What are the treatment options for diastasis recti?

Treatment of Diastasis Recti

Physiotherapy with structured abdominal core strengthening exercises is the first-line treatment for diastasis recti, and surgical repair should only be considered after a standardized 6-month exercise program has failed in patients with functional impairment and diastasis width ≥5 cm. 1

Initial Conservative Management

Diagnostic Confirmation

• Diagnosis should be made at clinical examination using a caliper or ruler to measure the inter-recti distance 1
• Ultrasound imaging should be performed when concurrent umbilical or epigastric hernia cannot be excluded clinically 1
• The condition involves separation of the rectus abdominis muscles with widening of the linea alba, commonly occurring during pregnancy and postpartum 2, 3

Exercise-Based Treatment (First-Line)

• All patients must undergo a rigorous 6-month standardized abdominal core training program before surgical consideration 1
• Targeted abdominal and core strengthening exercises are the primary intervention 2, 4
• Evidence suggests exercise during the antenatal period can reduce the presence of diastasis recti by 35% (RR 0.65,95% CI 0.46 to 0.92) 4
• Exercise may reduce diastasis width during both ante- and postnatal periods, though the quality of evidence is limited 4

Surgical Management

Indications for Surgery

Surgery should only be considered when ALL of the following criteria are met:

• Diastasis width ≥5 cm at its largest measurement 1
• Documented functional impairment affecting quality of life 1
• Failed 6-month standardized physiotherapy program 1
• At least 2 years elapsed since last childbirth 1
• No future pregnancy planned 1

Exception: Surgery may be considered with diastasis <5 cm if there is pronounced abdominal bulging or concomitant ventral hernia 1

Surgical Techniques

Open Approach

• Plication of the linea alba is the first-choice surgical technique 1
• Both open and laparoscopic approaches demonstrate high success rates with low recurrence and complication rates 2
• Surgical repair improves low back pain, urinary incontinence, and quality of life 2

Endoscopic/Laparoscopic Approach

• Preaponeurotic endoscopic repair (REPA) can be performed with suprapubic and bilateral iliac fossa approaches 5
• The technique involves creating a preaponeurotic cavity, performing recti plication with barbed suture, and reinforcing with polypropylene mesh 5
• This approach avoids entering the abdominal cavity and shows excellent outcomes with 96% patient satisfaction, no recurrences at 3 years, and average return to activities in 16.5 days 5
• External oblique release may be needed in approximately 32% of cases 5

Surgical Outcomes

• Average surgical time is approximately 83 minutes for endoscopic repair 5
• Seroma formation occurs in approximately 12% of cases 5
• Average hospital stay is 1.3 days with pain levels of 3/10 5
• Complications are minor when they occur, with low recurrence rates for both open and laparoscopic approaches 2

Common Pitfalls and Caveats

• Many patients are referred for surgery without completing an adequate trial of conservative therapy - ensure the full 6-month structured exercise program is completed 1
• Evidence on specific physiotherapy regimens is sparse, and success rates are not well-defined in the literature 2
• The correlation between anatomical correction and symptom improvement can be weak, emphasizing the importance of careful patient selection 6
• Surgery should not be performed if future pregnancy is planned, as recurrence risk is high 1
• Robotic-assisted surgery is emerging but lacks sufficient data for routine recommendation 2