When a true hernia is encountered in the setting of rectus diastasis (RD), the hernia defect determines the appropriate treatment. Several decisions need to be made, such as whether to perform a minimally invasive or open procedure, what type of mesh to use, and the plane of mesh placement. However, it is the presence of the concomitant RD that determines the extent of mesh reinforcement beyond the hernia defect itself. This is critically important because hernia recurrence risk at the junction of the hernia defect and area of RD is very high if the RD is not adequately addressed at the time of hernia repair. The mesh must be inset, both superior to and inferior to the hernia, to stable soft tissue such as normal (non-attenuated) rectus complexes, subxiphoid tissue, or the terminal insertion of the rectus musculofascia in the suprapubic region. The plane of mesh placement is at the discretion of the surgeon based on individualized patient factors, case complexity, and their surgical approach. Regardless of the tissue plane chosen, appropriate tension must be maintained across the mesh repair. The tension level should recreate the physiologic tension of the abdominal wall when the patient is standing. Excessive tension on the mesh–musculofascia suture line will cause attenuation and lead to peripheral failure of the mesh repair. Therefore, each patient should be evaluated individually and clinical judgment applied to establish the correct physiologic tension [1].

Our approach to managing RD in the face of a ventral hernia is determined by several key factors: patient morphology, defect size and location, degree of wound contamination, and quality of overlying soft tissue. Our first-line approach for clean cases with RD and small hernia defects < 6 cm is to perform a retro-rectus or preperitoneal repair with mid-weight macroporous polypropylene mesh with extensive dissection from the subxiphoid area superiorly into the space of Retzius inferiorly. In patients with a well-developed preperitoneal fat pad, the peritoneal tissues can be closed in the midline, insulating the mesh from the viscera. If there is a central deficiency of preperitoneal tissue, a mid-weight polypropylene mesh with an anti-adhesion barrier can be employed. For clean cases with hernia defects < 6 cm, a medium-weight macroporous polypropylene mesh can be used in the retro-rectus space. Linea alba reconstruction with direct coaptation of the medial rectus complex is performed with #1 polypropylene sutures. For defects where the posterior sheath cannot be approximated without undue tension, we perform either an anterior minimally invasive component separation (MICS) or transverse abdominis release (TAR).

In contaminated cases, we often use bioprosthetic mesh placed in an intraperitoneal, preperitoneal, or retro-rectus plane, as determined by the size and characteristics of the defect. An anterior component separation (CS) is an integral aspect of our abdominal wall reconstruction algorithm. We favor MICS which preserves rectus abdominis perforators to maintain perfusion of the medial skin rather than open CS. A comparative study of MICS and open CS patients showed that incidences of skin dehiscence, wound-healing complications, abdominal laxity/bulge and recurrent hernia were significantly lower in the MICS group [2].

In patients with RD and midline hernias, optimizing skin and soft tissue perfusion is critical to reducing wound-healing complications. In addition, removing devitalized, scarred, or redundant skin and subcutaneous tissue via vertical panniculectomy improves perfusion to the remaining skin and reduces dead space but does not increase the rates of hernia recurrence and surgical site occurrence [3]. The postoperative protocol for patients with RD and concomitant hernias parallels that of the ventral hernia population. Drains are removed when the output is ≤ 25 ml over 24 h. Patients should abstain from lifting and straining for 2 months after surgery to minimize the risk of hernia recurrence.

In summary, when a ventral hernia is encountered in the face of RD, it is critical to address the entire midline, from the subxiphoid area to the suprapubic region, to reduce the risk of hernia recurrence to the lowest level possible. Prospective studies evaluating the optimal surgical approach and mesh selection for RD with concurrent hernia are required, as hernia surgeons will encounter an ever-increasing number of RD patients given the international obesity trends.