneous fat n = 1 (5%)) | NR | NA | 5/16 |
Ranney, B. (1990) | NR | Case series | 673 | NR | NR | A, B (umbilical hernia) | Open midline plication of DRAM with umbilical hernia. Plication of posterior rectus fascia, and continuous suturing of the rectus muscles and anterior rectus fascia. | Recurrence rate, wound dehiscence | Wound dehiscence not observed. | 14.8 years (av) 67.28% of patients (clinical examination) | 0% | 5/16 |
Techniques
Results of plication techniques
Modified hernia repair techniques
Results of hernia repair techniques
Techniques for combined repair of DRAM and small midline hernia
Results of combined repair DRAM and midline hernia
Physiotherapy
Author (year of publication) | Type of study | Population | Intervention | Outcomes | Follow-up period (Method for IRD assessment) | Results | Study quality | |||
---|---|---|---|---|---|---|---|---|---|---|
N = … (time postpartum) | Age (years) | BMI (Kg/m2) | Type of DRAM* | |||||||
Walton, L.M. (2016) | RCT (physiotherapy vs. physiotherapy) | 8 (3 months–3 years postpartum) | 32.0 | 27.4 | A and B |
Traditional group: supine strengthening exercise
Experimental group: Core stabilisation including plank, posterior pelvic tilt, kegel, and Russian twist exercises. | IRD PFDI and ODI Disability scores | 1.5 months (US & dial caliper, 2 cm above/below umbilicus) | Both groups showed IRD decrease, though traditional therapy showed greater IRD reduction (10.97 to 6.63 cm), PFDI scores did not improve. | JADAD score: 7/13 Cochrane risk of bias tool: (see Table 4) |
Frequency: 3× per week, during 6 weeks (18 sessions) | ||||||||||
Emanuelsson, P. (2016) | RCT (abdominoplasty vs physiotherapy) | 30 (1 year postpartum) | 44.2 | 22.8 | A & B | Rectus abdominis, Internal/external oblique, and transvers abdominal muscle strengthening exercises | Pain, QoL (SF-36) Muscle strength (Biodex 4) | 3 months (NA) | Eighty-seven percent or patients dissatisfied with training results due to continued bulging and functional disability. | JADAD score: 11/13 Cochrane risk of bias tool: (see Table 4) |
Frequency: 3× per week, during 12 weeks (36 sessions) | ||||||||||
Khandale, S.R. (2016) | Prospective uncontrolled trial | 30 (NR) | 21.7 | 23.1 | A and B | Head lift, pelvic lock, plank, superman, and double leg raise | IRD | 2 months (dial caliper & palpation during muscle contraction, 2 cm above/below umbilicus) | IRD decrease above (25.3 mm to 21.9 mm) and below umbilicus (21.9 mm to 19.0 mm) (p < 0.0001). | MINORS: 6/16 |
Frequency: 5x per week, 30 min per day, during 8 weeks (40 sessions) | ||||||||||
Acharry, N. (2015) | Prospective uncontrolled trial | 30 (≤1 month postpartum) | 28.8 | NR | A and B | Head lift, pelvic tilt, and pelvic clock with bracing | IRD | 2 weeks (palpation at umbilicus) | IRD decrease from 3.5 fingerbreadths to 2.5 fingerbreadths (p < 0.001). | MINORS 7/16 |
Frequency: 2× per day, during 2 weeks (4 sessions) | ||||||||||
Litos, K. (2014) | case report | 1(7 weeks postpartum) | 32 | 21.6 | A | Core stabilisation exercise and strengthening hip and trunk muscles. | IRD, PSFS & pain scores | 4 months (palpation and tape measure during muscle contraction, 4.5 cm above/below umbilicus) | IRD decrease from 11.5 cm to 2.0 cm. Improvement of PSFS score from 4/30 to 30/30. | MINORS: 9/16 |
Frequency: 1–2× per week, during 16 weeks (18 sessions) | ||||||||||
Sheppard, S. (1996) | Case report | 1 (2 years postpartum) | NR | NR | A or B | Prone kneeling (trans abdominis rehabilitation) | IRD | 4 months (tape measure during muscle contraction, location not described) | IRD decrease from 60 mm to 7 mm. | MINORS: 8/16 |