What are the indications for Mayo repair of umbilical hernias?

Indications for Mayo Repair of Umbilical Hernias

The Mayo repair technique for umbilical hernias is primarily indicated for small umbilical hernias (<2 cm) where a tension-free repair without mesh is preferred, though mesh repair has demonstrated significantly lower recurrence rates and should be considered the standard of care for most umbilical hernias. 1, 2

Primary Indications for Mayo Repair

• Small defect size: Most appropriate for umbilical hernias with defects less than 2 cm in diameter, though mesh repair is increasingly preferred even for these small defects 1
• Clean surgical field: Mayo repair may be considered in clean, non-contaminated surgical fields (CDC wound class I) 3
• Patient preference: When patients prefer a non-mesh repair technique 2
• Surgeon experience: When the surgeon has specific expertise with the Mayo technique 2

Clinical Scenarios Where Mayo Repair May Be Considered

• Emergency repair situations where mesh placement may be contraindicated:
  • Though even in emergency settings with clean-contaminated fields, current guidelines suggest synthetic mesh can still be safely used 3
• Patients with contraindications to mesh placement:
  • Active local infection
  • Significant contamination
  • Patient allergies to mesh materials 2, 4

Limitations and Considerations

• Higher recurrence rates: Mayo repair has shown recurrence rates of up to 20% or higher compared to mesh repair techniques 4, 5
• Current practice trends: Despite guideline recommendations for mesh repair, registry data shows that approximately 75% of small umbilical hernias (<2 cm) are still repaired using suture techniques rather than mesh 1
• Long-term outcomes: Mesh repair demonstrates significantly lower recurrence rates (relative risk of recurrence with mesh = 0.28,95% CI = 0.13-0.58) with a number needed to treat of 13 patients 5

Modified Mayo Techniques

• Some surgeons have developed modified Mayo techniques that attempt to address the high recurrence rates while maintaining the benefits of the traditional approach 2
• These modifications focus on:
  • Avoiding tension in the repair
  • Not artificially enlarging the defect
  • Customizing the approach to the patient's specific anatomy 2, 4

Current Guideline Recommendations

• European Hernia Society and Americas Hernia Society guidelines recommend:
  • Mesh repair for umbilical hernias >1 cm
  • Suture repair (which may include Mayo technique) should only be considered for defects <1 cm 1
  • Preperitoneal mesh placement with at least 3 cm overlap of the defect is the preferred approach 1

Common Pitfalls to Avoid

• Tension on repair: The traditional Mayo technique can create tension on the repair, contributing to higher recurrence rates 4
• Ignoring defect size: Using Mayo repair for defects >2 cm significantly increases recurrence risk 1, 5
• Overlooking mesh benefits: Modern evidence strongly supports mesh repair even for small umbilical hernias to reduce recurrence 5
• Inadequate follow-up: Recurrences may develop over time, requiring adequate follow-up (at least 1 year) 1, 2

While the Mayo repair technique remains in the surgical armamentarium for umbilical hernia repair, current evidence and guidelines strongly favor mesh-based repairs for most umbilical hernias to minimize recurrence risk and improve long-term outcomes.