Brian P. Jacob, MD FACS

Products And Services

• Diastasis Recti

  Definition A diastasis of the abdominal wall , (diastasis recti), is not a hernia. Clinically, a diastasis may look like a hernia in the sense that when the abdomen is flexed, there is a noticeable and cosmetically unpleasing bulge, usually located in the upper abdomen in the midline, above your belly button. But there is a big difference. A hernia is a hole in the fascia. A diastasis is just stretched out midline fascia, and not a real hernia. Thus a diastasis has no real incidence of developing an emergent incarceration or strangulation. A diastasis, with stretched out midline fascia, results in your two rectus muscles being far apart. Presentation Diastasis recti can present as a bulge or pain (or both) in your abdomen. Abdominal wall function weakness is a common symptom, and has often been reported as improved after diastasis repair. However , despite being symptomatic, a diastasis repair alone is still considered elective, cosmetic, and is therefore not reimbursed by most insurance companies. Watch and Learn (no mesh laparoscopic diastasis recti repair) Dr. Brian Jacob offers a minimally invasive (laparoscopic) non-mesh diastasis repair. The procedure has been vetted and accepted by colleagues internationally. There is no skin excision, which is a big difference from a traditional plastic surgery abdominoplasty. This surgery is only offered to select patients. Please discuss all of the risks, expectations, and potential benefits with your surgeon. Recurrent diastasis recti and hernia formation is possible. Seromas are possible. Cosmetic results can not always be guaranteed. This surgical video may contain graphic surgical images for mature audiences only. It is designed with the sole intent to educate other surgeons. Next steps for you If you think you have a diastasis recti, then make an appointment with a hernia expert or a plastic surgeon to discuss your options. Most diastasis do NOT require surgery. Some surgeons are using minimally invasive approaches (laparoscopy and robotics) to suture close the stretched out fascia and thus reapproximate the rectus muscles. Insurance usually does not cover this procedure since technically this is not a hernia repair. Each case needs to be individualized. Most surgeons would recommend nonoperative attempts that include weight reduction and physical therapy. Specific physical therapy programs may exist in your region. Imaging for diastasis recti is sometimes useful and your surgeon may order a CTSCAN. This CTSCAN can identify the extent and size of the diastasis, and can be used to accurately measure how far apart your rectus muscles are, and confirm that it is not a hernia. Some patients have small hernias, or an umbilical hernia, within the diastasis. Repair options for diastasis recti include: no surgery. Trial of time and / or physical therapy. open primary repair (often done by a plastic surgeon at the same time as an abdominoplasty to removed excess skin) open mesh repair (This is rarely done or needed for primary diastasis). laparoscopic or robotic diastasis suture repair with or without mesh reinforcement. If mesh is used, then suture fixation, tack fixation, or a combination are common. The main objective here is to use a suture to reapproximate your rectus muscles to the midline. Dr. Jacob offers a laparoscopic repair of diastasis without mesh for select cases. Some surgical risks include, but are not limited to: Recurrences, chronic pain, bowel obstruction, enterotomy, mesh erosion, fistula, seroma, hematoma, and infection. Surgical Preparation Patients with obesity (BMI greater than 35) should try to lose weight to keep a body mass index less than 35 if possible. If you have obesity, it is not advised to have a diastasis repair as the recurrence rates are quite high.

  Video: Diastasis Recti

  Link: Diastasis Recti

• Hidden (Occult) Hernia

  Chronic groin pain can sometimes be from a “hidden” inguinal or femoral hernia Figuring out how to diagnose the cause of long term (chronic) groin and pelvic pain can be challenging. Sometimes chronic groin pain in women and men are from a really small, “hidden” inguinal hernias.

