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 REPA^6,7,8,9, 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.