Abstract
Background
Rectus diastasis is a prevalent condition associated with functional impairment and aesthetic deformity. Although minimally invasive techniques have emerged, they remain limited by technical constraints and incomplete integration with body contouring procedures.
Objectives
The aim of this study was to report the clinical experience of the authors with the Minimally Invasive Robotic Endoscopic Lipoabdominoplasty (MIRELA) technique for rectus diastasis repair and abdominal contouring.
Methods
A retrospective descriptive study was conducted including 55 female patients who underwent MIRELA between 2023 and 2025. After loss to follow-up, 53 patients were included in the final analysis. The procedure combined VASER-assisted liposculpture with robotic-assisted extraperitoneal rectus plication using the da Vinci Xi system. Demographic characteristics, perioperative variables, postoperative complications, reinterventions, and hospital readmissions were evaluated. Continuous variables were reported as mean ± standard deviation, and categorical variables as frequencies and percentages.
Results
The mean age was 39.4 ± 5.1 years, and the mean follow-up was 6 months, ranging from 4 to 9 months. Mean BMI was 21.9 ± 3.4 kg/m2; among patients with available BMI category data, 89.8% were classified within the normal weight range. Mean rectus diastasis width was 3.22 ± 0.95 cm, with 66.0% of patients presenting a diastasis ≥3 cm. Concomitant umbilical hernia was present in 75.5% of cases. All procedures were completed under general anesthesia, with a mean operative time of 190.0 ± 6.1 min. No intraoperative or postoperative complications, reinterventions, or hospital readmissions were observed.
Conclusions
MIRELA is a feasible and reproducible technique that integrates robotic-assisted precision with minimally invasive aesthetic surgery principles. It represents a promising option for a very selected group of patients with minimal-to-moderate rectus diastasis and no excess skin requiring cutaneous excision. Further studies with longer follow-up are required.
Level of Evidence: 4 (Therapeutic)
Rectus diastasis is a highly prevalent condition, particularly among postpartum patients, and is associated with both functional compromise such as impaired core stability and aesthetic concerns related to abdominal contour deformity.1,2 Conventional open abdominoplasty continues to be regarded as the gold standard for its correction; however, it is inherently associated with extensive cutaneous incisions, visible scarring, and a higher degree of surgical morbidity.3,4
In response, minimally invasive strategies have been developed with the aim of reducing surgical trauma while achieving effective midline restoration. Laparoscopic and endoscopic approaches have demonstrated technical feasibility; nevertheless, they are limited by constrained instrument articulation, suboptimal 3-dimensional visualization, and reduced capacity for precise tissue handling.5,6 Furthermore, these techniques present challenges in the seamless integration of aesthetic procedures, particularly liposuction and contour refinement.
An additional limitation lies in the reliance of many of these approaches on intra-abdominal access or multidisciplinary collaboration involving general and plastic surgeons, which may restrict the surgeon's ability to fully control and optimize aesthetic outcomes.7
These constraints underscore the need for an advanced minimally invasive solution that enables accurate myofascial repair while preserving comprehensive aesthetic control. In this context, the Minimally Invasive Robotic Endoscopic Lipoabdominoplasty (MIRELA) technique was developed as an innovative approach that incorporates robotic-assisted technology into a plastic surgery–driven platform, allowing simultaneous rectus diastasis repair and high-definition body contouring within a single, integrated procedure.
The objective of this study was to describe our surgical experience with the MIRELA technique, including patient clinical characteristics, perioperative variables, and postoperative outcomes, such as intraoperative and postoperative complications, reinterventions, and hospital readmissions during the follow-up period, supported by data derived from a retrospective analysis.
METHODS
This retrospective descriptive study evaluated a consecutive series of 55 female patients who underwent MIRELA for rectus diastasis repair at 2 specialized robotic surgery centers in São Paulo, Brazil, between 2023 and 2025. Two patients were lost to follow-up, yielding a final analytical sample of 53 patients.
