How should I manage an otherwise healthy adult with diastasis of the rectus abdominis and bilateral reducible ventral (umbilical or incisional) hernias?

Management of Rectus Abdominis Diastasis with Bilateral Reducible Ventral Hernias

Surgical repair with mesh reinforcement is recommended for this patient, addressing both the hernias and the diastasis through linea alba plication combined with mesh placement. 1, 2

Initial Assessment and Diagnostic Workup

• Measure the diastasis width using a caliper or ruler during clinical examination, with the patient performing a head lift maneuver to engage the rectus muscles 1
• Obtain CT imaging to confirm the presence of bilateral hernias, exclude other pathology, and precisely measure the diastasis width and hernia defect sizes 3, 1
• Document any functional impairment including abdominal pain, musculoskeletal complaints, or quality of life concerns 1, 4

The presence of reducible hernias alongside diastasis changes the management algorithm significantly, as comorbid rectus diastasis is a documented risk factor for hernia recurrence (12% recurrence rate in one series) 3.

Treatment Algorithm

Step 1: Determine if Conservative Management is Appropriate

Conservative management is NOT appropriate in this case because:

• The patient has concurrent hernias requiring repair 5, 1
• Hernias do not resolve with physiotherapy and require surgical intervention 5
• While isolated diastasis may warrant a trial of physiotherapy first, the presence of hernias mandates surgical planning 1, 4

Step 2: Surgical Planning Considerations

Proceed directly to surgical repair addressing both pathologies simultaneously 2, 6. The key decision points include:

• Timing requirements: If the patient is female and of childbearing age, ensure at least 2 years have elapsed since last childbirth and no future pregnancies are planned 1
• Diastasis width threshold: The diastasis should ideally be ≥5 cm for surgical consideration, though concomitant ventral hernia justifies surgery even with smaller diastasis 1
• Patient stability: Confirm the patient is hemodynamically stable and the hernias are truly reducible without signs of incarceration or strangulation 7, 5

Step 3: Surgical Technique Selection

The recommended approach is mesh-based repair with linea alba plication, as this addresses both pathologies through a single intervention 1, 2, 6. Specific technical options include:

Primary Recommendation: Hybrid or Sublay Mesh Repair

• Perform linea alba plication to correct the diastasis by approximating the rectus muscles 1, 2, 6
• Place mesh in the retromuscular (sublay) position after plication, ensuring at least 5 cm overlap beyond all defect edges 8, 6
• Use synthetic mesh (such as polypropylene) in this clean surgical field, as it provides durable reinforcement 6
• The sublay position preserves the retromuscular plane for potential future repairs and provides optimal biomechanical support 2, 6

Technical Approach Options:

• Open midline mesh repair: Excise excess linea alba, close posterior rectus sheath with running suture, place mesh retromuscularly with U-shaped stitches 5 cm from midline, then close anterior fascia 6
• Laparoscopic or robotic-assisted approach: May be considered in experienced centers for patients meeting criteria (stable, no bowel compromise, clean field) 8, 2
• Hybrid ENDOP technique: Combines endoscopic plication with open preperitoneal mesh repair through a single incision, though this requires specialized expertise 2

Step 4: Critical Technical Points

Mesh reinforcement is mandatory even if the hernia defects appear small, because:

• Primary tissue repair alone has a 42% recurrence rate in the setting of diastasis 3
• Non-absorbable suture material must be used for all fascial closures to prevent recurrence 3
• Mesh should overlap the hernia defect edges by at least 5 cm in all directions 8, 5
• In the presence of diastasis, mesh placement is recommended irrespective of hernia size 3

Common Pitfalls to Avoid

• Do not repair the hernias alone without addressing the diastasis, as this significantly increases recurrence risk 3
• Never use absorbable suture material or absorbable mesh, as complete dissolution leads to inevitable recurrence 5
• Do not attempt primary tissue repair without mesh reinforcement in the setting of diastasis, given the 42% recurrence rate 3
• Avoid synthetic mesh if there is any contamination (though this patient with reducible hernias should have a clean field) 9, 8
• Do not proceed with minimally invasive approaches if there is any concern for bowel compromise or if bowel resection might be needed 8, 7

Expected Outcomes

• Low recurrence rates with proper mesh-based repair addressing both pathologies 4, 6
• Minor complications are possible including seroma formation (common but typically self-limited) and hematoma 2
• Improvement in functional outcomes including reduction in abdominal pain, improved core stability, and enhanced quality of life 4
• Same-day discharge is feasible in uncomplicated cases 2