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Revista argentina de cirugía

versão impressa ISSN 2250-639Xversão On-line ISSN 2250-639X

Rev. argent. cir. vol.115 no.4 Cap. Fed. dez. 2023  Epub 29-Nov-2023

http://dx.doi.org/10.25132/raac.v115.n4.1774 

Opinion article

MILA (Minimally invasive lipoabdominoplasty) for diastasis recti. Are general surgeons and plastic surgeons fighting or playing together?

*Minimally Invasive Surgery Department, Jacques Perissat Institute, Positivo University, Curitiba. Brazil.

**Instituto Universitario Italiano de Rosario (IUNIR). Rosario, Santa Fe. Argentina.

In recent years, abdominal wall repair has undergone a profound transformation. It all starts with understanding that the abdominal wall, lined with muscles, does much more than just hold the abdominal organs. As such, it has been considered an organ per se. It has even been called CORE Health, a name that is clinically difficult to translate into languages such as Portuguese and Spanish. We now understand that the abdominal wall plays a vital role in maintaining body posture, urinary continence, and bowel function1.

Other problems besides hernias can occur in the abdominal wall. Another issue that has attracted the attention of healthcare professionals is the separation of the rectus abdominis muscles, known as diastasis recti abdominis (DRA). This finding is relevant not only because it is a common condition, but also because of its potential impact2.

At least one-third of women after pregnancy will experience persistent DRA, which means that even after 18-24 months, they may still have it even if they lost weight and underwent physiotherapy and strengthening treatments. Despite some benefits, these measures are not very effective in “closing” a DRA larger than 2.5 cm two years after pregnancy.

But this problem does not exclusively target women, as men with a profile of visceral fat accumulation and increased abdominal pressure are also frequently affected by DRA3.

In general, DRA has been overlooked by general surgeons as it does not result in complications. Furthermore, the approach using a longitudinal midline incision promptly dissuaded patients. However, these perceptions have been modified by three facts: first, the negative impact of DRA on abdominal wall function; second, the increased risk of recurrence in abdominal hernia repair, especially in midline hernias4, when associated with DRA; and third, recent advances in minimally invasive techniques for repairing abdominal hernias.

On the other hand, plastic surgeons have long been treating patients with DRA using classic abdominoplasty. However, patients without excessive subcutaneous tissue or flaccid skin and those who prefer to avoid large incisions and a “new belly button” have limited options.

Recently, the minimally invasive technique for repairing DRA has been revitalized. The same concept, originally developed in 19955 by Brazilian surgeon Dr. Marco Correa, has been adapted using laparoscopic or robot-assisted surgical instruments along with the assistance of carbon dioxide, similar to laparoscopic and endoscopic procedures. Although many different names have been published in literature, such as SCOLA and REPA6,7,8,9, they all share the common principle of dissecting the subcutaneous tissue with three small suprapubic incisions. Following this, the midline is plicated with concomitant repair of any associated hernia defects. Then, a mesh is usually placed.

Although this technique caught the general surgeons’ attention quickly, its indications are restricted to slim patients with no excess fat or subcutaneous tissue flaccidity, with DRA associated with a small abdominal wall hernia. Using this technique in obese patients is a topic of controversy. For instance, it fails to address excess skin and subcutaneous tissue, which are common issues for these patients. The use of the technique for larger hernias and incisional hernias is also a matter of debate. This is because there is a tendency to position the mesh on the posterior side of the abdominal wall rather than directly on it. In fact, among the potential “side effects” of the technique, seroma is the most common due to the significant detachment of subcutaneous tissue and the need for drains and abdominal bands.

