Postpartum Anterior Abdominal Wall Insufficiency Syndrome (PPAWIS)

Until recently, changes in the abdominal wall following pregnancy were regarded merely as morphological tissue alterations. However, research conducted by Dr. Maciej Śmietański’s team between 2017 and 2020 has demonstrated that this condition is a far more complex clinical entity. The studies involved over 250 patients operated on by Dr. Śmietański. Diastasis of the linea alba — that is, the widening of the gap between the rectus abdominis muscles — leads not only to the abdomen taking on a conical shape, but is also a cause of lower back pain due to disruption of the entire trunk’s biomechanics.

Skin changes, such as stretch marks and excess skin (abdominal apron), do not only impair aesthetics but also cause decreased self-esteem, diminished sense of attractiveness, and sexual dysfunction. They lead to loss of confidence in social situations, such as going to the beach, swimming pool, or exercising at the gym. For these reasons, the current trend is to view these changes — morphological, neurological, and psychosocial — as a syndrome rather than an isolated abdominal wall disorder.

Over the last two decades, the incidence of this syndrome has increased. This is linked to later maternal age at childbirth in developed countries, as well as mothers’ concern for their newborns’ health. Improved diets, vitamins, and supplements contribute to higher birth weights, resulting in greater abdominal stretching during pregnancy. It is understandable that during pregnancy the child’s well-being is the priority, and therefore no blame should be attributed to women for the postpartum condition of their abdomen. This syndrome significantly lowers quality of life, and thus treatment should not be dismissed as mere vanity or a desire for a “flat stomach.” Indications for surgery are medical and relate to health improvement.

The main surgical treatment goals are:

  • Restoration of the rectus muscles’ position and repair of any concomitant umbilical hernia, which is crucial for trunk function.
  • Prevention of recurrence of the linea alba diastasis through implantation of a mesh (hernia mesh).
  • Preservation of peritoneal continuity, i.e., avoiding opening the abdominal cavity. Each opening leads to adhesion formation, so if the peritoneal cavity can remain intact for decades of the patient’s life, it should be preserved. Therefore, laparoscopic methods, where the implant is placed inside the peritoneum, are not used.
  • Avoidance of damage to the rectus sheaths. Hence, the mesh is not placed in the sublay (retromuscular) position but sewn onto the anterior rectus sheath (onlay position). This placement completely protects the function of the rectus muscles.
  • Achieving a good cosmetic outcome via abdominoplasty at the end of the procedure. A lower abdominal incision (removing the cesarean section scar) is made to access the entire linea alba subcutaneously. Sometimes, besides skin flap shortening, umbilical repositioning is required, leaving a circular scar around the navel.

This surgical approach provides durable results, improving not only the abdominal appearance but also trunk function and positively impacting the psychological disturbances described above.

The procedure is typically performed approximately six months after the last planned pregnancy. Scientific studies show that if the linea alba diastasis does not reduce by about three months postpartum through rehabilitation, spontaneous resolution is unlikely later; thus, prolonged physical therapy beyond this period is ineffective. Surgery is also postponed until the patient reaches her desired body weight after weight loss. While the specific weight does not matter, if the patient plans to lose more than 7–10 kg, surgery is deferred until this goal is achieved to ensure better cosmetic outcomes.

Patients should anticipate the need for support from family or close persons during the postoperative period. For at least two weeks after surgery, patients should avoid managing household duties and full-time care of (young) children. The full rehabilitation period lasts approximately six weeks.