Recurrent hernias after previous Shouldice operation

For all 158 surgical operations performed on hernia recurrences throughout the period from March 2000 until the end of May 2001, we compared the intra-operative findings to the information contained in the operation reports--as far as available--as part of our quality management. In less than 20 % of the patients for whom a Shouldice repair had been documented in the operation reports, we found evidence of the actual performance of a Shouldice repair (typical cicatrised modifications on the rear wall or the fascia transversalis, sutures or residues of sutures). 74 % of the patients were treated with a Marlex(R) Perfix plug, avoiding the resection of stable cicatrisation fractions with incision of the rear wall in the case of an intact fascia. On 26 % of the patients it was possible to perform a Shouldice repair in compliance with the original technique. Meanwhile, mesh techniques have outpaced the Shouldice technique with respect to the recurrence rates in the efficiency statistics. This, however, is not caused by the technique as such, but rather by the fact that in many clinics the anatomical situations are obviously incorrectly assessed and/or that insufficient knowledge about suturing techniques prevails. As a consequence, worse results are reported for the Shouldice technique than for the mesh techniques. It is not the Shouldice technique that is insufficient but its performance suffers in many hospitals from substantial insufficiencies in terms of quality.     

Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice

BACKGROUND: The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres. METHODS: Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor. RESULTS: There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36-77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1.3 to 8.1) and one in the mesh group (95 per cent c.i. 0.0 to 2.0). Chronic groin pain was reported by 4.2 and 5.6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation. CONCLUSION: Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit.     

Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs

INTRODUCTION: There is an ongoing debate about the preferred technique for inguinal hernia repair. In this randomized study the long-term results of Shouldice, Lichtenstein and transabdominal preperitoneal (TAPP) hernia repair were compared. METHODS: Some 280 men with a primary hernia were randomized prospectively to undergo Shouldice, tension-free Lichtenstein or laparoscopic TAPP repair. Patients were examined after 52 months to assess hernia recurrence, nerve damage, testicular atrophy and patient satisfaction. RESULTS: Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair. CONCLUSION: Tension-free repair was superior to the non-mesh Shouldice technique. The open anterior approach to the groin was associated with demonstrable nerve injury, and laparoscopic TAPP repair was the most effective approach in the hands of an experienced surgeon.     

Results of surgical quality assurance in Westphalia-Lippe--recurrence data in inguinal hernia operation. A coomparison of literature and reality

The data of 90,289 patients of the quality-control program of the Arztekammer Westfalen-Lippe have been analyzed in regard of the patients age at the time of the primary operation and in case of operation because of recurrent inguinal hernia. In both groups of patients distribution of age was identical in principle but transferred to higher age in recurrent hernia by about 3.4 years thus indicating that recurrent hernia mostly occur early after primary operation. Shouldice method showed decreasing acceptance due to increasing numbers of repair operations by laparoscopy and Lichtenstein's method. This tendency was even more pronounced in case of recurrent inguinal hernia. Obviously the surgeons' selection of methods in inguinal hernia repair is not only influenced by evidence based data since Shouldice repair is reported to be superior in each regard.     

10 Years’ controlled results of suture repair

Summary Background: Over a period of 10 years, we prospectively evaluated the Shouldice technique for primary inguinal hernia repair with regard to recurrence rates and hernia type-related risk profiles. Methods: 196 unselected patients with 237 primary inguinal hernias were prospectively examined 1, 5 and 10 years after hernia repair was performed by 36 different surgeons (71% senior surgeons) using the standardized Shouldice technique. Follow-up included primarily physical examination and comprised 91.1%, 85.6% and 73% of the patients after 1, 5 and 10 years. Results: Early and late complications of inguinal hernia repair occurred in 11.4%. Eighty-eight per cent were not limited in their daily life activities 10 years after the operation. Recurrent hernia was found in 1.3% after 5 years and 2.95% (7 out of 237) after 10 years. The rate of recurrence tended to be higher after direct (4.8%) and combined hernias (4.2%) than after indirect hernia (1.6%). Almost all recurrences were found in stage III hernias. Conclusions: Ten years after Shouldice repair, 97% of the patients are free of recurrence. These results indicate that there is no need to abandon the Shouldice technique with local anaesthesia as the standard procedure for primary inguinal hernia repair.      

Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia

BACKGROUND: The Shouldice technique is the 'gold standard' of open non-mesh hernia repair. The aim of this study was to compare 5-year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia. METHOD: Men with a primary unilateral inguinal hernia were randomized to either Shouldice or TAPP operation. An independent observer scored the surgeons' performance. Follow-up comprised clinical examination after 1 year, a questionnaire after 2 and 3 years, and a clinical examination after 5 years. RESULTS: Between February 1993 and March 1996, 1183 patients were included. Nine hundred and twenty patients were followed for 5 years, 454 in the TAPP group and 466 in the Shouldice group. Recurrences were evenly distributed between groups throughout the follow-up period. The cumulative recurrence rate after 5 years was 6.6 per cent in the TAPP group and 6.7 per cent in the Shouldice group. Postoperative pain was a risk factor for recurrence after Shouldice operation but not after TAPP repair. There was a correlation between a low surgeon's performance score and recurrence. CONCLUSION: The 5-year recurrence rate is acceptable, with no difference between TAPP and Shouldice repair. Poor operative performance resulted in a higher recurrence rate. The TAPP operation represents an excellent alternative for primary inguinal hernia repair.     

Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia.

The lowest recurrence rates after inguinal hernia repair have been achieved by specialized hernia clinics. The Shouldice repair achieves success through application of a meticulous standardized operation carried out by specialist hernia surgeons. In a trial designed to rule out surgeon-dependent variables, 322 inguinal hernias were randomized prospectively to Shouldice repair or plication darn. Fifteen general surgeons operated on 322 patients. Fourteen surgeons in training not familiar with Shouldice repair received constant supervision for six repairs before independent operation. The mean (s.d.) patient age was 58.3(1.5) (range 20-84) years for Shouldice repair and 57.0(1.2) (range 18-85 years) for plication darn. The sex ratio (M:F) was 17:1 and right side to left side ratio 1.8:1. Six-week complication rates for wound infection (Shouldice repair, 5 per cent; plication darn, 4 per cent) and haematoma (Shouldice repair, 7 per cent; plication darn, 5 per cent) were similar in both groups. There were a similar number of sliding hernias in the Shouldice repair (14) and plication darn (20) groups. After a mean follow-up of 30 (range 24-48) months there were seven recurrences in the Shouldice group and four in the plication darn group (P > 0.05). The recurrences suggest that additional supervision of junior surgeons is required during the Shouldice repair learning period.     

Comparison of laparoscopic vs open modified Shouldice technique in inguinal hernia repair.

Inguinal hernia repair has been a common procedure performed by general surgeons. Recently, a newly developed approach has been introduced using the pre-peritoneal laparoscopic repair. The laparoscopic approach allows patients to recover faster, with less pain, however, a disadvantage is the higher cost. We conducted a retrospective study of inguinal hernia repairs performed by one surgeon at the same institution, comparing the laparoscopic technique to the modified Shouldice procedure with regard to surgical time, postoperative recovery time, charge, and time to return to work and to activities. Patients undergoing laparoscopic hernia repairs were able to return to work and to activities sooner than patients undergoing the modified Shouldice procedure. The results obtained in this study showed a higher charge for the laparoscopic procedure, with longer surgical and recovery room time. The more rapid return to work and activities may outweigh the higher charge and longer surgical and recovery room time.     

Equal results with laparoscopic and Shouldice repairs of primary inguinal hernia in men. Report from a prospective randomised study.

