Subcutaneous versus retromuscular approach for the minimally invasive surgical treatment of rectus diastasis with concomitant ventral hernia: systematic review and meta-analysis of current techniques

Purpose: This systematic review and meta-analysis aims to evaluate the outcomes of laparoendoscopic extraperitoneal techniques for repairing rectus diastasis (RD) with concomitant ventral hernias, focusing on recurrence rates, surgical site occurrences, and the effectiveness of various surgical approaches and mesh placement sites. Methods: A comprehensive literature search was conducted using PubMed and the Cochrane Library, adhering to PRISMA guidelines. Prospective and retrospective cohort studies involving adults with RD and concomitant ventral hernias were included. Surgical techniques were classified based on working space (subcutaneous vs. retromuscular) and wall repair technique (stapled vs. fascial plication suture). The primary outcome was recurrence of RD or hernia, and secondary outcomes included seroma, surgical site infections (SSIs), and bleeding. Results: Twenty-two studies comprising 1,616 patients were analyzed. Mean age was 45.6 years, BMI 30.5 kg/m², with a mean follow-up of 10.5 months. All studies were non-randomized and rated as having a “Serious” risk of bias using the ROBINS-I tool. Recurrence occurred in 19 patients (0.99%), with no significant differences between subcutaneous and retromuscular approaches (0.93% vs. 1.16%, p = 0.802) or between stapled and fascial plication techniques (0% vs. 1.18%, p = 0.090). Seroma rates were significantly higher in the subcutaneous group compared to retromuscular approach (11.8% vs. 0.70%, p < 0.001). SSIs were more common in subcutaneous approaches (2.33% vs. 0.58%, 0.005). Bleeding was low across all groups (1.3%), with higher rates in the stapled compared to the fascial plication group (6.39% vs. 0.37%, p < 0.001). Conclusions: Laparoendoscopic extraperitoneal approaches for RD and ventral hernia repair demonstrate favorable outcomes, with low and comparable recurrence rates among subgroups. The subcutaneous approach is associated with a higher risk of seroma formation while the stapled technique may increase bleeding risk. Further studies with higher methodological quality are needed to guide optimal technique selection.