1. Surgery for DRA is successful in terms of very low recurrence rates of the DRA.
Amazingly, most of the surgical literature only looks at surgical complications (infections, seromas—pockets of fluid, etc) and recurrence rates. Improvement in function or appearance is reported very rarely if at all! So we have a long way to go there, but at least we know that surgery is very successful for DRA repairs. Most studies report no recurrences of DRA out of hundreds of patients, with very few studies reporting one recurrence (Mommers 2017).
2. Patients should be given a trial of PT prior to considering surgery.
How long the trial should last is up for debate, but most studies include a 3-6 month trial. Plus, most will not consider surgery until 1 year postpartum, and the patient needs to be certain they are done having children. It has been shown to be possible to carry pregnancies to term successfully following DRA repair, but with more pain and discomfort in the abdomen reported, as well as a return of the DRA during pregnancy that resolved afterwards (Swedenhammar 2021). Frequently when discussing with other PTs, many will recommend at least 12 months of conservative rehab & core exercise before considering surgery.
3. In patients that have not been successful with PT, surgery can improve many outcomes that matter to patients.
This is especially true for physical function, but not necessarily for appearance. In one study of 60 subjects (Olsson 2019), at one year post-op 98% self-reported improved abdominal function after surgery, and 76% showed improvement on endurance tests of the back and abdominal muscles. 37-47% reported an improvement in incontinence depending upon the survey used, while interestingly 8-13% reported worsened incontinence. However, across the board quality of life scores were improved, and reached a level equal to or greater than the general population. And, all of these improvements were maintained at 3 years post-operatively as well (Olsson 2021).
Another study of 86 subjects (Emanuelsson 2016) showed improved quality of life, better objective abdominal strength, and improved perception of abdominal strength as well at one year post-op. Interestingly, these functional improvements were maintained at 3 years post-op, but only 29-39% reported satisfaction with their appearance at that time (Swedenhammar 2021).
4. The type of DRA repair does not seem to matter at this time.
In all of the references below, many different types of surgeries are compared against one another. They don't show any difference in outcomes, although some authors will make arguments for certain types of surgeries over others, based on things like the extensiveness of the surgery.
The takeaway?
If a DRA is not improving despite PT and consistent attempts at core rehabilitation for at least 3-6 months, and the patient is at least 1 year postpartum, surgery can be considered. The recovery is typically extensive from these surgeries, with an abdominal brace usually being worn for 12 weeks, and no heavy physical exercise for 12 weeks as well. But, sometimes surgery is the right answer, and it certainly never hurts to get a consultation.
Whether or not insurance will pay for DRA repair is another can of worms, as most of the time DRA repair is considered "cosmetic" by insurance companies. So that is another consideration and area of research the patient will need to undertake. But hopefully as the research catches up on reporting more functional outcomes, insurance coverage for DRA repairs will change too!
References:
Emanuelsson, P., Gunnarsson, U., Dahlstrand, U., Strigård, K., & Stark, B. (2016). Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures. Surgery, 160(5), 1367–1375. https://doi.org/10.1016/j.surg.2016.05.035
Mommers, E., Ponten, J., Al Omar, A. K., de Vries Reilingh, T. S., Bouvy, N. D., & Nienhuijs, S. W. (2017). The general surgeon's perspective of rectus diastasis. A systematic review of treatment options. Surgical endoscopy, 31(12), 4934–4949. https://doi.org/10.1007/s00464-017-5607-9
Nahabedian M. Y. (2018). Management Strategies for Diastasis Recti. Seminars in plastic surgery, 32(3), 147–154. https://doi.org/10.1055/s-0038-1661380
Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., & Stackelberg, O. (2019). Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. BJS open, 3(6), 750–758. https://doi.org/10.1002/bjs5.50213
Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., & Stackelberg, O. (2021). Surgical repair of diastasis recti abdominis provides long-term improvement of abdominal core function and quality of life: a 3-year follow-up. BJS open, 5(5), zrab085. https://doi.org/10.1093/bjsopen/zrab085
Swedenhammar, E., Strigård, K., Emanuelsson, P., Gunnarsson, U., & Stark, B. (2021). Long-term follow-up after surgical repair of abdominal rectus diastasis: A Prospective Randomized Study. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society, 110(3), 283–289. https://doi.org/10.1177/1457496920913677
Photo by cottonbro studio: https://www.pexels.com/photo/a-woman-arranging-medical-tools-in-an-operating-room-7583382/