AIM: To compare the laparoscopic and Shouldice techniques for repair of inguinal hernia. MATERIAL: 261 healthy men over 50 years with primary, unilateral inguinal hernia were randomly allocated to laparoscopic (total extraperitoneal approach, TEP) treatment (n = 131) or to a modified Shouldice technique (n = 130). RESULTS: Apart from a longer operative time in the laparoscopic group, there were no significant differences between the two methods with regard to perioperative complications, hospital stay, recurrencies or pain in the groin. CONCLUSIONS: Results following the total extraperitoneal laparoscopic and the Shouldice technique do not differ significantly 2 years after hernia repair.     

Shouldice standard 2020: review of the current literature and results of an international consensus meeting

Hernia - For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair has been proven to entail better results in randomized trials. Since the first...     

Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients.

BACKGROUND: Hernia repair is the second most frequently performed operation in France and in the United States, the prevalence being 36 for every 1000 males. Lowering the recurrence rate by 1% would mean 1000 fewer operations for hernia repair per year in France. METHODS: Between 1983 and 1989, 1578 adult males with a total of 1706 nonrecurrent inguinal hernias were prospectively and randomly allotted to undergo either a Bassini's repair, Cooper's ligament, or Shouldice repair with polypropylene or a Shouldice repair with stainless steel for determination of which technique was associated with the lowest recurrence rate. Fifty-nine hernia repairs were withdrawn after inclusion. Of the 1647 remaining hernias, 52.2% were indirect, 25.6% were direct, and 23.2% were combined. Patients were seen every 6 months for 3 years and then every year. Median follow-up was 5 years 8 months (range, 3 months-8.5 years). RESULTS: At 8.5 years, 5.6% of hernias were lost to follow-up. Ninety-seven hernia repairs failed, 50% during the first 2 years. The actuarial recurrence rate was 7.94% at 8.5 years. The Shouldice repair (stainless steel or polypropylene) was associated with fewer recurrences (6.1%) than either the Bassini's (8.6%) or Cooper's ligament repair (11.2%) technique (p < 0.001). This difference remained significant even when the maximal bias test was used. Fewer recurrences (5.9%) were observed with the stainless steel wire Shouldice repair than with polypropylene version (6.5%), but the difference was not significant. CONCLUSIONS: Shouldice hernia repair provides the patient with the best chances of nonrecurrence regardless of the anatomical type of hernia. The Shouldice hernia repair should be the gold standard for inguinal hernia repair in men and serves as the basis for comparison with all other techniques, be they prosthetic or laparoscopic.     

Two-layer repair of the transversalis fascia is sufficient for inguinal hernia repair.

The Shouldice four-layer repair is considered to be the gold standard procedure for repair of inguinal hernia with low recurrence rates around 1%. Tension-free two-layer repair of the transversalis fascia may be all that is required to avoid recurrence. We compared the early recurrence rate after two-layer repair of the transversalis fascia or the standard four-layer Shouldice technique in a randomised study of elective inguinal herniorrhaphy. In 48 patients (53 repairs) who had a two-layer transversalis fascia repair, there was one recurrence (2%) in the first 12 months after operation, though there was one more recurrence within 36 months (total 4%). In 39 patients who had a four-layer Shouldice repair (42 repairs), there was no recurrence at 12 months but at 36 months two recurrences (5%) were found. We conclude that a two-layer repair of the transversalis fascia is anatomically correct, physiologically sound and can provide equivalent results to the standard Shouldice repair for inguinal hernia.     

Modified Shouldice hernia repair: a study of 421 inguinal herniorrhaphies by a single community surgeon over ten years

The evolution of a technique of inguinal hernia repair, progressively incorporating more modern materials and concepts, is described and evaluated. Anatomic precepts of hernia anatomy put forth by Condon form the foundation of this technique. The Shouldice methodology dominates the original plan of patient management but more modern suture materials and local anesthetics afford even greater ease and efficiency to this hernia repair plan. The results of 421 herniorrhaphies done by the primary author over ten years are reported with three patients lost during follow-up (0.7%). No cases are included unless a minimum of three years since surgery has elapsed. The unselected recurrence rate is 2.77 per cent. All ten recurrences are studied and related to changes in surgical technique. Cost effectiveness goals such as early discharge and same-day surgery are also discussed as they apply to this approach.     

