Dr Enrico Pöschmann and the Swiss Hernia Center offer first-class care and a wide range of innovative procedures in hernia surgery. With two locations in the canton of Zurich and further centers in Schaffhausen, Schwyz and Zug, the Hernia Center has established itself as a leading point of contact and serves as a recognized center of excellence for hernia treatment. Under the leadership of Dr Pöschmann, an experienced specialist in surgery, the range of services includes diagnosis, consultation and the selection of the appropriate surgical procedure. Dr Pöschmann has a wealth of experience, particularly with complex hernias, including incisional hernias, rectus diastasis and sports hernias.
This high level of medical expertise is supported by modern diagnostic procedures such as ultrasound, CT scans and MRI. A wide range of surgical techniques, including open surgery, minimally invasive procedures and robot-assisted surgery, enables personalized treatment. The Swiss Hernia Center also offers mesh implantation, with patients having the choice between permanent synthetic meshes and biodegradable (resorbable) meshes.
Dr Pöschmann and his team are committed to accelerating patients’ recovery and minimizing the risk of recurrence. Close collaboration with various first-class clinics in and around Zurich ensures patients have access to the best facilities and operating theaters. The most common types of hernia treated include inguinal hernias, umbilical hernias, incisional hernias, diaphragmatic hernias and rectus diastasis. The choice of treatment method is made on an individual basis, taking into account factors such as age, general health and the type of hernia. Dr Pöschmann attaches great importance to ensuring that his patients can return to their normal daily lives as quickly as possible. With extensive experience and leadership roles in leading clinics, as well as academic training and teaching experience, Dr Pöschmann brings impressive expertise in hernia surgery to the table.
The Swiss Hernia Center is a certified center of excellence and is committed to continuous quality improvement in hernia surgery. Close links with national and international professional societies, as well as collaboration with colleagues, ensure that patients always receive the latest and most innovative care. The editorial team of the Leading Medicine Guide wanted to find out more about rectus diastasis and complex abdominal wall hernias and took the opportunity to discuss this with Dr Pöschmann.
Rectus diastasis and complex abdominal wall hernias are medical conditions affecting the abdominal wall and can occur in both men and women of all ages. Rectus diastasis describes the separation of the rectus abdominis muscles, leading to a bulge or stretching of the central abdominal region. Complex abdominal wall hernias can have various causes and refer to hernias or ruptures in the abdominal wall that require more complex surgical interventions. These conditions can lead to pain, functional impairment and cosmetic issues. Treatment often requires a multidisciplinary approach, encompassing surgical procedures, physiotherapy and careful aftercare.
“Normally, these muscles are connected by a firm connective tissue structure called the linea alba. In rectus diastasis, this connective tissue structure is weakened or stretched, leading to a noticeable gap between the abdominal muscles. The main cause of rectus diastasis is excessive stretching of the abdomen, such as can occur during pregnancy,” explains Dr Pöschmann at the start of our conversation. During pregnancy, the abdominal wall undergoes significant stretching due to the growing fetus and the expanding uterus, which can lead to a separation of the rectus muscles. However, this condition can also occur in people who have not been pregnant, particularly in cases of obesity, intensive and incorrect exercise, or in people who have experienced a weakening of the abdominal wall due to abdominal surgery.
Not everyone with a certain gap between the abdominal muscles automatically develops rectus diastasis. A diagnosis usually requires a gap of more than two centimeters and often accompanying symptoms such as abdominal wall tension and back pain. The exact cause and severity of rectus diastasis can vary from person to person.
Rectus diastasis can cause various symptoms that indicate the presence of this muscle separation.
“Signs include a visible bulge or bulge in the abdominal area, which becomes particularly visible when tensing the abdominal muscles or when sitting up from a lying position. This slit-like bulge usually appears lengthwise in the center of the abdomen. In addition, patients may experience a general feeling of abdominal weakness or discomfort in the abdominal area, which indicates increased abdominal wall tension. Back pain may also occur, as the weakened abdominal muscles provide less support for the spine. “The main symptom, however, is a lack of stability, for example when trying to lift something heavy,” explains Dr Pöschmann. Some people with rectus diastasis experience digestive problems such as bloating or constipation, which may be linked to this muscle separation. In rare cases, incontinence issues may also arise, with noticeable difficulty controlling urine.
