What is the management approach for diastasis recti with a few loops of bowel on computed tomography (CT) scan, without evidence of strangulation or incarceration?

Management of Diastasis Recti with Bowel Loops on CT (No Strangulation/Herniation)

Conservative management with physiotherapy is the appropriate first-line treatment for diastasis recti when CT shows bowel loops without evidence of strangulation or true herniation, as this represents anatomic diastasis rather than a surgical emergency. 1

Key Distinction: Diastasis vs. Hernia

• Diastasis recti is NOT a true hernia—it represents separation of the rectus abdominis muscles along the linea alba with bulging of abdominal contents, but without a fascial defect through which bowel herniates. 2
• The presence of bowel loops on CT in the context of diastasis simply reflects the anatomic widening and anterior displacement of abdominal contents, not incarceration or herniation requiring urgent intervention. 3
• If there is no evidence of strangulation, incarceration, or true fascial defect with herniation, this is managed conservatively, not surgically. 1

Immediate Management

• No urgent surgical intervention is indicated when CT confirms absence of strangulation, bowel obstruction, or true herniation. 4
• Clinical examination should confirm the diagnosis using a caliper or ruler to measure the inter-rectus distance (diastasis diagnosed when >2 cm, though some use >2.7 cm as threshold). 1, 3
• Imaging with ultrasound or CT is appropriate when concurrent umbilical/epigastric hernia or other pathology cannot be excluded clinically—which has already been done in this case. 1

Conservative Treatment Protocol

• Initiate a standardized 6-month abdominal core training program focused on strengthening the transversus abdominis muscle. 1
• Physiotherapy is the first-line treatment for diastasis recti and should be exhausted before any surgical consideration. 1
• Conservative therapy comprising exercises to strengthen the transversus abdominis should be attempted for at least 3-6 months. 5, 1

Criteria for Surgical Consideration (If Conservative Management Fails)

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

• Failure of standardized 6-month physiotherapy program 1
• Functional impairment (not cosmetic concerns alone)—such as musculoskeletal pain, urogynecological symptoms, or significant disability 5, 1
• Inter-rectus distance ≥5 cm at the widest point (smaller diastasis may be considered if pronounced bulging or concomitant ventral hernia exists) 1
• At least 2 years since last childbirth with no future pregnancy planned 1

Surgical Approach (When Indicated)

• Plication of the linea alba is the first-line surgical technique when surgery is undertaken. 1
• Minimally invasive approaches using Rives-Stoppa technique with retromuscular mesh placement have shown promising results with lower infection risk and better cosmetic outcomes. 5, 6
• Laparoscopic repair can be safely performed for diastasis without strangulation or need for bowel resection. 4

Critical Pitfall to Avoid

• Do not confuse diastasis recti with incarcerated ventral hernia—the CT findings described (bowel loops without strangulation/herniation) indicate anatomic diastasis, not a surgical emergency requiring urgent repair. 4, 2
• Surgical repair does not guarantee symptom resolution, as anatomical correction often correlates weakly with functional improvement. 7