A comparison of a new two-layer anatomic repair to the traditional shouldice herniorrhaphy.

Since 1976, the Shouldice repair has been the herniorrhaphy of choice at the Veterans Administration Medical Center, Augusta, Georgia. The authors previously reported their experience with this technique, and their recurrence rate of 1.8 per cent was consistent with the experience of the Shouldice clinic. It is often difficult to obtain adequate tissue for a four-layer repair in patients with recurrent hernias or in those patients with large direct or indirect inguinal hernias. In these instances, a two-layer running closure similar to the Shouldice was performed, but the shelving edge of the inguinal ligament was sewn to the conjoined area in one layer and then the fascia of the internal oblique to the inguinal ligament in the second layer. To obtain an estimate of the recurrence rate with this modification, the authors reviewed their herniorrhaphy experience from 1984 to 1988. During this period, 420 herniorrhaphies were performed. Two hundred twenty-six patients were available for follow-up. Of this group, 154 patients had a traditional four-layer Shouldice repair; there were two recurrences in this group (1.2%). Seventy-two patients underwent the described two-layer repair; there were no documented recurrences in this group. Based on this experience, the authors believe that the described running two-layer herniorrhaphy is a valuable alternative when the tissue is inadequate to allow a traditional Shouldice repair. This procedure has now become the authors' method of choice for the majority of repairs.     

Short-stay surgery (Shouldice technique) for repair of inguinal hernia.

Short-stay surgery for inguinal hernia repair using the Shouldice technique, with local anaesthesia in the great majority of cases, has achieved a recurrence rate of less than 1% in the repair of both primary and recurrent inguinal hernia. A personal series of 14 982 consecutive inguinal herniorrhaphies performed during a 21-year period with an overall recurrence rate of 0.6%, using the Shouldice technique exclusively, is documented and discussed in some detail. The results suggest that the adoption of these methods on a national scale would result in a saving to the economy of many millions of pounds.     

The influence of inguinal mesh repair on the spermatic cord: a pilot study in the rabbit.

The permanent implantation of a polypropylene mesh during inguinal hernia repair causes chronic inflammatory changes in the surrounding tissue. We investigated the effect of this foreign body reaction on the structures of the spermatic cord in the rabbit. Eight Chinchilla rabbits underwent unilateral inguinal hernia repair by the Lichtenstein technique using Marlex (n = 4) or Ultrapro (n = 4) mesh. The contralateral side was operated upon using the Shouldice repair. Three animals served as controls. Three months after operation we analyzed testicular size, testicular temperature, and arterial perfusion by excitation light of a 780-nm laser after injection of 0.5 mg/kg indocyanin green. Histological evaluation included spermatogenesis (Johnsen score) and foreign-body reaction. Testicular volume increased about 10% after each operation. The decrease of arterial perfusion and testicular temperature was more significant after mesh repair than following Shouldice operation. After mesh implantation we found fewer seminiferous tubules classified as Johnsen 10 (Marlex: 51.3%, Ultrapro: 45.0%) than after Shouldice repair (63.8%) or in the controls (65.8%). The spermatic cord showed a typical foreign-body reaction at the interface between mesh and surrounding tissue, which was not detectable after Shouldice repair. Preserved cremasteric muscle fibers protected the structures of the spermatic cord. The inflammatory foreign-body reaction of the surrounding tissue induced by the inguinal prosthetic mesh includes the structures of the spermatic cord. This may have an influence also on spermatogenesis. Therefore, we recommend strict indications for implantation of a prosthetic mesh during inguinal hernia repair.     

Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training.

