What is the Mayo technique for rectus closure in abdominal wall reconstruction?

Mayo Technique for Rectus Closure

The Mayo technique is not a method for abdominal wall reconstruction in complex defects or open abdomen scenarios—it is a historical approach for umbilical hernia repair involving overlapping fascial layers in a "vest-over-pants" fashion, which is not recommended for modern abdominal wall reconstruction due to high recurrence rates and tension-related complications.

What the Evidence Actually Addresses

The provided evidence does not describe the Mayo technique. Instead, it focuses on modern abdominal wall reconstruction methods for complex defects, open abdomen management, and component separation techniques. The Mayo technique is not mentioned in any guideline or research evidence provided because it has been largely abandoned in favor of tension-free repairs with mesh reinforcement.

Modern Approaches to Abdominal Wall Reconstruction (What You Should Use Instead)

Primary Closure Hierarchy

Primary fascial closure is the ideal solution to restore abdominal closure when feasible 1. However, for large defects where primary closure creates excessive tension, modern techniques are required.

Component Separation Technique (CST)

Component separation is an effective technique that should be considered only for definitive closure, not temporary closure 1.

• Anterior component separation (external oblique release with posterior rectus sheath release) is associated with higher wound complication rates (42.9%) but low recurrence rates (7.0%) 2
• Posterior component separation (transversus abdominis release) demonstrates lower wound complications (31.2%) and recurrence rates (2.7%) 2
• Component separation allows for musculo-fascial approximation of large abdominal wall defects that would otherwise be impossible to close primarily 2
• Prehabilitation and perforator-sparing techniques have reduced anterior component separation wound complications to 19.6% since 2013 2

Mesh-Mediated Closure

For clean surgical fields, synthetic mesh is recommended for hernia repair 3.

• Non-cross-linked biologic meshes are preferred in sublay position when the linea alba can be reconstructed 1
• Cross-linked biologic meshes in fascial-bridge position may be associated with less ventral hernia recurrence when linea alba closure is not possible 1
• Synthetic meshes in contaminated fields are not recommended in emergency abdominal wall reconstruction 1
• For contaminated or dirty fields, primary repair for small defects or biological mesh for larger defects is recommended 3

Technical Principles for Fascial Closure

Use continuous suture technique for fascial closure as it is faster than interrupted sutures with no difference in hernia or dehiscence rates 3.

• Maintain a suture-to-wound length ratio of at least 4:1 for continuous closure 3
• Use small bite technique to prevent incisional hernia and wound complications 3
• Employ mass closure rather than layered closure for speed and equivalent outcomes 3

When Standard Techniques Fail

Flap Reconstruction

For Type II defects with unstable or absent skin coverage, flap reconstruction is advisable in 80% of cases 4.

• Tensor fascia lata represents the flap of choice, particularly in the lower abdomen 4
• Rectus femoris muscle flap provides an easy and safe possibility to reconstruct the abdominal wall with relatively low donor site morbidity 5
• Contralateral component separation technique can be performed when VRAM flap is harvested, allowing lower tension closure 6

Planned Ventral Hernia

Planned ventral hernia (skin graft or skin closure only) remains an option for the complicated open abdomen in the presence of entero-atmospheric fistula or protracted open abdomen where no other alternatives are viable 1.

Critical Pitfalls to Avoid

• Never use synthetic mesh as a fascial bridge in contaminated fields—this induces adhesions, erosions, and fistula formation 1
• Avoid primary closure under tension—this is a common cause of failure 4
• Do not use component separation for temporary closure—reserve it for definitive reconstruction only 1
• Complete fascial closure and lack of wound complications significantly improve outcomes 2