  Link: Hidden (Occult) Hernia

• Chronic Groin Pain After Hernia Surgery

  Dr. Brian Jacob operates on select patients with chronic groin pain and chronic pelvic pain. “Dr. Jacob has extensive experience with hernia mesh removal procedures in New York City.” Acute and Chronic Pain – It is very important to tell your surgeon if you have any chronic groin pain or leg pain BEFORE the operation. The typical recovery after a laparoscopic inguinal hernia repair is associated with mild to moderate incisional pain and mild groin discomfort. This may last anywhere from 2 – 14 days, but is almost always gone by the 3rd or 4th week after surgery. The groin discomfort may be secondary to the gas used during surgery, the dissection, or rarely the mesh material or tacks (if used). There are a variety of mesh fixation materials that surgeons may choose to use, and all have a rare, but possible association with causing groin pain. These fixation options include (staples, permanent tacks, absorbable tacks, or glues). Some surgeons do repair without using mesh fixation materials at all. Acute severe groin pain – Groin pain that is severe immediately after surgery should be brought to your surgeon’s attention, as this can be due to direct irritation from surgical material and could warrant return to the operating room to remove the foreign material or tack (if used). Fortunately, this risk is extremely rare. Should it occur, however, acute nerve injury could increase the risk of developing chronic pain. Chronic groin pain (can be mild or severe) is defined as the presence of pain, discomfort, or hypersensitivity (not present before surgery) existing for more than 3 months after surgery. According to one national database, even a healthy male with no previous history of groin pain has as high as a 6% risk of developing chronic discomfort after undergoing any type of inguinal hernia repair. While the general risks of developing this chronic discomfort exist, our group’s experience has kept this complication at an absolute minimum. There are 6 nerves in the groin that your surgeon is aware of and will avoid harm to. Lateral femoral cutaneous nerve – This nerve is the most lateral nerve in the groin, innervates the upper lateral thigh skin, and in the past was the most common nerve irritated during a laparoscopic repair. If irritated, there may be pain or hypersensitivity experienced along the lateral thigh. Genitofemoral (GF) nerve (both the femoral branch and the genital branch) – This nerve and its terminal branches are not routinely dissected out during a routine laparoscopic repair, but are well known to exist in the region just medial to the psoas muscle and lateral to the external iliac vein. The location of the two terminal branches varies. The trunk or either branch, however, can be potentially irritated or injured by the dissection, a tack, or by the mesh material. By limiting the use of tacks near its known location, injury to it can be minimized. The genital branch runs in the inguinal canal, under the spermatic cord in men and round ligament in women, and innervates the inner thigh and the lateral scrotal skin in men, and the labia majora in women. Its irritation is usually perceived by a hypersensitive scrotum in males and hypersensitive labia majora in females. The femoral branch innervates the anterior thigh, and irritation can lead to pain or hypersensitivity of the upper anterior thigh. Femoral nerve (and its anterior cutaneous branches) – Like the GF nerve above, this nerve is not routinely identified during routine laparoscopic hernia dissection, but it does exist just lateral to the psoas muscle and entering the leg lateral to the femoral artery. Rather rarely, it at risk to be irritated or injured by use of a tack below the ileopubic tract. Even rarer, mesh can irritate this nerve. By limiting the use of tacks near its known location, injury to it can be minimized. If irritated or injured, leg muscles may feel heavy or weak, or pain along the leg may result. Iliohypogastric nerve – This nerve may only be injured during a laparoscopic repair if a tack were to penetrate through the muscle and into the nerve. The incidence of irritation during a laparoscopic repair is extremely rare. Pain or hypersensitivity to the suprapubic region or groin may occur. Ilioinguinal nerve – this nerve may be injured during a laparoscopic inguinal hernia repair only if your surgeon uses tacks and these tacks penetrate through muscle into this nerve. Its injury during a laparoscopic repair is extraordinarily rare. Irritation causes pain or hypersensitivity to the medial thigh, shaft of the penis, or groin. Paravasal nerve fibers (tiny nerves along the vas deferens in a male) – irritation of these may cause temporary testicular discomfort.

  Link: Chronic Groin Pain After Hernia Surgery