OBJECTIVE: To compare the outcome following Lichtenstein open mesh technique or Shouldice repair for inguinal hernia operated on by surgeons in training. DESIGN: Prospective, randomised, trial. SETTING: District hospital, Sweden. SUBJECTS: 200 men with primary inguinal hernias. INTERVENTIONS: Lichtenstein mesh repair or Shouldice repair. MAIN OUTCOME MEASURES: Duration of operation, postoperative pain assessed by visual analogue scale (VAS), complications within 30 days, duration of sick leave, and recurrence within one year. RESULTS: 178 patients were available for evaluation (n = 89 in each group). There were no significant differences in duration of operation, pain score, or incidence of postoperative complications. Patients in the mesh group took significantly less sick leave (mean 18.2 days) than those in the Shouldice group (23.8 days, p<0.05). The number of recurrences differed significantly between the groups with 9 in the Shouldice group and none in the mesh group (p<0.01). CONCLUSION: For surgeons in training the Lichtenstein open mesh technique is a better method of inguinal hernia repair than the Shouldice technique. The outcome is better for the patients and it is more cost-effective.     

Randomized controlled trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice repair

Background: There is a scarcity of data on long-term results after laparoscopic hernia repair. Herein we report on the outcome of a group of patients who were followed up for 5 years in a multicenter study on hernia repair. Methods: A total of 100 patients with 127 hernias were randomized to undergo either transabdominal preperitoneal (TAPP) or Shouldice hernia repair. Follow-up was by clinical examination and standardized questionnaire. Results: Of the 100 patients who underwent surgery, 84 were available for follow-up at 5 years. The TAPP procedure was less painful than the Shouldice repair, with fewer patients receiving narcotic analgesics. The median time to return to 100% activity was shorter in the laparoscopic group (21 days) than in the Shouldice group (40 days). Up to 60 months after the operation, the complication rate was lower in laparoscopically repaired hernias (19/66) than in the open group (25/61). There were two recurrences (3.9%) in the TAPP group and five in the Shouldice group (10.2%). Conclusion: The TAPP hernia repair yields comparable or better results than Shouldice herniorrhaphy in terms of postoperative pain, recovery, and recurrence rate.     

Ultrasonographic characteristics of different methods of inguinal hernia repair

A randomized blind sonography estimation analysis of seven different methods of inguinal hernia repair was performed using a commercially available linear scanner with a 5-MHz transducer frequency. A total of 58 male patients with a mean age of 56 years who had been free of recurrence since undergoing a hernia repair were examined 3–12 years after surgery. The analysis was accomplished by three static and four dynamic indices. A five-grade scale was used to assess the operated side while control pattern images of the unoperated side, and of a control group of five men who had not undergone surgery, were assessed with four points. The score from the static ultrasound assessment ranked the methods of Lotheissen-McVay and Shouldice first and the methods of Marcy and Postempsky-Halsted I second, while the score from dynamic indices ranked iliopubic tract repair and the methods of Marcy and Shouldice first and the method of Lotheissen-McVay and bilateral preperitoneal prosthetic repair second. The highest aggregate score was demonstrated by the Shouldice method and the lowest by Bassini's method. The results of this study provide additional information which may be clinically useful in the context of the current state of inguinal hernia surgery.     

The Shouldice Hospital technique

The Shouldice repair is used for all types of inguinal hernia whether indirect, direct, sliding, multiple, recurrent, male or female. Local anesthesia is given in more than 95% of cases. The repair is a modified Bassini. Essential preliminaries are accurate dissection at the internal ring with adequate treatment of any indirect hernia. The cremaster is excised. Accurate recognition and definition of the transversalis plane is routine and fundamental. Essentially the repair is an overlap of the divided transversalis plane utilising 4 lines of continuous monofilament stainless steel wire 34 gauge. Patients, ambulant immediately, stay in hospital 2-3 days postoperatively. A large personal series of more than 20,000 inguinal repairs performed almost exclusively in this hospital during a 30 year period from 1954 to 1984 is tabulated. Recurrence rates of less than 1% for repair of primary inguinal hernia and re-recurrence rates of 2-4% for repair of recurrent inguinal hernia are reported. Surgeons in other countries now employing this technique achieve comparable results, often using other non-absorbable suture material.