Inclusion criteria comprised age 18 to 50 years, aesthetic dissatisfaction with abdominal contour, and consent for data and image use. Exclusion criteria included diastasis >6 cm, visceral fat >12% with InBody 120 body composition analyzer (InBody Co., Ltd, Seoul, Republic of Korea), and moderate-to-severe abdominal laxity (Matarasso ≥II). Patients with generalized abdominal wall weakness, marked musculoaponeurotic laxity, or moderate-to-severe skin laxity were not considered ideal candidates for this technique and were excluded by the selection criteria. In this case series, all plications were performed by approximating the true medial borders of the rectus muscles, and no patient required a wider plication beyond the medial rectus edges.
Preoperative evaluation included anthropometric data, and umbilical hernia and diastasis size were determined preoperatively by ultrasonographic assessment and recorded as the largest transverse diameter of the fascial defect. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the Institutional Ethics Committee of Hospital e Maternidade São Luiz (HMLS) and the corresponding ethics committee of the participating robotic surgery center. Given its retrospective design, institutional authorization was obtained for access to medical records and follow-up data. All patients provided written informed consent for the surgical procedure and authorized the use of their clinical data and images for academic and research purposes. All data were recorded in a coded, password-protected database and analyzed using SPSS software (version 25.0; IBM Corp., Armonk, NY).
Minimally Invasive Robotic Endoscopic Lipoabdominoplasty (MIRELA) Technique
Under general anesthesia with prophylactic tranexamic acid (1 g), surgical access was established using three 8 mm suprapubic robotic ports positioned along a Pfannenstiel-type line, ∼6 cm apart. In addition, 6 auxiliary 4 mm incisions were placed in concealed anatomical locations along the lower abdominal and suprapubic region to facilitate tumescent infiltration, liposuction access, drainage, and transcutaneous umbilical fixation, while avoiding visible abdominal scarring. Tumescent infiltration (saline with epinephrine 1:1,500,000 plus tranexamic acid) was followed by VASER-assisted liposculpture ultrasonic-assisted liposuction system (Solta Medical, Inc., Bothell, WA; Figure 1).
Figure 1.
Robotic port placement. Three suprapubic ports are positioned along a Pfannenstiel-type line, ∼6 cm apart, with a central optical port and 2 lateral working ports. No assistant port is used to avoid additional scars.
The da Vinci Xi Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was then docked. A subcutaneous preaponeurotic working space was developed superficial to the anterior rectus sheath, corresponding to the lower abdominal undermining plane and extended from the suprapubic region to the xiphoid as required for complete xiphopubic plication.
Before plication, the Sanfurgo maneuver, a robotic-assisted intraoperative mapping technique developed by the senior author, was systematically performed to improve anatomical accuracy during midline reconstruction. The maneuver consists of controlled monopolar electrocautery stimulation along the anterior abdominal wall to elicit selective contraction of the rectus abdominis fibers, allowing precise identification of the true medial borders of each rectus muscle before suture placement using predefined anatomical reference points, including the xiphoid region, supraumbilical segment, umbilical level, and infraumbilical region.
These sequential markings were then interconnected to establish a continuous and anatomically accurate plication pathway, serving as a reproducible guide for suture placement and ensuring consistent medialization of the rectus muscles along the entire xiphopubic axis.
Xiphopubic plication was completed using a continuous barbed suture Stratafix Zero Symmetric PDS Plus Knotless Tissue Control Device (Ethicon, Inc., Raritan, NJ), guided by these markings to ensure accurate midline reconstruction.
The umbilicus was managed using an umbilical float-type technique. No circumferential skin incision was made around the umbilicus, and the umbilicus was not detached from the surrounding abdominal skin envelope. Its cutaneous and subdermal vascular connections were preserved. When required to allow adequate midline plication and associated umbilical hernia repair, only the deep fascial attachment was released. The umbilicus was then repositioned and secured with transcutaneous 3-0 nylon fixation (Figure 2). A 10-Fr Blake drain was then placed, and all incisions were closed in layers according to standard postoperative protocols.
Figure 2.
