What is the initial management for a patient with diastasis recti and few loops of bowel involved?

Management of Diastasis Recti with Bowel Involvement

For diastasis recti with few loops of bowel involved, immediate surgical evaluation is warranted to assess for incarceration or strangulation, followed by supportive management with bowel decompression, fluid resuscitation, and urgent surgical repair if signs of bowel compromise are present. 1

Initial Assessment and Stabilization

Immediate Clinical Evaluation

• Assess for signs of bowel compromise: Look specifically for peritoneal signs, severe unremitting pain (suggesting ischemia), abdominal distension, and hemodynamic instability (tachycardia, hypotension, altered mental status). 1
• Examine all potential hernia sites: Carefully inspect the diastasis defect for incarcerated bowel loops, checking for tenderness, erythema, and reducibility of the bulge. 1
• Obtain vital signs immediately: Tachycardia, tachypnea, cool extremities, mottled skin, and oliguria indicate shock requiring aggressive intervention. 1

Laboratory and Imaging Workup

• Order complete blood count, renal function, electrolytes, and lactate: Elevated lactate, low bicarbonate, marked leukocytosis, and metabolic acidosis suggest bowel ischemia requiring immediate surgery. 1
• Obtain CT scan of abdomen/pelvis with IV contrast: This is the gold standard to evaluate bowel involvement, assess for ischemia, perforation, or strangulation, and guide surgical planning. 1, 2
• Plain abdominal X-rays have limited utility: Sensitivity is only 50-60% for bowel obstruction and should not delay CT imaging if clinically indicated. 1

Supportive Management

Immediate Interventions

• Begin aggressive IV crystalloid resuscitation: Use isotonic dextrose-saline or balanced crystalloids with supplemental potassium to replace losses, targeting adequate urine output (>0.5 mL/kg/hr). 1
• Insert nasogastric tube for decompression: This prevents aspiration pneumonia, decompresses proximal bowel, and allows diagnostic assessment of gastric contents (feculent aspirate suggests distal obstruction). 1
• Place Foley catheter: Monitor urine output as a marker of adequate resuscitation. 1
• Administer antiemetics and maintain bowel rest: Nothing by mouth until surgical evaluation is complete. 1

Surgical Decision-Making Algorithm

Class A Patients (Hemodynamically Stable, No Peritonitis)

• Attempt gentle manual reduction if bowel appears viable without signs of ischemia or perforation, using Trendelenburg positioning and IV sedation/analgesia. 1
• If reduction successful: Plan elective surgical repair of diastasis recti with mesh reinforcement using either open (Rives-Stoppa technique) or laparoscopic approach. 3, 4, 5
• If reduction unsuccessful after conservative measures: Proceed to urgent surgical exploration. 1

Class B/C Patients (Hemodynamically Unstable or Peritonitis Present)

• Do not delay surgery for conservative management attempts: Immediate surgical exploration is required to prevent mortality from bowel necrosis or perforation. 1
• Perform damage control surgery if severely unstable: Resect compromised bowel, create temporary stoma if needed, and leave abdomen open with temporary abdominal closure device. 1
• Primary anastomosis should be avoided in hemodynamically unstable patients or those with significant peritoneal contamination. 1

Surgical Approach for Diastasis Recti Repair

When Bowel is Viable After Reduction

• Open repair with plication and mesh reinforcement is the most established approach, using either single or double-layer permanent suture plication of the rectus muscles with retromuscular mesh placement (Rives-Stoppa technique). 3, 4, 5
• Laparoscopic/endoscopic approach can be considered in experienced centers for fit patients, offering superior cosmetic outcomes and reduced infection risk. 3, 5
• Transversus abdominis release (TAR) may be necessary for large defects to achieve tension-free closure and prevent recurrence. 3

When Bowel Requires Resection

• Resect compromised bowel segments and perform primary anastomosis only if patient is hemodynamically stable (Class A) with minimal contamination. 1
• Create diverting stoma for Class B/C patients or when anastomotic integrity is questionable due to bowel edema, ischemia, or significant contamination. 1
• Repair diastasis recti at the same operation if feasible in stable patients, or stage the repair after physiologic recovery in unstable patients. 1

Critical Pitfalls to Avoid

• Never delay surgical consultation when bowel loops are involved in diastasis recti, as progression to strangulation dramatically increases mortality. 1
• Do not attempt conservative management in patients with peritoneal signs, hemodynamic instability, or imaging evidence of bowel ischemia. 1
• Avoid primary anastomosis in contaminated fields or unstable patients, as anastomotic leak in this setting carries high mortality. 1
• Do not close fascia under tension as this increases recurrence rates and may compromise bowel perfusion; use component separation techniques or staged repair instead. 1, 3

Postoperative Management

• Continue antibiotics for 3-5 days in Class A patients with minimal contamination, or until resolution of infection signs in Class B/C patients. 1
• Monitor for complications: Infection, bleeding, bowel obstruction from adhesions, and recurrence are the primary concerns requiring close surveillance. 4, 5
• Plan definitive diastasis repair at 6-12 months if damage control surgery was performed, allowing resolution of inflammation and physiologic optimization. 1