What is the treatment for abdominal wall diathesis?

Treatment for Abdominal Wall Diathesis

The primary treatment for abdominal wall diathesis is surgical repair, with component separation technique being a useful and low-cost option for large midline abdominal wall defects. 1

Understanding Abdominal Wall Diathesis

Abdominal wall diathesis refers to a weakness or separation in the abdominal wall muscles, particularly the rectus abdominis muscles (rectus diastasis). This condition can result from:

• Congenital weakness
• Pregnancy
• Obesity
• Previous surgeries
• Aging

Diagnostic Approach

Before treatment, proper evaluation is essential:

• CT imaging is the preferred modality to determine:
  • Precise size and location of the defect
  • Presence of rectus diastasis and/or muscle atrophy
  • Proportion of the defect relative to the abdominal wall 2
  • Associated hernias or complications

Treatment Options

Non-Surgical Management

Non-surgical approaches are generally limited and may include:

• Core strengthening exercises (for mild cases)
• Abdominal binders/supports (temporary relief)

Surgical Management

1. Primary Fascial Closure

   • Ideal solution to restore abdominal closure for smaller defects 1
   • Recommended when the risk of excessive tension is minimal

2. Component Separation Technique (CST)

   • Highly recommended for large midline abdominal wall defects (Grade 1B) 1
   • Based on enlargement of abdominal wall surface by translation of muscular layers
   • Preserves muscle innervation and blood supply
   • Variants include:
     • Anterior component separation (ACS/Ramirez technique)
     • Posterior component separation (PCS)
     • Transversus abdominis release (TAR) 3

3. Mesh-Mediated Repair

   • For clean surgical fields (CDC wound class I):

     • Synthetic mesh is recommended (Grade 1A) 1
     • Associated with lower recurrence rates compared to tissue repair

   • For contaminated fields:

     • Non-cross-linked biologic meshes preferred in sublay position when linea alba can be reconstructed (Grade 2B) 1
     • Cross-linked biologic meshes may be used in fascial-bridge position with less ventral hernia recurrence (Grade 2B) 1
     • Synthetic mesh should be avoided in contaminated fields 1

4. Progressive Closure

   • For cases where early definitive closure is not possible
   • Abdomen is incrementally closed during surgical revisions

5. Planned Ventral Hernia

   • Skin graft or skin-only closure remains an option for complicated cases (Grade 2C) 1
   • Subsequent eventration can be managed later with delayed closure and synthetic mesh repair (Grade 1C) 1

Special Considerations

For Unstable Patients

• Open management is recommended to prevent abdominal compartment syndrome (Grade 2C) 1
• Intra-abdominal pressure may be measured intraoperatively
• Following stabilization, attempt early definitive closure of the abdomen

For Contaminated Fields

• Primary repair is recommended when defect size is small (<3 cm) (Grade 2C) 1
• When direct suture is not feasible, biological mesh may be used
• If biological mesh is unavailable, polyglactin mesh or open wound management with delayed repair are alternatives

Outcomes and Follow-up

Recent studies show significant improvement in quality of life and abdominal wall functionality after proper reconstruction:

• Abdominal wall function scores improve significantly post-repair
• Quality of life metrics show substantial improvement at 12 months post-surgery 4
• Improvement depends on hernia size and individual patient factors (diabetes, cardiovascular disease, age)

Potential Complications

• Recurrence (up to 38.7% reported after component separation) 1
• Wound infection
• Seroma formation
• Mesh-related complications (adhesions, erosions, fistula formation)
• Abdominal compartment syndrome

Conclusion

The treatment of abdominal wall diathesis requires a structured approach based on the size of the defect, patient stability, and field contamination. Component separation technique is particularly valuable for large defects, while mesh-mediated repair should be selected based on the surgical field classification.