Rectus diastasis is not a single entity: phenotype-specific controversies in surgical management

Rectus diastasis (RD) is increasingly treated by general, abdominal wall and plastic surgeons, but controversies persist because clinically distinct phenotypes are often analysed together. This critical narrative review re-examines surgical management of RD through a phenotype-specific framework.

PubMed, MEDLINE, Embase and Cochrane Library were searched for English-language studies, systematic reviews, meta-analyses, consensus statements and guidelines addressing adult RD management. Evidence was interpreted by phenotype, anatomical severity, associated hernia status, operative goal and outcome domain rather than pooled quantitatively.

RD should not be considered a single operative problem. Postpartum women commonly present with core instability, back pain, pelvic floor symptoms, skin redundancy and aesthetic concerns, whereas male or obesity-associated patients more often present with concomitant midline hernia and potentially different abdominal wall mechanics. This distinction alters the relevance of conservative treatment, suture plication, mesh-suture or planar mesh reinforcement, abdominoplasty-based repair and minimally invasive surgery. Available comparative data support the feasibility of both suture and mesh-supported repair in selected patients, but evidence remains limited by short follow-up, heterogeneous recurrence definitions and inadequate aesthetic outcome reporting.

The central unresolved controversy is not which technique is best for RD in general, but which technique is best for which phenotype and treatment goal. Future studies should stratify patients by sex, parity, tissue compliance, diastasis width, hernia status, skin-adipose excess, body mass index or weight-loss history, and functional versus aesthetic indication.