VH with concomitant DR presents a challenging scenario for surgical repair due to complexity of abdominal wall defects. In addition to aggravating the instability of the core muscles and promoting hernia development, DR itself can cause an undesired bulge in the abdomen, and patient experiences both bodily and emotional distress from it.
Diagnosis
The majority of patients of VH with DR can be identified with a careful physical examination. Placing the patient in supine position and performing straight leg raising test demonstrates smooth bulge over the anterior abdominal wall. DR can extend variably from the xiphoid to pubis.
The most precise way to identify and confirm a diagnosis is through imaging, which also help in planning treatment. These consist of the application of ultrasound, computed tomography (CT) scan and magnetic resonance imaging (MRI) [8]. Ultrasound is the most affordable and widely used imaging modality to assess DR with hernia. Nowadays CT scan is used more frequently to assess the status of rectus muscle [8]. CT scan is more useful when defect is more than the ultrasound probe size. MRI is very expensive investigation and not routinely done.
Based on the location of the defect and the inter-rectus distance, various classification schemes for DR have been developed. These includes, but not limited to, Beer classification [2], Rath classification [9] and Nahas classification [10].
Management
It appears that surgeons have overlooked the significance of considering the concurrent existence of DR while treating midline hernias [4]. Though DR is not considered as a reason for concern, the midline weakness it induces, have been linked to an increased chance of relapse in hernia repair. Kohler et al reported that after a 24-month follow-up, patients with epigastric or umbilical hernia repair with DR saw a 31.1% relapse, compared to 8.3% in those who did not have DR [3].
Surgery is the only treatment option for treatment of VH with DR. Numerous approaches, including open, laparoscopic (endoscopic) and hybrid procedures, have been reported [11, 12, 13].
Traditional open surgery methods: Open surgery includes a long midline vertical incision with closure of hernia defect, plication of DR and mesh placement. But this approach is linked to poor cosmesis, potentials risk of infection, long hospital stays and patients’ unacceptability.
The other open surgery method includes Abdominoplasty in which a huge flap is created through very big lower abdomen transverse incision and hernia defect is sutured along with plication of DR. It is especially suitable for patients with extra skin in lower abdomen, where dermolipectomy can improve aesthetic outcome. Nonetheless, a sizable portion of patients do not desire a major incision in the lower abdomen or do not have extra skin [14]. Additionally proper mesh cover over dissected area can’t be possible without excising umbilicus, with resultant poor cosmetic outcome.
Minimally invasive procedures: A variety of new minimally invasive surgery have come up in recent years. They can be classified based on the site of mesh placement as Sublay, Ipom plus and Onlay repair.
Sublay repair: These includes MILOS (Mini or Less-Open Sublay Operation) [15], eTEP-RS (Extended Totally Extra Peritoneal Rives-Stoppa) [16] and Umbilical TAPP (Trans Abdominal Preperitoneal Repair) [17]. The procedure involves extensive dissection into the retro-rectus muscle space, which spread laterally upto semilunar line, cutting both posterior rectus sheath from linea alba in its entire length, suturing DR in midline at “rooftop position” and placement of mesh into the space created. They have been described with the primary benefit of reduction in the incidence of seroma formation. However, these techniques are very complex, difficult to learn and need thorough laparoscopic skill [4]. Additionally, there is potential to damage important neurovascular perforators laterally near semilunar lines [18].
Ipom plus (Intraperitoneal onlay meshplasty with suturing) repair: It is a technique in which peritoneal cavity is entered laparoscopically. Closure of hernia defect and plication of DR is done either by transfascial sutures or by posterior plication and placement of special intraperitoneal mesh which is fixed by tackers. The main problem of this technique is the cost of this special mesh and tucker and that alone is 10–20 times costlier than routine mesh and sutures. Beyond the additional expenditure, transfascial sutures cause pain [19], and laparoscopic posterior plication is technically more demanding. Other long-term complications include high rate of recurrence and bowel obstruction [20].
Onlay repair: Various techniques under this category are ELAR (Endoscopic Linea Alba Reconstruction), REPA (Preaponeurotic endoscopic repair) and SCOLA [4–6]. Here, the plane is made in subcutaneous tissue flush to anterior rectus aponeurosis up to xiphoid, the hernial defect is closed, the DR is plicated and polypropylene mesh is laid down over anterior rectus aponeurosis. In ELAR plus, the initial access is made through umbilicus, while in REPA and SCOLA, it is through small suprapubic transverse incision. They replicate traditional open onlay surgery procedure but is carried out with very small incision with the help of laparoscopy instruments, imparting great cosmetic benefit. Unlike sublay repairs, the great advantages of these techniques are the simplicity and replicability, as the dissection is done in area with which all surgeons are familiar with. And unlike IPOM plus, by not entering the peritoneal cavity all its related complications are avoided, and by not needing intraperitoneal mesh and tucker, the cost of the procedure reduced drastically. VH and DR is addressed simultaneously and the integrity and stability of abdominal wall is restored excellently with best possible reconstruction. The availability of barbed suture made this procedure quick and easy to perform. It is best suited for group of non-obese patients without excess skin, who are not candidate for abdominoplasty [14].
Postoperative seroma is the primary side effect of these onlay repair procedures. In our study it occurred in 33% of the patients, which is little more than reported in other studies. This may be attributed to the leniency with which the patient selection was made in our study, i.e. BMI upto 35 35kg/m2, as seroma formation is linked with BMI [21, 22]. However, the seroma is absolutely benign complication and all resolved with expectant management in our study. The etiology of seroma formation is still unclear, though lymphatic channel disruption, dead space formation and shearing force between abdominal flap and fascia have been implicated [22–25]. Efforts have been made to reduce the seroma formation, and include use of drain and abdominal binder. In addition, multiple preventive strategies have been proposed and include preservation of fascia scarpa, use of tissue adhesive and progressive tension suture [22].
Recommended modifications from our study: We follow all steps of SCOLA as described by C Claus et el in the publish article [4]. However, we have done 3 important refinements in the technique and these include: (a) Locating bottom of umbilicus inside by hypodermic needle insertion from outside, which helps avoid umbilical skin damage, (b) Internal elliptical marking of VH with DR with methylene blue dye, which helps precise midline reconstruction and (c) Avoiding suture fixation of umbilicus towards the end of the procedure, as we found it to be cumbersome and avoidable step. In all our cases umbilicus stuck to underlying structure by its own.