MSCT in diagnostics of rectus abdominis diastasis

Transcription

1 MSCT in diagnostics of rectus abdominis diastasis Poster No.: C-0021 Congress: ECR 2016 Type: Authors: Keywords: DOI: Scientific Exhibit D. Petrenko, O. Sharmazanova, N. Bortnuy; Kharkiv/UA Abdomen, Anatomy, Musculoskeletal soft tissue, CT, Comparative studies, Surgery, Pathology, Dilatation, Tissue characterisation /ecr2016/C-0021 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 9

2 Aims and objectives The anterior abdominal wall consists of abdominal rectus muscles being separated by the linea alba, which is a fusion of the external and internal oblique and transverse abdominal muscles aponeuroses [1,2]. Rectus abdominis diastasis (RAD) (diastasis recti or abdominal muscle separation) is an anatomic term that describes a condition when two rectus muscles are separated by an abnormal distance [3]. Also an acquired RAD is distinguished, which is a complication of conditions weakening the linea alba and resulting in abdominal protrusion. Such condition can be caused by physiological changes such as pregnancy and obesity or by previous abdominal surgery [1,2]. Surgeons often correct RAD during abdominoplasties but there is no current agreement when RAD is pathologic. During systematic search in literature we found 3 well-known classifications, that explain when inter-rectal distance (IRD) is normal. Nahas has formed a qualitative classification based on the myofascial deformity [4]. Beer et al. [2] and Rath et al. [5] classified RAD quantitatively and determined normal values of IRD at three reference points. Multislice computed tomography (MSCT) is often used to examine patients of surgery department during preoperative period [6,7,8]. Despite of the surgical need in progressive diagnostic methods there is no MSCT criteria of pathologic rectus abdominis diastasis for future surgical repair. So the aim of the study was to create simple MSCT criteria of pathologic rectus abdominis diastasis for future myoaponeurotic surgical repair. Methods and materials There were 70 surgical patients examined (mean age 49±11, 42 women and 28 men). Scanning was performed on 16-MSCT Toshiba Aquilion scanner with a standard scan length from the dome of the diaphragm to the inferior margin of the pubic symphysis. During examination patients received both oral and intravenous contrast material if there were no contraindications. Obtained scans were processed to get maximal inter-rectal distance (IRD) and maximal anteroposterior diameter of both rectus abdominis muscles (r1 and r2 respectively). Then rectus diastasis index (RDI) was calculated using formula RDI = (r1+r2)/ird. Images for this section: Page 2 of 9

3 Fig. 1: Patient 41 y.o. Photograph of abdomen with borders of rectus abdominis diastasis and surgical access marked before abdominoplasty. Dmytro Petrenko Page 3 of 9

4 Results The MSCT scanning was performed with 1 mm collimation so measurement accuracy was at millimeter level. To improve practical use of proposed method the decision of measuring the maximal inter-rectal distance (IRD) was made thus avoiding dissociation in measuring at different levels. The mean IRD in patients below 45 year of age (42,9 %) was 31,12 mm, the mean IRD in patients above 45 years of age (57,1 %) was 38,45 mm. According to our research the changes in linea alba are highly connected with changes in rectus abdominis muscles themselves and that could effect on explanation of when RAD is pathological. The mean maximal anteroposterior diameter of rectus abdominis muscles in patients below 45 year of age (42,9 %) was 13,55 mm, the mean maximal anteroposterior diameter of rectus abdominis muscles in patients above 45 years of age (57,1 %) was 9,40 mm. With the next step rectus diastasis index (RDI) was calculated. In 20 patients (28,6%) RDI was over 1,14, in 29 patients (41,4%) RDI was 0,5-0,97, in 21 patients (30,0 %) RDI was less than 0,49. Surgical repair of RAD can be done through an open or laparoscopic access with different techniques such as plication during limited dissection, mini- or classic abdominoplasties, plication using absorbable or non-absorbable sutures, plication combined with absorbable mesh and sutures [9,10,11,12]. The best way to decide what exactly should be done is to correlate the received diagnostic data with most appropriate methods of operative treatment. On the basis of acquired MSCT data of RDI we created 3 grades of RAD for future surgical differential approach: For 1st grade (minor diastasis or normal linea alba, RDI > 1,0) there is no special myoaponeurotic surgical repair needed because the physiological condition of tissues is still on acceptable level and so shouldn't be impaired. For 2nd grade (medium pathologic diastasis, RDI = 0,5-1,0) we recommend abdominoplasty with interrupted sutures which allows to reestablish connective integrity of anterior abdominal wall with less risk of soft tissue ischemia. For 3rd grade (severe pathologic diastasis, RDI < 0,5) we recommend abdominoplasty with use of mesh implant that is a best choice for closure of abdominal defects and has good postoperative period. Images for this section: Page 4 of 9