Rectus diastasis is typically diagnosed by a surgeon or a gastroenterologist.
The doctor will carry out physical examinations and check the abdomen for visible bulges and the width of the gap between the rectus muscles. “A clinical examination in itself provides a clear diagnosis. In some cases, small bowel loops can be felt simply by palpation. An ultrasound scan or a computed tomography (CT) scan is also often used to determine the severity of the diastasis and the exact position of the muscle separation. Grade 1 rectus diastasis is up to 3 cm, Grade 2 is 3–5 cm, and Grade 3 refers to separations of 5 cm or more. Precise biomechanical studies are available on this,” says Dr Pöschmann. It is important to obtain a correct diagnosis, as not all abdominal symptoms automatically indicate rectus diastasis, and treatment may vary depending on the severity.
Treatment options for rectus diastasis vary depending on the severity and individual circumstances.
“In milder cases, conservative measures such as targeted abdominal exercises as part of physiotherapy and the use of abdominal belts, kinesiology tape or compression garments can help to alleviate symptoms and stabilize the abdomen. Lifting and breathing techniques can also be taught by physiotherapists, and in the case of women post-delivery, by
midwives. If rectus diastasis is significant, measuring 20 cm or more, this means that the bowel is also positioned differently in the pelvis or body than is normally the case. In such more severe cases, or where symptoms are severe, surgery may or should be considered. There are 48 different surgical techniques worldwide, ranging from a large incision from top to bottom to robot-assisted surgery. This also determines the length of stay in hospital and the follow-up treatment.
Ultimately, I offer my patients two options, which also depend somewhat on the aesthetic aspect. For men, I generally recommend open surgery due to the high level of stability it provides, as men are often less stable in terms of body weight than women. For women, I usually recommend the classic laparoscopic surgery, a minimally invasive procedure, or surgery using robotic assistance – in our case with the da Vinci robot – because it requires only three small incisions. This does not alter the amount of skin or fat involved. The abdominal incision line is restored and reinforced using a synthetic mesh (absorbable or non-absorbable). With minimally invasive surgery, the patient naturally recovers more quickly.
With standard, open surgery, an incision is made across the mid-abdomen from right to left or in the lower abdomen, where a cesarean section is also performed. At the same time, a tummy tuck can be performed here, which is recommended for many women with severe damage to the connective tissue, as part of the abdominal wall with the damaged skin can be removed. However, this results in a large wound and requires special vacuum dressings. For the patient, this means that they will initially be unable to walk upright for the first two weeks. It is important to understand that when the rectus diastasis – that is, this wide gap – is closed again, the pressure in the abdomen increases significantly. This initially causes pain and puts pressure on the bowel, which can lead to bowel paralysis at first. The length of the patient’s hospital stay depends on the level of pain. Normally, the hospital stay is 4–7 days, and the patient can be discharged with mild painkillers. Afterward, patients wear an abdominal support belt for around 6 weeks to provide stability and to prevent fluid build-up around the wound. Physical activity should be avoided during this period. After the 6 weeks, there is another ultrasound scan to confirm that the muscles are indeed lying flush against one another. Then rehabilitation begins with very intensive physiotherapy,” explains Dr Pöschmann, outlining the surgical options and the measures following a successful operation.
The use of synthetic meshes in abdominal wall hernias has come to play a significant role in modern surgery.
These innovative meshes, also known as hernia meshes, are used in the treatment of hernias to support and stabilize the weakened abdominal wall. Their use has proven to be one of the most effective and commonly used techniques to support the restoration of the abdominal wall and reduce the likelihood of a recurrence. Dr Pöschmann describes the differences between the meshes: “A distinction is primarily made between two types of mesh: permanent meshes and biological/biodegradable meshes. The permanent ones remain in the patient’s abdomen for life. Biological meshes used to be derived from cattle and pigs – we know that these do not achieve good results. These have not yet disappeared from the market, but are hardly ever used anymore – I do not use them either. And then there are the synthetic biodegradable meshes, which are broken down by the body in a controlled manner over a certain period of time (approx. 15–18 months) and replaced by the body’s own stable connective tissue. Ultimately, it always comes down to the surgeon’s experience as to which type of mesh they use and when.”
Complex abdominal wall hernias.