Intraoperative view of preaponeurotic dissection and rectus plication. The procedure is performed in the preaponeurotic plane using robotic instrumentation, allowing precise dissection and continuous midline plication without intra-abdominal access.
Postoperative care included intermittent pneumatic compression stockings throughout the surgical procedure as part of the venous thromboembolism prophylaxis protocol. Pharmacologic thromboprophylaxis with enoxaparin was initiated 12 h after surgery and continued for 7 days, in accordance with international recommendations for patients undergoing large-volume liposuction and body contouring procedures. Early assisted ambulation was encouraged on the day of surgery, and incentive spirometry was initiated 24 h postoperatively. Patients were instructed to wear an abdominal compression garment for 6 weeks and underwent routine outpatient follow-up. Light daily activities were allowed after the first postoperative week, whereas strenuous exercise and abdominal wall strengthening were restricted for at least 4 to 6 weeks. The 10 Fr Blake drain was removed when output was below 30 mL over 24 h, typically between postoperative Days 5 and 7 (Video).
RESULTS
A total of 53 patients underwent the MIRELA procedure and were included in the final analysis. The cohort consisted exclusively of female patients, with a mean age of 39.4 ± 5.1 years (range, 29-50 years). The most represented age group was 35 to 39 years (35.8%), followed by 40 to 44 years (24.5%; Table 1). The mean follow-up period was 6 months, with a range of 4 to 9 months.
Table 1.
Baseline Demographic and Clinical Characteristics (MIRELA Procedure, N = 53)
| Variable | n/Mean | %/SD | Range |
|---|---|---|---|
| Demographic data | |||
| Total patients | 53 | — | — |
| Age (years) | 39.4 | ±5.1 | 29-50 |
| Age group (years) | |||
| <30 | 2 | 3.8% | — |
| 30-34 | 10 | 18.9% | — |
| 35-39 | 19 | 35.8% | — |
| 40-44 | 13 | 24.5% | — |
| 45-49 | 7 | 13.2% | — |
| 50+ | 2 | 3.8% | — |
| Body composition | |||
| BMI (kg/m2) | 21.9 | ±3.4 | 18.9-26.1 |
| BMI category | |||
| Underweight (<18.5) | 1 | 1.9% | — |
| Normal weight (18.5-24.9) | 44 | 83.0% | — |
| Overweight (25.0-29.9) | 4 | 7.5% | — |
| Obese (≥30.0) | 0 | 0.0% | — |
| Missing data | 4 | 7.5% | |
| Body fat percentage | 24.6 | ±5.5 | 13.0-34.3 |
| Visceral fat index | 5.7 | ±1.8 | 2-9 |
| Obstetric history | |||
| Number of pregnancies | 1.7 | ±0.7 | 0-4 |
| Gravidity | |||
| G0 | 1 | 1.9% | — |
| G1 | 18 | 34.0% | — |
| G2 | 26 | 49.1% | — |
| G3 | 5 | 9.4% | — |
| G4 | 1 | 1.9% | — |
| Missing data | 2 | 3.8% | |
| Abdominal wall findings | |||
| Rectus abdominis diastasis (cm) | 3.22 | ±0.95 | 1.2-6.0 |
| Diastasis ≥3 cm | 35 | 66.0% | — |
| Diastasis <3 cm | 18 | 34.0% | — |
| Concomitant umbilical hernia | 40 | 75.5% | — |
| Umbilical hernia sizea (cm) | 0.88 | ±0.43 | 0.3-2.0 |
Continuous data expressed as mean ± SD. Categorical variables as n (%).
MIRELA, Minimally Invasive Robotic Endoscopic Lipoabdominoplasty; SD, standard deviation.
aOnly in patients with umbilical hernia (n = 40).
Regarding obstetric history, most patients had a history of previous pregnancy. Gravidity data were available for 51 patients, whereas 2 patients had missing gravidity data. Within the final analytic cohort, 49.1% were classified as G2 and 34.0% as G1, whereas nulligravidity was uncommon, accounting for 1.9% of patients (Table 1).
