Abdominal separation operation expert Reinpold
Your specialized center for hernia treatment

Diastasis recti: surgery yes or no?

Diastasis recti surgery – where can I find help in Hamburg? What exactly is a diastasis recti? When do exercises help, when should surgery be performed? Why does diastases recti often occur together with an abdominal wall hernias?

At the Hamburg Hernia Center, we will answer your questions – first with the following summary as well as gladly in person at our practices.

Diastasis recti: 3 reasons for our hernia center

  • If your diastasis recti requires surgery, with us you will meet only proven specialists.
  • Together, our team of physicians looks back on a worldwide unique experience of 30,000 operations – in addition to hernias, we also treat diastases recti in very large numbers.
  • At our locations throughout Hamburg, we are there for you throughout the entire course of treatment – from the preliminary consultation, to the possible surgery and aftercare.

Beforehand in a nutshell

How are diastases recti detected?
A diastasis recti – i.e. the separation of the straight abdominal muscles – can be easily palpated, especially when lying down. Ultrasound can be used to precisely measure and confirm a diastasis recti.

Is a diastasis recti dangerous?
There is a health risk if diastases recti are accompanied by abdominal wall hernias, which can lead to incarceration of intestines, among other things. Very large diastases recti after multiple pregnancies can also cause significant health problems.

When does a diastasis recti require surgery?
Very large diastases recti after multiple pregnancies can severely affect patients’ health and require surgery for medical reasons. In addition, surgery is usually advisable if hernias with a risk of incarceration occur at the same time – both in women and men.

Diastasis recti: particularly common after pregnancy

A diastasis recti is a sagging of the abdominal wall, which occurs particularly in women as a result of pregnancy and frequently after several pregnancies. To create space in the abdominal cavity, the straight abdominal muscles move apart. A gap develops in the middle of the abdomen, which can vary in severity.

After childbirth, targeted exercises very often help in the regression of diastasis recti. Especially after several pregnancies, however, the cleft may be so pronounced that involutional gymnastics and other conservative measures are not successful.

Depending on the severity, diastases recti can then bring medical symptoms as well as physical and also psychological distress.

Symptoms and consequences of a pronounced diastasis recti can be

  • Impairment of abdominal press, difficulty in going to the toilet and resulting bowel problems.
  • Back pain due to the overload of the back muscles
  • Excess skin, sometimes to a massive extent
  • Visual impression of continuing pregnancy even long after birth

Diastasis recti surgery? The severity decides

When is surgery advisable for diastases recti? In order to assess this objectively and transparently for those affected, abdominal wall specialists, with the participation of physicians from the Hamburg Hernia Center, have created a classification of diastasis recti. The width of the scissure, the position of the diastasis recti and the texture of the skin are assessed. In addition, the number of previous pregnancies and any additional existing hernias are important criteria.

A pronounced diastasis recti can be easily palpated, especially when the patient is lying down. However, in order to clearly classify a diastasis recti and to provide a well-founded answer to the surgical question, ultrasound is the tool of choice.

In the following, we distinguish diastases recti according to three degrees of severity. From a medical point of view, surgery should only be considered from a second-degree diastasis recti (wider than 3cm) and even then requires careful consideration. Often a gentle minimally invasive procedure is possible and useful – even if additional abdominal wall hernias are present. At the Hamburg Hernia Center, we rely on MILOS or eMILOS surgery in these cases. This very gentle endoscopic surgical method was developed by our head physician Dr. Wolfgang Reinpold and team in Hamburg and has now established itself worldwide.

In case of very severe manifestation (degree 3, gap width 5 cm and more), a combined procedure performed jointly by abdominal wall specialists and plastic surgeons is recommended. In both procedures, any hernias should be treated in the same procedure.

Abdominal separation diagnostics symptoms Reinpold
Classification according to severity: Ultrasound shows the extent and position of a diastasis recti.

Diastasis recti degree 1: no need for surgery

In first-degree diastases recti, the gap between the two straight abdominal muscles measures less than 3 cm. There is no or hardly any excess skin. Surgery is not advisable for this minor expression of diastases recti.

We recommend conservative measures such as targeted exercises with strengthening especially of the oblique abdominal wall muscles in the sense of postnatal gymnastics. It is important to do adapted training, classic abdominal exercises such as sit-ups tend to aggravate the problem. Specific exercises to regress diastases recti may be useful therapy when combined with neuromuscular electrical stimulation (NMES), if appropriate.

Diastasis recti degree 2: eMILOS surgery with tiny incisions

In the case of a second-degree diastasis recti (gap width 3 to 5cm), surgery may be considered – especially if the patient suffers from health impairments and/or there are additional abdominal wall hernias. This is not uncommon, as a diastasis recti is a weak point of the abdominal wall and the risk of hernias is correspondingly greater here.

In our hernia center in Hamburg, we primarily rely on endoscopic eMILOS surgery developed in Hamburg by our head physician Dr. Wolfgang Reinpold for second degree diastases recti – with or without an additional abdominal wall hernia.

This variant of diastasis recti surgery requires only a very small incision. The abdominal wall is stabilized with a synthetic mesh and any hernias are closed in the same procedure.