Then we reach what could be the inflection point: the collaboration between general surgeons and plastic surgeons. Dr. Ezequiel M. Palmisano and Dr. Guillermo Di Biasio10 were the pioneers in joining forces to expand the use of the technique. The technique formerly known as VER (Vaser/ Endoscopy/ Renuvion)

-acronyms that list the procedures used during the techniquehas now been appropriately renamed as MILA (minimally invasive lipoabdominoplasty) according to both general and plastic surgeons. It comprises three stages: 1) liposuction of the subcutaneous tissue; 2) endoscopic or robot-assisted midline plication of the DRA with or without abdominal hernias; and 3) skin retraction. In this way, the technique can be applied to overweight patients with a body mass index (BMI) up to 27-28 who have midline diastasis, with or without an associated hernia, and mild or moderate skin flaccidity. It is crucial to recognize the synergy among the steps of the procedure: 1) liposuction, plication, and skin retraction devices use the same suprapubic incisions; 2) by eliminating fat, liposuction streamlines the dissection of subcutaneous tissue necessary to plication, and, 3) postoperative care involves common practices, such as use of drains, abdominal bands, and lymphatic drainage, among others.

Despite the initial enthusiasm surrounding the technique and its presence on social media even before scientific articles, it is important to approach it critically. The proper indications, real benefits and potential complications must be elucidated through scientific research.

Another issue that arises is: who will deal with the technique? Will general surgeons learn how to handle liposuction cannulas and provide post-operative care for abdominoplasty? Or will plastic surgeons learn laparoscopic and robot-assisted techniques or how to use abdominal wall meshes? While both options are possible, we understand that playing together is better. As the saying goes, “every man to his trade”. General surgeons and plastic surgeons can and should work together. In everyday practice, laparoscopic procedures are performed by general surgeons, while plastic surgeons manage liposuction and skin retraction techniques, along with postoperative care.

Referencias bibliográficas /References

1. Cuccomarino S. ¿Por qué el cirujano de pared abdominal debería operar la diástasis de rectos? Rev Hispanoam Hernia. 2019;7(2):43-46 [ Links ]

2. Pou Santonja G. Historia natural de la reparación endoscópica preaponeurótica (REPA). Rev Hispanoam Hernia. 2018;6(4):165-166 [ Links ]

3. Juárez Muas DM, Palmisano E, Pou Santoja G y cols. Reparación endoscópica preaponeurótica (REPA) como tratamiento de la diástasis de los músculos rectos asociada o no a hernias de la línea media. Estudio multicéntrico. Rev Hispanoam Hernia. 2019;7(2):59-65 [ Links ]

4. Köhler G, Luketina RR, Emmanuel K. Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus diastasis is a significant risk factor for recurrence. World J Surg. 2015 Jan;39(1):121-6; discussion 127. doi: 10.1007/s00268-014-2765-y. PMID: 25217109. [ Links ]

5. Corrêa MA. Videoendoscopic subcutaneous techniques for aesthetic and reconstructive plastic surgery. Plast Reconstr Surg. 1995;96(2):446-53. [ Links ]

6. Claus CMP, Malcher F, Cavazzola LT, Furtado M, Morrell A, Azevedo M, et al. Subcutaneous onlay laparoscopic approach (SCOLA) for ventral hernia and rectus abdominis diastasis repair: technical description and initial results. Arq Bras Cir Dig. 2018;31(4): e1399 [ Links ]

7. Juárez Muas DM. Preaponeurotic endoscopic repair (REPA) of diastasis recti associated or not to midline hernias. Surg Endosc. 2019;33(6):1777-82. [ Links ]

8. Malcher F, Lima DL, Lima RNCL, Cavazzola LT, Claus C, Dong CT, et al. Endoscopic onlay repair for ventral hernia and rectus abdominis diastasis repair: Why so many different names for the same procedure? A qualitative systematic review. Surg Endosc. 2021;35(10):5414-21. [ Links ]

9. Palmisano EM. Proposal for a single name in the endoscopic treatment of abdominal diastasis: a scientific need. Rev Hispanoam Hernia. 2023;11(1):1-3 [ Links ]

10. Palmisano EM, Di Biasio G. Minimally invasive management alternative for the treatment of patients with abdominal diastasis and dermo-fat flap using the VER tactic: Vaser(r) + Endoscopy + Renuvion(r) Rev Hispanoam Hernia. 2022;10(4):167-171 [ Links ]

Correspondence: Ezequiel Palmisano. E-mail: ezequielpalmisano@yahoo.com.ar

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