When is surgical consultation needed for diastasis recti (separation of abdominal muscles)?

When Surgical Consultation is Needed for Diastasis Recti

Surgical consultation for diastasis recti should be considered only after a mandatory 6-month standardized abdominal core training/physiotherapy program has failed, and only when the inter-rectus distance is at least 5 cm with documented functional impairment. 1

Initial Conservative Management (First-Line Treatment)

• Physiotherapy is the mandatory first treatment step for all patients with diastasis recti before any surgical consideration 2, 1
• Patients should avoid abdominal strengthening exercises (such as abdominal curls) during pregnancy and early postpartum, as these may worsen the condition and increase the likelihood of requiring postnatal repair 3
• Continuing aerobic exercise such as walking is associated with decreased odds of developing diastasis recti 3
• A standardized 6-month abdominal core training program must be completed before surgery is even considered 1

Criteria for Surgical Consultation

Absolute prerequisites that must ALL be met:

• Inter-rectus distance ≥5 cm at the widest point measured clinically with a caliper or ruler 1
• Documented functional impairment (not cosmetic concerns alone) after completing 6 months of physiotherapy 1
• At least 2 years elapsed since last childbirth with no future pregnancy planned 1
• Failed conservative management with persistent symptoms affecting quality of life 2, 1

Exceptions where smaller diastasis may warrant surgical consultation:

• Pronounced abdominal bulging with significant functional limitation 1
• Concomitant umbilical or epigastric hernia requiring repair 1
• Persistent symptoms including lower back pain, urinary incontinence, or significant discomfort despite conservative treatment 2

Diagnostic Workup Before Surgical Referral

• Clinical examination with caliper or ruler measurement of the inter-rectus distance 1
• Ultrasound or other imaging modality should be performed when concurrent umbilical/epigastric hernia or other causes of symptoms cannot be excluded 1
• Document specific functional impairments: pain, musculoskeletal problems, urogynecological symptoms, or impaired quality of life 2

Important Clinical Pitfalls

• Do not refer for surgery based on cosmetic concerns alone - functional impairment must be documented 1
• Do not bypass the mandatory 6-month physiotherapy trial - evidence shows physiotherapy is effective as first-line treatment, though optimal regimens need further study 2, 1
• Do not operate if future pregnancy is planned - wait at least 2 years after last childbirth 1
• Do not refer patients with inter-rectus distance <5 cm unless there is pronounced bulging or concomitant hernia 1
• Success rates for surgical repair are high (low recurrence and complication rates), and surgery improves low back pain, urinary incontinence, and quality of life when appropriately selected 2