866 Hernia (2021) 25:863–870 13 both the abdominal wall and for the overall improvement of skin contours. Rectus diastasis repair with a narrow well‑fixed mesh No matter the skin incision, the anterior rectus sheath is opened on its medial border to expose the rectus muscle. The muscle is bluntly freed from the underlying posterior rectus fascia from the xyphoid to several centimeters below the umbilicus where these two fascial incisions are joined and the Space of Retsius is entered. It is important to remain extra-peritoneal for this dissection. Typically, a small blood vessel from the deep inferior epigastric artery (DIEA) is identified traveling to the umbilicus, and this is preserved. An uncoated mid-to lightweight macroporous polypropylene mesh, (Soft Prolene, Ethicon, New Brunswick NJ) is cut to fit into the space, with its widest dimension being 10–11 cm transversely in the supraumbilical area. The key to this procedure is the placement of transfascial sutures that pass through the anterior rectus fascia and muscle near the semilunar lines, grab a small element of the mesh as a "U" bite, and then return back through the muscle and anterior rectus fascia. 0-polypropylene sutures are typically used for securing the mesh, but the thinnest patients receive 0-polydiaxanone sutures to limit palpability. The sutures are placed long and snapped for later tying. Full visualization of the undersurface of the rectus muscle is necessary to avoid encircling an intercostal nerve that could cause long-term pain. A tongue of mesh is placed into the Space of Retsius without fixation, both for the functional reason that tension needs to be greatest in the epigastrium, as well for the practical reason to avoid a puncture of the DIEA. Eight or nine sutures a side are placed for each hemi-abdomen. These multiple sutures place the tension on the mesh to close down the linea alba, and to narrow the rectus muscles to a pre-pregnancy "ideal" of 6 cm wide [14]. Half of the mesh (about 5.5 cm) underlies the left rectus, and half (about 5.5 cm) underlies the right rectus muscle–angling on the trajectory of the suture makes up for the final half centimeter on each side. Above the immediate supraumbilical area and with the narrowing of the midline from the rib cage, the mesh is cut to fit and narrowed. The sutures are placed as cephalad as possible. Immediately before closing, an assessment of umbilical stalk viability is made. If one or both of the small feeder vessels to the posterior sheath is in continuity, then a hole is made in the mesh for the umbilical stalk to emerge. With the patient fully muscle relaxed, the abdominal wall is then closed with tying down of the snapped lateral sutures. Though the closure may seem tight and under tension, this style of abdominal wall closure is tolerated by the tissues and has been reliable without any recurrences for either rectus diastasis or incisional hernia repair with a documented 2-year follow-up [15]. In the epigastrium for women, the medial borders of the rectus are tacked down to the mesh to create two separate rectus muscles, while this is not performed in the hypogastrium. Strips of mesh are used for the midline closure in patients with thick skin flaps [16]. Other than occasionally in the area of the xyphoid, Fig. 1 Preoperative photo of slender woman with 6 cm rectus diastasis and widened rectus muscles Fig. 2 Intraoperative photo of narrow polypropylene mesh inset with transfascial sutures | The Surgical Technologist | MAY 2022 212
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