rectus muscle

I had a myomectomy(removal of fibroids) in Aug 02.  I was having left lumbar discomfort.  I had a large fibroid pressing on my colon.  After this surgery, I had intense pain and discomfort in the very same area where the pain before was dull, nagging and constant.  I also couldn't sit or lay comfortably in that area afterwards. It also became a really tight pulling sensation in that area.  It has been until now Jan and a few more surgeries to remove all my feminine parts basically because they thought that is what might be causing the pain. I do have endometriosis and adhesions that were removed also.  I have been to urologists, neurolgists, neurosurgeons. general docs, orthopedic and the list goes on with many mri's and colonoscopy, barium enema etc etc all ormal..  The pain is so severe it has affected my physical and emotional life. The pain again is a pulling tautness from the top of myhip/buttock to the lower left lumbar that goes into the left flank area. It feels as though it is a muscle sprain.  It is a burning irritating feeling that when after I move my bowels each time the pain in the flank and lumbar area gets worse and moves upward to right underneath my lower left ribcage.  It feels raw.  It also have a pulling feeling/sensation that goes up my left upper back.  There are times I feel like I am being choked.  At times when I have to move my bowels and cannot my left flank area feels as though something is pushing/sticking out like being kinked, it hurts awful and my lumbar area has pressure on it too. It even looks a little swollen when I feel this. After the bowel movement it burns in those areas but the pushing in the lumbar area feels a little better.  Not to be graphic either, but when I move my bowels now, it comes out soft but I have never had such a wide/thick bowel movement in my life, like something is being compressed and its getting harder to go and the bowel movement is building up.Now the question after allthis.....  I was finally reading the operative report after this procedure and it states on there, that after they replaced my uterus, they RE-APPROXIAMATED the rectus muscles.  This to me makes sense finally.  Could that muscle(which is what the pulling stretching sensation feels like in my lumbar/flank area) have been not reconnected right or a ligament or nerve/muscle been also not connected right or irriated.  If this can happen, can this be reversed.  I am so miserable and no one seems to be able to give answers until now hopefully.  I am going to a special endo clinic to make sure its not the endo or adhesions but also want them to check this out.  So if you could give me your opinion.  What does this rectus muscle actually do and where in your body does it go.  Please help  thank you

[Kevin Pho, MD]

Hello - thanks for asking your question.

The rectis abdominis muscle originates at the pubic crest and attaches to either the 5th, 6th or 7th ribs.  The rectus abdominis controls the tilt of the pelvis and curvature of the lower spine.  A picture of this muscle can be found here:
http://www.exrx.net/Muscles/RectusAbdominis.html

You note left sided abdominalal and flank pain.  There is burning when you move your bowels.  You state you have been to urologists, neurologists, neurosurgeons, general docs, orthopedic surgeons and have had many MRI's, colonoscopy, barium enema without a definitive etiology.  

With such a comprehensive workup, it is difficult to definitively say what is causing your discomfort, especially since I cannot examine you myself.  It is certainly possibile that the surgery affecting your rectus muscle may be causing your discomfort.  

One test to consider would be electrodiagnostic testing (i.e. EMG) to evaluate the innervation of the affected area.  A neurologist would be the specialist you may want to discuss this with.  

If every test is negative (i.e. CT, MRI, colonoscopy, electrodiagnostic testing etc.), and every single consultant comes up empty (neurology, OB/GYN, gastroenterology, urology, surgery, etc.), then the focus should shift to managing your discomfort.  A referral to a physiatrist (a rehabilitation physician), would help in long-term management of your discomfort.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[lilwe]

a reply to Kevin MD

If the rectus muscle was not replaced properly or still having severe problems why wouldn't the surgeon go back in laprascopicly
and see what happened. He could back trace all his moves.  I don't think the right fix is seeing a doctor to manage the discomfort.  I am barely managing and I personally don't want to take pain meds for the rest of my life!   It's quite easy for doctor's without the pain to suggest these things when to me the obvious would be to correct it or see what happened.  This was the wrong answer as far as I am concerned. I have been going to doctors of every kind and had every test to rule other things out, it was the surgery that prob. caused this in the first place.

[kevinmd]

Hello,
It is extremely unlikely that I would be able to give you definitive answers without even examining you.  

By all means you should visit your original surgeon to determine if damage to the rectus muscle is causing your symptoms.  I was under the impression that this was already done.  

I hope that I can impress to you that there is no "right" or "wrong" answer.  It is entirely possible that different physicians will have different opinions.  

You have been to urologists, neurologists, neurosurgeons, general physicians, and orthopedic surgeons.  With me included, that makes at least 6 physicians.  Your tests includes MRIs, colonoscopies, and barium enemas.  It is entirely possible that a definitive cause may never be found.

I wish you all the best in your continued quest of finding a satisfatory answer.  

Thanks,
Kevin, M.D.

[nurse12hr]

Just a comment:
When they do abdominal surgery, all that REAPPROXIMATING the rectus muscle means is that they put ONE OR TWO stitches through them to bring them into closer contact with each other.  They do not stitch them tight, they just get them closer.  This is not always done, but the common practice is to do it.  If you don't, some believe healing will take longer, the patient will be more uncomfortable, and a separation along the midline between the muscles may occur.  

They don't stitch the muscles TO anything like ligaments or nerves.  Just a loose stitch to bring them closer.  

Some people form adhesions after surgery.  It is just a body reaction of scarring in response to surgery.  Those CAN pull and cause discomfort.  The bad thing is, furthur surgery, even a laparoscopy, CAN cause more of them to form.  But, some doctors would consider a laparoscopy to look and see if adhesions have formed, but you have to be willing to take the risk that the laparoscopy itself may not help, and may cause more scarring and pain.

I hope that helps.  I am not a doctor, I am a nurse who has assisted at abdominal surgeries.  I have seen the reapproximation you describe many, many times.  It is routine and not hard to do.  Let me re-emphasize, it does not reconnect the muscles TO anything, or TO each other.  Just brings them nearer to each other.  Mostly  for support.

[surgeon]

the rectus muscles are separated when entering the abdomen in a midline incision. They are reapproximated (meaning put back where they belong) on closing. What you found in the op note is a perfectly normal statement about closing an incision.