“A rectus diastasis is a complex abdominal wall hernia. In the past, these were referred to as incisional hernias, for example when the scar ruptures in a patient who has previously undergone surgery and the intestine protrudes, or when the hernia is so large that a significant portion of the small intestine is no longer in the abdominal cavity but within the hernial sac itself. Even if hernias are not in the middle but more to the side, these are also complex abdominal wall hernias because they are more difficult to treat,” explains Dr Pöschmann.
Rectus diastasis primarily refers to the separation of the abdominal muscles, whereas a complex abdominal wall hernia involves the presence of a hernia or defect in the abdominal wall itself, through which abdominal organs or tissue can enter the hernial sac. In a complex abdominal wall hernia, organs such as the bowel, peritoneum or other structures can pass through the gap in the abdominal wall and become trapped in the hernial sac. In a rectus diastasis, organs do not normally protrude.
Risk factors for complex abdominal wall hernias can be varied and depend on individual anatomy and lifestyle.
A history of abdominal surgery, particularly operations that affect the abdominal wall, can increase the risk of complex abdominal wall hernias. “Women who have been through multiple pregnancies or
given birth to multiple babies have an increased risk of abdominal wall hernias, as the abdominal muscles are put under significant strain during pregnancy and there is increased weakness of the connective tissue. Being overweight or obese, as well as weight fluctuations, put additional pressure on the abdominal wall and increase the risk of abdominal wall hernias. Recurrent hernias can also be triggered by a ruptured appendix. Age naturally plays a role too, as connective tissue is usually weakened in older people as well,” explains Dr Pöschmann.
There are a number of preventive measures that anyone can take.
“A certain amount of daily exercise for the abdominal muscles is always beneficial. Naturally, this is only advisable if there are no complications in the form of abdominal wall hernias, which can also be painful. After pregnancy, postnatal exercise is really important to keep engaging the muscles so that they do not become progressively weaker. It’s about achieving a balance between the back and abdominal muscles. This creates a good foundation. It’s no guarantee that rectus diastasis won’t occur – I’ve even had elite athletes with this diagnosis. There’s a certain element of fate involved there. Ultimately, what matters is feeling good about your body, and if you notice something becoming looser or weaker, it’s important to try to train against it. And if that doesn’t work, it needs to be medically assessed,” Dr Pöschmann strongly recommends.
Complex abdominal wall hernias can occasionally recur after surgery, particularly if the patient is exposed to further risk factors.
Long-term effects on quality of life can be compromised by pain, scarring or loss of function. Regular follow-up care and rehabilitation can help to maintain or improve quality of life. “In any case, it is important to maintain a good sense of physical well-being after the operation and to notice small changes. The risk of recurrence is very low today, precisely because of the good surgical techniques and the high quality of the meshes used. Women should be more vigilant when they go through the menopause, and men when they put on weight and their overall body anatomy changes as a result. This increases the risk of recurrence or even new hernias,” advises Dr Pöschmann to those affected after surgery.
In safe hands at the Hernia Center in Switzerland!
The Hernia Center in Switzerland is a leading medical center at the forefront of hernia treatment. With a highly specialized and multidisciplinary approach, the center offers innovative and tailor-made solutions for patients suffering from various forms of abdominal wall hernias or diaphragmatic hernias. Full pelvic floor reconstructions are also performed at the Hernia Center in Switzerland. Through the use of state-of-the-art techniques and under the guidance of experienced surgeons, comprehensive care and support of the highest medical standard are guaranteed here. “We have a structure that wasn’t initiated by a single clinic, but rather through a collaboration of colleagues who also perform a great many hernia operations. Direct and personal contact with the patient is clearly our top priority. We also benefit from short lines of communication and a high level of interaction between colleagues. This means we discuss our cases within the team and operate together. This means we always have two specialists at the operating table, so that by working together we can achieve the best possible outcome for the patient. We have several locations across different cantons in Switzerland, operate in collaboration with various partner hospitals, and undergo continuous professional development to ensure we are always up to date. Furthermore, we have a very robust internal and external quality assurance system, which ultimately demonstrates that we perform very well, with very few complications and a very low risk of recurrence,” emphasises Dr Pöschmann, bringing our conversation to a close.
Dr Pöschmann, thank you very much for such a clear insight into the treatment options and the challenges involved in treating abdominal wall hernias!