In terms of body composition, the mean BMI was 21.9 ± 3.4 kg/m2. BMI category data were available for 49 patients, whereas 4 patients had missing BMI category data. Within the final analytic cohort, most patients were classified as normal weight (83.0%), followed by overweight (7.5%) and underweight (1.9%), with no cases of obesity. Mean body fat percentage was 24.6 ± 5.5%, and the visceral fat index averaged 5.7 ± 1.8, reflecting a generally low-risk metabolic profile (Table 1).
The mean rectus diastasis width was 3.22 ± 0.95 cm (range, 1.2-6.0 cm), with 66.0% of patients presenting a separation ≥3 cm. Concomitant umbilical hernia was identified in 75.5% of cases, with a mean defect size of 0.88 ± 0.43 cm among patients with umbilical hernia (Table 1).
From a surgical and anesthetic standpoint, all procedures were performed under general anesthesia, and preoperative cardiovascular risk was uniformly classified as low (Goldman Class I) across the entire cohort. According to the American Society of Anesthesiologists (ASA) classification, 66.0% of patients were ASA I and 34.0% ASA II (Table 2).
Table 2.
Surgical Procedure Characteristics (MIRELA Procedure, N = 53)
| Variable | n/Mean | %/SD | Range |
|---|---|---|---|
| Preoperative risk assessment | |||
| Goldman index—Class I (low risk) | 53 | 100% | — |
| ASA physical status classification | |||
| ASA I | 35 | 66.0% | — |
| ASA II | 18 | 34.0% | — |
| Anesthesia | |||
| General inhalational anesthesia | 53 | 100% | — |
| Operative time | |||
| Operative time (min) | 190.0 | ±6.1 | 180-200 |
| Intraoperative findings | |||
| Rectus diastasis repair | 53 | 100% | — |
| Concomitant umbilical herniorrhaphy | 40 | 75.5% | — |
| No intraoperative complications | 53 | 100% | — |
| Postoperative complications | |||
| Transient skin ischemia | — | — | — |
| Complete wound dehiscence | — | — | — |
| Muscular complication | — | — | — |
Continuous data expressed as mean ± SD. Categorical variables as n (%). Goldman Class I: ≤5 points (low cardiovascular risk).
ASA, American Society of Anesthesiologists; MIRELA, Minimally Invasive Robotic Endoscopic Lipoabdominoplasty; SD, standard deviation.
The mean operative time was 190.0 ± 6.1 min (range, 180-200 min). Notably, rectus diastasis repair was successfully completed in all cases, with concomitant umbilical hernia repair performed in 75.5% of patients. No intraoperative or postoperative complications were observed (Table 2).
DISCUSSION
Minimally invasive approaches for rectus diastasis repair have gained increasing attention; however, current techniques remain limited by technical constraints, including restricted instrument mobility, suboptimal visualization, and incomplete integration with aesthetic procedures. Previous work by Eaves et al on endoscopic abdominoplasty and endoscopically assisted mini-abdominoplasty represents an important precedent in the development of minimally invasive abdominal contouring techniques.8 In this context, robotic surgery has emerged as a transformative modality, offering enhanced precision, tremor filtration, and 3-dimensional visualization, which are particularly advantageous for accurate midline reconstruction.9-12
The MIRELA technique addresses these limitations by integrating robotic technology within a plastic surgery–driven approach, allowing a single surgeon to perform both myofascial repair and aesthetic contouring in a fully coordinated manner. The robotic platform provides enhanced precision through motion scaling and physiological tremor filtration, eliminating the involuntary hand movements that limit manual surgical accuracy, enabling microsurgical-level dexterity in the myofascial repair. Unlike previously described techniques that rely on intra-abdominal access or multidisciplinary execution, MIRELA is performed entirely in an extraperitoneal plane, thereby reducing visceral risk while prioritizing aesthetic outcomes and avoiding the additional scarring associated with traditional abdominoplasty (Figures 3-6).13
Figure 3.