5 Fig. 1: Patient 41 y.o. Photograph of abdomen with borders of rectus abdominis diastasis and surgical access marked before abdominoplasty. Dmytro Petrenko Page 5 of 9

6 Fig. 2: Patient 37 y.o, where 1 - maximal anteroposterior diameters of both rectus abdominis muscles (r1 and r2), 2 - maximal inter-rectal distance (IRD). This patient has 1st grade of rectus abdominis diastasis (RAD), so there is no need in special myoaponeurotic surgical repair. Dmytro Petrenko Fig. 3: Patients 58 y.o (a) and 61 y.o (b), where 1 and 3 - maximal anteroposterior diameters of both rectus abdominis muscles (r1 and r2), 2 - maximal inter-rectal distances (IRD). Note there is a small difference between inter-rectal distances, but patient "a" has Page 6 of 9

7 2nd grade and patient "b" has 3rd grade of rectus abdominis diastasis (RAD), which will surely lead to different myoaponeurotic surgical repair. The state of anterior abdominal wall in patient "b" is explained by long-term ascites due to cirrhosis. Dmytro Petrenko Page 7 of 9

8 Conclusion With use of MSCT three grades of rectus abdominis diastasis based on rectus diastasis index (RDI) were distinguished: 1st grade (minor diastasis or normal linea alba, RDI > 1,0), 2nd grade (medium pathologic diastasis, RDI = 0,5-1,0), 3rd grade (severe pathologic diastasis, RDI < 0,5). The calculation of represented simple MSCT criteria can help surgeons in future myoaponeurotic surgical repair. Personal information Dr. Dmytro Petrenko "Doctor Alex" clinic, radiology department Kharkiv, Ukraine dpet@ukr.net References 1. Brauman D. Diastasis recti: Clinical anatomy // Plastic and reconstructive surgery Vol # P Beer G. M. et al. The normal width of the linea alba in nulliparous women // Clinical anatomy Vol # P Ranney B. Diastasis recti and umbilical hernia causes, recognition and repair // South Dakota journal of medicine Vol # P Nahas F. X. An aesthetic classification of the abdomen based on the myoaponeurotic layer // Plastic and reconstructive surgery Vol # P Rath A. M. et al. The abdominal linea alba: an anatomo-radiologic and biomechanical study // Surgical and Radiologic Anatomy Vol # P Nahas F. X., Ferreira L. M., de Arimatéia Mendes J. An efficient way to correct recurrent rectus diastasis // Aesthetic plastic surgery Vol # P Page 8 of 9

9 7. Franklin B. R. et al. Predicting abdominal closure after component separation for complex ventral hernias: maximizing the use of preoperative computed tomography // Annals of plastic surgery Vol # P Emanuelsson P. et al. Analysis of the abdominal musculo-aponeurotic anatomy in rectus diastasis: comparison of CT scanning and preoperative clinical assessment with direct measurement intraoperatively // Hernia Vol # P van Uchelen J. H., Kon M., Werker P. M. The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography // Plastic and reconstructive surgery Vol # P Batchvarova Z. et al. Use of a submuscular resorbable mesh for correction of severe postpregnancy musculoaponeurotic laxity: an 11-year retrospective study // Plastic and reconstructive surgery Vol # P Rosen A., Hartman T. Repair of the midline fascial defect in abdominoplasty with long-acting barbed and smooth absorbable sutures // Aesthetic Surgery Journal Vol # P Kanjoor J. R., Singh A. K. Lipoabdominoplasty: An exponential advantage for a consistently safe and aesthetic outcome // Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India Vol # P. 77. Page 9 of 9