Learn more about our E/MILOS Center

The gap between the straight abdominal muscles can additionally be sewed together endoscopically under the skin. With the gentle eMILOS surgery, a functionally and aesthetically very convincing result can be achieved for the medium-sized form of diastasis recti without a large amount of excess skin.

If abdominal surgery with mesh insertion is necessary, many women fear complications with a possible further pregnancy. A common concern is that the synthetic mesh may tear during another pregnancy. Our experience: The synthetic meshes are resilient. At least smaller meshes are not problematic even if the desire to have children continues, so that eMILOS surgery can be considered in this case.

Abdominal separation operation expert Niebuhr Dag Berger
Diastasis recti – what to do? From a medical point of view, surgery is only advisable from the second degree of severity.

Diastasis recti degree 3: combined surgery with abdominoplasty

In third-degree diastases recti, there is a gap of more than 5 cm between the two straight abdominal muscles, and in many cases the gap is even much larger. There is almost always a significant amount of excess skin with such a substantial diastasis recti.

In these cases we, at the Hamburg Hernia Center, rely on the cooperation with plastic surgeons – and work here with long-standing partners. Within the framework of a complex combined surgery, the diastasis recti can be corrected and the abdominal wall can be additionally tightened.

The task of abdominal wall surgeons in this combined procedure is to reconstruct and strengthen the deep abdominal wall layers. Plastic surgeons then tighten the sagging abdominal wall and skin.

Combined surgery for diastasis recti: Preparation

Important to know for those affected: The so-called hybrid surgery – i.e. surgery of the diastasis recti with simultaneous abdominoplasty – is a major operation. We advise our patients in any case to inform themselves in advance about the possibilities, risks as well as the costs and to prepare well for the surgery.

At the Hamburg Hernia Center, we offer joint consultation hours with our plastic surgery colleagues – ideally with the involvement of the life partners or spouses of the affected women. Such an operation is a far-reaching decision that couples should make together. As such, the question of further family planning is always on the agenda in our consultation hours. If possible, we recommend the major procedure only when there is no longer a desire to have children. This is because even if further pregnancies are theoretically possible after surgery, it is not advisable to stretch the previously tightly reconstructed abdominal wall again.

Diastasis recti surgery with abdominoplasty: Procedure

The combined form of diastasis recti surgery with abdominoplasty requires a cross-section from pelvic bone to pelvic bone. Then the skin and subcutaneous tissue are first completely detached from the underlying inner abdominal wall. The inner abdominal wall layer is exposed and in the next step the abdominal wall layers are gathered and stabilized with the help of a synthetic mesh. The abdominal skin above is adapted to the now stabilized inner abdominal wall by the plastic surgeon. Even for the largest form of diastasis recti, a functionally and aesthetically convincing result can be achieved with this surgery – however, a healing process of a about eight weeks should be expected.

What happens after the operation?

Diastasis recti surgery with abdominoplasty involves an inpatient stay of six to eight days. Immediately after surgery, the patient is mobilized. To prevent the accumulation of fluids, the patient must wear an abdominal bandage – for a period of six to eight weeks. Afterwards, the full load is usually possible again.

Diastases recti and abdominal wall hernias

A diastasis recti is equated by many sufferers with an abdominal wall hernia. However, we only speak of hernias when there are holes or tears in the abdominal wall. A diastasis recti, on the other hand, is “only” a gap that is caused by overstretching of the straight abdominal muscles. Similar to a hernia, however, in pronounced cases there may be saccular protrusion of the intestine and thus bowel movements visible from the outside.

So even though they are different diagnoses, diastases recti are often accompanied by hernias. For example, umbilical herniasor upper abdominal hernias, also called epigastric hernias, often occur in association with diastases recti. In some cases, there are also entire rows of small tears in the abdominal wall of the upper abdomen, which doctors then refer to as swiss cheese hernias.

The explanation for the common occurrence of diastases recti and abdominal wall hernias is obvious: Due to the gap between the straight abdominal muscles, the abdominal wall is weakened and correspondingly more susceptible to the occurrence of hernias under stress – for example, due to the additional pressure during pregnancy.

If the diastases recti is accompanied by abdominal wall hernias, these are treated together– in both surgery types: the major operation and in the minimally invasive MILOS operation. However, as a rule, the hernias occurring with diastases recti are comparatively small and do not cause abdominal wall dysfunction. Accordingly, the sole treatment of possible hernias without simultaneous treatment of diastases recti is not effective, at least in younger women.

Diastases recti in men

Since diastases recti in connection with pregnancy are particularly common, it is primarily women who are affected. However, diastases recti can also occur in men – predominantly overweight patients of advanced age are affected. In male patients, however, a diastasis recti is a much less frequent reason for surgery than in women. Symptoms or dysfunction rarely occur in men and the diastasis recti is a predominantly aesthetic problem.

With certain movements, e.g. during abdominal exercises, the diastasis recti can still be clearly visible and is therefore often mistaken for a large hernia. But in men, additional hernias rarely occur in association with diastases recti. Therefore, surgery is required only in very few cases.