A 26-year-old female patient is shown in (A) preoperative and (B) 3-month postoperative oblique (3-quarter) views after the MIRELA technique, demonstrating improved abdominal contour and waist definition without visible abdominal scars. During the same operative procedure, a 2 cm umbilical hernia was also repaired. MIRELA, Minimally Invasive Robotic Endoscopic Lipoabdominoplasty.
Figure 6.
A 30-year-old female patient. (A) Preoperative and (B) 9-month postoperative lateral views demonstrating a marked improvement in abdominal projection and contour following the MIRELA procedure. MIRELA, Minimally Invasive Robotic Endoscopic Lipoabdominoplasty.
Figure 4.
A 31-year-old female patient, presented in (A) preoperative and (B) 3-month postoperative oblique (3-quarter) views, illustrating enhanced abdominal contour and waist definition, with no visible abdominal scarring after the MIRELA technique. MIRELA, Minimally Invasive Robotic Endoscopic Lipoabdominoplasty.
Figure 5.
A 28-year-old female patient, shown in (A) preoperative and (B) 9-month postoperative oblique (3-quarter) views, demonstrating refined abdominal contour and a natural aesthetic outcome following the MIRELA technique. MIRELA, Minimally Invasive Robotic Endoscopic Lipoabdominoplasty.
In this series, the robotic-assisted approach demonstrated consistent feasibility across varying degrees of diastasis severity without increased morbidity, with no intraoperative or postoperative complications, reinterventions, or hospital readmissions observed. A critical technical challenge in robotic diastasis repair is the accurate identification of the rectus muscle borders, particularly in altered anatomical contexts. To address this, the Sanfurgo Maneuver was systematically incorporated, using controlled monopolar electrostimulation to delineate true muscular margins and guide precise suture placement. This strategy may enhance alignment of muscle fibers and contribute to standardized and reproducible midline reconstruction while preserving aponeurotic integrity. Additional extension of abdominal wall dissection after plication was not required.
The combination of VASER-assisted liposculpture and planned preaponeurotic dissection provided adequate exposure for xiphopubic plication and sufficient contour refinement without the need for further flap undermining after the repair.
The ability to simultaneously correct associated conditions, such as umbilical hernias, without additional morbidity further highlights the versatility of this approach. Clinically, patient complaints were predominantly aesthetic, although functional symptoms were also present, reinforcing that rectus diastasis represents both a structural and aesthetic condition requiring integrated management.
These findings should be interpreted in the context of careful patient selection, because the study population was characterized by low surgical risk profiles, which may have influenced outcomes. Additionally, although robotic platforms offer technical advantages, they are associated with increased cost and logistical complexity. Therefore, the selection of surgical approach should be individualized based on patient characteristics, surgeon expertise, and institutional resources.
This study is limited by its retrospective design, relatively small sample size, the absence of a control group, and short follow-up. In addition, no validated patient-reported satisfaction instruments, objective aesthetic outcome measures, or functional assessments of abdominal wall strength and core stability were included. The technique also requires access to a robotic surgical platform, surgeon training in robotic instrumentation, and institutional resources that may not be universally available. For surgeons without previous robotic experience, the learning curve may be significant, particularly with respect to docking, orientation in the preaponeurotic plane, intracorporeal suturing, and safe integration with liposculpture. Moreover, the increased cost and logistical complexity associated with robotic surgery must be considered when determining whether this approach is appropriate for a given patient and institution. Further prospective studies with longer follow-up, comparative groups, cost-effectiveness assessment, and validated functional and patient-reported outcomes are warranted.
CONCLUSIONS
The MIRELA technique represents an innovative, plastic surgery–driven approach to rectus diastasis repair, integrating robotic-assisted precision with minimally invasive aesthetic surgery principles in a very selected group of patients with minimal-to-moderate rectus diastasis and no excess skin requiring cutaneous excision. In this selected early clinical experience, the technique demonstrated feasibility and reproducibility. Further studies with larger cohorts, longer follow-up, validated patient-reported outcome measures, and objective functional assessment are warranted to better define its long-term outcomes and broader clinical applicability.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.
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