What is the relationship between divarication of recti (separation of abdominal muscles) and umbilical hernia?

Relationship Between Divarication of Recti and Umbilical Hernia

Divarication of recti (rectus muscle separation) and umbilical hernia frequently coexist, with umbilical hernias developing in approximately 20% of patients with weakened abdominal muscles, creating a higher risk of hernia recurrence following repair. 1

Pathophysiological Connection

• Divarication of recti occurs when the linea alba thins and stretches, causing separation of the rectus abdominis muscles 2
• This weakening of the abdominal wall predisposes patients to umbilical hernia formation due to:
  • Increased abdominal pressure
  • Weakened abdominal muscles
  • Compromised structural integrity of the midline 1, 3
• The connection is particularly common in postpartum patients who often present with both conditions simultaneously 4

Clinical Implications

Diagnosis

• Physical examination reveals:
  • Visible midline bulge (divarication)
  • Palpable fascial defect at the umbilicus (hernia)
  • Increased prominence with Valsalva maneuver
• Imaging studies (ultrasound or CT) can confirm the diagnosis and measure:
  • Width of rectus muscle separation
  • Size of umbilical hernia defect
  • Presence of hernia contents

Surgical Management Considerations

When both conditions coexist, special surgical considerations apply:

1. Higher recurrence risk: Patients with divarication and umbilical hernia have weak abdominal musculature and pose a higher risk of recurrence following umbilical hernia repair alone 3

2. Combined repair approach:

   • For small umbilical hernias (<4 cm) with rectus divarication, extending mesh reinforcement to address both conditions is recommended 3
   • Self-adhesive mesh techniques can avoid extensive suture fixation in the superior abdomen 3

3. Mesh selection and placement:

   • Synthetic non-absorbable mesh for clean fields
   • Biologic or biosynthetic meshes for contaminated fields
   • Mesh overlap of 1.5-2.5 cm is recommended 5
   • Retromuscular (sublay) mesh placement has shown good outcomes 6

4. Technique options:

   • Laparoscopic approach for stable patients with adequate visualization
   • Open repair with mesh reinforcement for larger defects
   • Combined abdominoplasty with hernia repair in selected cases 4, 7

Outcomes and Complications

• Recurrence rates: May be as high as 40% when divarication is not addressed during umbilical hernia repair 2
• Common complications:
  • Seroma formation (most common)
  • Hematomas
  • Wound infections
  • Skin necrosis
  • Nerve damage 2

Key Considerations for Management

1. Recognize the association: Always assess for divarication when evaluating umbilical hernias

2. Surgical planning: Consider addressing both conditions simultaneously when they coexist

3. Technique selection:

   • For small umbilical hernias (<4 cm) with divarication: Consider extended mesh repair 3
   • For larger defects: Consider retromuscular mesh placement 6
   • For patients with cosmetic concerns: Consider combined functional and aesthetic approaches 4, 7

4. Postoperative care:

   • Monitor for seroma formation
   • Appropriate pain management
   • Activity restrictions to prevent recurrence

The evidence clearly demonstrates that divarication of recti and umbilical hernia have a significant association, and addressing both conditions simultaneously during surgical repair leads to better outcomes and reduced recurrence rates.