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Theresia Skytte Eriksen, Helle Sjøstrand and Ida Felbo Pold. Case 10: Plication of rectus diastasis 2 years after twin-birth. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
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Theresia Skytte Eriksen1, Helle Sjøstrand and Ida Felbo Pold1
38-year-old woman underwent plication of symptomatic diastasis of the rectus abdominal muscles after twin-birth by caesarean section. The diastasis had a maximal width of 6,6 cm just above the umbilicus and her symptoms included core-instability, back-pain, and a feeling of being unprotected around her abdomen especially while handling her children. Patient medical history 38-year-old woman had after twin-birth developed symptomatic diastasis of the rectus abdominal muscles. She had no comorbidities. She had an older child of 6 years, and the twins were 2 years old. All children were delivered by uncomplicated caesarean section. The patient described symptoms as back-pain, nausea, core instability, discomfort during running, and pain when encountering pressure to the abdomen especially while handling the children. Physical rehabilitation with physiotherapists had not been successful and hard to complete do to discomfort and pain. Before and After Patient examination The patient was initially examined 15 months postpartum and at an additionally examination two years postpartum by the same surgeon. A preoperative CT-scan at 15 months postpartum, showed a rectus diastasis with the maximal width of 6,6 cm just above the umbilicus. The objective examination confirmed those findings, and a small umbillical hernia was detected. No change in symptoms and width of the diastasis was found between the two examinations. Pre-operative considerations Physical training alone has not been found to reduce the width of the diastasis [1]. Surgery was in one randomized controlled trial superior to physical training with regard to reduction of pain and increase abdominal muscle strength [2]. The swedish guidelines currently recommend that surgery is indic
38-year-old woman had after twin-birth developed symptomatic diastasis of the rectus abdominal muscles. She had no comorbidities. She had an older child of 6 years, and the twins were 2 years old. All children were delivered by uncomplicated caesarean section. The patient described symptoms as back-pain, nausea, core instability, discomfort during running, and pain when encountering pressure to the abdomen especially while handling the children. Physical rehabilitation with physiotherapists had not been successful and hard to complete do to discomfort and pain.
The patient was initially examined 15 months postpartum and at an additionally examination two years postpartum by the same surgeon.
A preoperative CT-scan at 15 months postpartum, showed a rectus diastasis with the maximal width of 6,6 cm just above the umbilicus. The objective examination confirmed those findings, and a small umbillical hernia was detected. No change in symptoms and width of the diastasis was found between the two examinations.
Physical training alone has not been found to reduce the width of the diastasis [1]. Surgery was in one randomized controlled trial superior to physical training with regard to reduction of pain and increase abdominal muscle strength [2]. The swedish guidelines currently recommend that surgery is indicated if the diastasis is greater than 5 cm and symptomatic. In case of severe symptoms, a diastasis as low as 3 cm can indicate the need for surgery [3]. With that in mind a surgical plication of the diastasis was considered to be the optimal treatment for this patient.
The patient was informed of the possible complications related to surgery as bleeding, infection, scarring, sensory disturbances, tissue necrosis, placement of suction drain, lift of pubic hair, and asymmetric cosmetic result because of loose skin.
Furthermore, the patient must not have a wish for future pregnancy, and it is recommended that at least 2 years has passed since the latest pregnancy, in order to comply with post-op restrictions.
The perioperative drawings are made in a standing position estimating the amount of loose skin expected to be excised.
Incision was made according to the caudal drawing and the skin was undermined at the plan of the fascia. The flap was raised up to 2-3 cm under the curvature of the ribs.
2
The maximum width was measured to 6,5 cm. The diastasis stretched from 1 cm below proc. xiphoideus to 4 cm above the symphysis.
3
The small umbilical hernia only contained fat which was excised and the defect in the fascia was closed with 3-0 Vicryl.
The plication of the diastasis was made with PDS 0 Loop-suture as a continuous suture. The suture was continued around the umbilicus. Starting cranially, locking the suture in the loop. At the end of the plication, one tread was cut and the two sutures were knotted together. The knot and suture ends were buried in the tissue.
4
Carefully measurement of the amount of extensive loose skin which can be surgically removed, so that the incision could be closed without too much tension. Approximately 550g of skin tissue was removed.
5
After thorough hemostasis the new hole for the umbilicus was made with a diamond-shaped incision. The umbilicus was sutured to the skin with 3-0 Novosyn and 5-0 Prolene.
The distal incision was closed in 3 layers with 2 layers of 3-0 Novosyn in the depth and the skin intracutaneously with 3-0 Biosyn.
Tranexamic acid were administrated both intravenously and in diluted state directly into the cavity.
A suction drain, and pain regulating catheter was placed. 8 ml of ropivacaine 7,5 mg/ml was administrated by the catheter at the end of the surgery. All incisions were covered by micropore tape.
The patient was discharged two days later.
6
The patient was seen two weeks postoperatively for suture removal around the umbilicus. There was no sign of infection, and no patient-reported pain. On the lower left side, a small seroma formation was detected.
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