Is it a hernia or diastasis?

Diastasis recti is a common clinical condition and is frequently confused with hernia. The two are distinctly different and, thus, require different treatments. The term diastasis means a separation of two parts. Recti is the plural of rectus which is the straight muscles of the midline of the abdominal wall, frequently referred to as the “six-pack” muscles. With a diastasis, a bulge may become noticeable in the midline of the abdomen, especially when the patient raises his/her head while lying flat. For this reason, it is frequently confused with a hernia.

Diastasis, or separation, of the rectus muscles can occur naturally, meaning that the patient is born this way. Over time, especially if the patient gains excess weight, pressures can widen the separation and make the bulge more apparent. Separation of the midline muscles may also occur in women following pregnancy. As the abdominal wall expands to accommodate the baby, widening of the gap between the rectus muscles may occur. The separation may persist following delivery of the baby. Typically, men have separation of the rectus muscles in the upper portion of the abdominal wall, whereas females are more likely to have diastasis of the lower portion of the abdomen below the umbilicus.

It is very important to distinguish a diastasis from a hernia. With a diastasis, there is a widening of the muscles; however, the fascia of the abdominal wall stays intact. The fascia is the collagen sheet that covers the muscles and gives patients the shape and form of their abdominal wall. If there is an actual hole or defect in the fascia, this condition is the definition of a hernia. The implications of the two are dramatically different.

As you can imagine, distinguishing a diastasis from a hernia can be challenging. However, there are some clues to characterize each. A diastasis occurs in the midline of the abdominal wall, whereas hernias can occur anywhere. Hernias of the abdominal wall are typically in the site of previous surgery. Weakness of the abdominal wall results from a breakdown in wound healing which usually results due to a wound infection. Diastasis does not enlarge over time, whereas hernias typically do. Most importantly, hernias can incarcerate or strangulate which can present as emergent situations due to potential harm to the intestines. This concern does not exist with a diastasis, as the fascia remains intact.

The only definitive treatment of a hernia involves surgery with closure of the hole, usually supported by mesh. Patients may elect to not have surgery if the hernia is small in size, is not painful, or if other conditions make surgery too risky. For a diastasis, treatment rarely involves surgery. In the majority of cases, it is important to reassure the patient that there is no possibility of the bowel becoming trapped with a diastasis. Additionally, it is uncommon for a diastasis to enlarge or worsen.

Exercise to strengthen the core muscles may help to minimize the bulging; however, the normal anatomy will never be restored. Rarely, if the diastasis causes significant pain or loss of support of the back, surgery may be appropriate. Usually in this situation, the surgery is considered cosmetic, and repair may be combined with the assistance of plastic surgery.

If you have a bulge in your abdominal wall and are concerned about a hernia or diastasis, we are more than happy to evaluate you and provide treatment options. Please call the Prisma Health Hernia Center at 864 676-1072.

Blog post author Dr. William Cobb is a surgeon with Prisma Health’s Hernia Center/Minimal Access Surgery.

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