Key results and interpretation
According to results, PPAWI is a combination of morphological changes with the inclusion of back pain and social functioning disorders affecting a significant proportion of women after pregnancy. Sperstad in a large study of Norwegian women found that mild diastasis (2–3 fingers, ca. 5–6 cm) was found in 31% of women one year after delivery, and in 1%, the diastasis was moderate or severe (over 3 fingers) (24). Interestingly, in that study, none of the studied factors describing the pregnancy (age, height, weight and weight gain, baby’s birth weight or delivery mode) influenced the prevalence of RD. Other previous studies have shown similar results (25). It must be mentioned that only few studies have measured quality of life before and after surgical correction of PPAWI and only one was measuring the effect of operation on the depression syndromes (9).
Surgical treatment of RD does not have a consensus. Various options have been described from simple suture plication to endoscopic or robot-assisted procedures. A recently published review by Jessen, Öberg and Rosenberg summarizing these operative approaches found no solid data about the superiority of any method (11). Recent papers by ElHawary et al. did not showed superiority of one technique above others (26, 27). Only double plication of diastasis has showed lower complication rate, still not increasing recurrence rate. The guidelines of the European and Americas Hernia Society for patients with RD and small concomitant umbilical or epigastric hernia recommended mesh placement instead of suture repair based on the high risk of recurrence in the sutured group (28). This recommendation has been given; however, it was not focused on PPAWI, and the quality of evidence is low.
The choice of the technique in our study was based on various assumptions. One must keep in mind that the subject of the procedure is young women with a long life expectancy, the procedure is not lifesaving, the peritoneal cavity should be left intact to prevent possible adhesions, and the technique should not have a negative impact on the function of the trunk. This is why the laparoscopic IPOM procedure was abandoned. Even though the results of IPOM have been reported to be valuable for ventral hernias and rectus diastasis, there are still many publications showing adhesion formation due to intraperitoneal mesh placement and postoperative pain due to the application of tackers for mesh fixation (18, 19). The sublay technique requires opening the rectus sheath and involves a posterior layer of the rectus muscle in the inflammatory process of mesh ingrowth. In the past, onlay mesh was associated with seroma formation, but recently published data with the use of macroporous monofilament meshes did not confirm these findings (19). Knowing that thinning and stretching of the linea alba is an important risk factor for actual development of midline hernias (umbilical, epigastric, trocar, incisional hernia) due to the deterioration of the connective tissue and the pulling of the abdominal muscles (16) and to compare the procedure with other surgical techniques, the mesh is used for the prevention of future RD recurrences and hernia formation. Trials have shown positive results with onlay mesh for incisional hernia prevention with a low rate of seroma and other wound complications (20, 21). Based on this assumption, the onlay mesh position was chosen for this study.
We demonstrated that simultaneous single midline plication with onlay mesh and abdominoplasty is a safe, feasible, fast, and in our opinion, minimally invasive method for PPAWI treatment. It should be recognized that there are no long-term results comparing onlay and retromuscular mesh in women with PPAWI or IPOM or endoscopic techniques versus open ones. On the other hand, the follow-up protocols are concentrated on widely accepted end points of the studies, including short-term complications such as seroma or infection and long-term recurrence. The authors believe that tailored approach should be considered when non life-saving procedures in young women are proposed to improve their shape and quality of life. Even though intraperitoneal complications (e.g., adhesions) are rare, one can avoid them using onlay mesh, which requires leaving the peritoneal cavity intact along with the muscle layer. Our study demonstrated that with a relatively short and simple procedure, good results can be achieved.
We did find only few previously published papers describing psychological, sexual and social problems in the context of belly deformation or about the possible impact of the operation on these aspects of life. However they were mainly focused on the impact of RD of various origin alone. In one paper by Olsson, QoL was assessed, and a significant improvement in the SF-36® numerical values was observed one year after surgery (24). However, in that study, the authors focused on trunk function and urinary incontinence and correlated the improvement in the QoL with an improved body status. In study by Temel the operation reduces significantly depression signs assessed with BDI scores (6). In our study, we found that the shape of the front abdominal wall after pregnancy leads to social anxiety and shame in contact with partners, and self-exclusion from society with decreased self-esteem. These phenomena mostly disappeared after the operation in the majority of our patients.
Limitations and strength of this study.
This study has limitations. It was not planned to be, and it is not a randomized controlled trial comparing different operative techniques or conservative treatment of women with PPAWI. Additionally, the inclusion criteria were restricted to symptomatic PPAWI and patients looking for surgical intervention, so the results may not be applicable to all PPAWI cases. The patients were qualified for surgery a minimum of six months after delivery, but it was not checked in the protocol if they had had sufficient physiotherapy before the surgery, simply accepting the patient statement. The protocol assessed only a few areas of human well-being because it was based on interviews with PPAWI patients. That is why other potentially important areas of mental health could be missing in this study. The protocol is also not validated to the general population of women after delivery. It is based on authors experience and does not have any similar ones in the literature. We have decided to apply this protocol in the study to show the importance of psycho-sexual factors on the well-being of described women population. We found that protocols validated for measuring impact of RD or hernia operations does not fully apply in this specific situation. That is why authors believe that creating and conducting fresh questionnaire for newly described phenomena is a strong element of this study. However there is and understanding that some may spot a potential weakness and limitation in this approach.
On the other hand, this study was performed by an experienced team, and the surgical procedure was performed by one surgeon with over 20 years of experience in large ventral hernia repair. Compared to the other published studies on this topic, it is based on a relatively large heterogeneous group of patients, which makes its findings more valuable. It has also been proven that there is no necessity for the presence of plastic surgeons during the operation. In our opinion personal training in the procedure showed to be sufficient for general surgeon. The study team included female secretaries, and the anaesthesiologists were also women, which possibly bridges the divide in the interview touching on personal areas of the patient. To our knowledge, this is the first study assessing the impact of surgery on chosen behavioural areas in women’s lives. In light of this study, it must be pointed out that PPAWI is a complex pathology not expected as a consequence of pregnancy but resulting in long-lasting deformation. Struggling to raise a child while suffering from a loss of self-esteem leads to a decreased quality of life and social problems. Therefore, PPAWI should not be defined just as a morphological pathology but instead as a complex psycho-anatomical syndrome and should be treated as a disease. PPAWI shouldn’t also be considered equal to RD, because RD is only one component of broader disease presented as PPAWI. Findings from this study shows that morphological changes (extended skin with panniculus and/or visible striae gravidarum) and coexisting small hernia (umbilical or linea albae) are also key problem in women after pregnancy. In the questionnaire for psychological assessment, most of the women reported a strong influence of PPAWI on back pain, social functioning, self-esteem and sexual life (Table 1). In the descriptive assessment (collected as comments), the most frequently noted problems were at the beach or swimming pool, the necessity of changing the style of dressing (can only wear sac-like clothing), being treated as pregnant again (e.g., on public transport or in the office) and stress during sexual activity independent of the type of partner (in a long-term relationship or a brand new one). Another conclusion coming from this study shows that umbilical hernia is present in most cases and should also be included in the description of PPAWI. This also revalidate what Kohler et al previously stated (29).