Shouldice Repair

Shouldice Repair for Inguinal Hernias

Overview of the Shouldice Repair Technique

The Shouldice repair is a surgical method for treating inguinal hernias. This technique is distinctive for its avoidance of mesh use, focusing instead on sewing distinct anatomical layers together. The process involves four layers using permanent sutures. Recognized internationally, this technique is one of the safest and most effective methods for hernia repair.

Procedure Details

Initial Steps: The procedure starts with repositioning any protruding fatty tissue or intestine back into the abdomen.
Layer-by-Layer Repair: Each muscle layer is repaired individually, ensuring minimal tension on the natural tissue.
Reinforcement: The overlapping and securing of each layer strengthen the abdominal wall using the patient’s natural tissue.

Recovery Process

Rapid Return to Routine: Many patients return to regular activities within a week, with some resuming work immediately post-discharge.
Recovery Program: The Shouldice recovery program requires a short stay at the hospital to enhance healing.

Success Rate and Risks

High Success Rate: The technique boasts a low recurrence rate of about 1-3% for primary inguinal hernias.
Potential Risks: Risks include hernia recurrence (1-3%), infection (1/200), and chronic pain (1/50).

Suitability for Patients

Ideal Candidates: Best suited for thin, healthy individuals with smaller hernias and strong groin tissue.
Limitations: Not recommended for patients with a high Body Mass Index (BMI).
Preferred in Certain Jobs: Beneficial for those in labor-intensive roles and athletes.

Conclusion

The Shouldice repair, an established and efficient method for inguinal hernia treatment, offers high success and low recurrence rates. However, selecting appropriate candidates is key to achieving optimal outcomes.

Steps of the Shouldice Repair Procedure

Initial Steps

Anesthesia and Incision:
- Sedation and local anesthesia administered.
- Left lower quadrant oblique incision made through subcutaneous tissues and external oblique.
Local Anesthetic Infiltration:
- Each layer infiltrated with a local anesthetic.
- Ilioinguinal nerve block performed.
Exposure of External Oblique:
- External oblique separated along the length of its fibers.
Cremaster Muscle and Cord Management:
- Anterior cremaster muscle fibers divided.
- Cord retracted laterally.
- Iliohypogastric nerve mobilized and placed in situ.
- Longitudinal opening of the cremaster muscle covering the spermatic cord to identify and free the indirect hernia sac.
- Preperitoneal fat dissected, divided, or returned to the preperitoneal space.
- Penrose drain placed around the cord for mobilization and protection.

Investigation and Preparation for Repair

Cleaning the Posterior Floor:
- Posterior cremaster fibers divided.
- Partial excision of the genital branch of the genitofemoral nerve.
- Transversalis fascia intentionally opened to investigate potential femoral hernia.
Assessment for Femoral Hernia:
- Essential due to 4–14% incidence of occult femoral hernias in inguinal hernia patients.
Management of Direct Hernia:
- In significant direct hernias, redundant transversalis fascia excised.
- Placement of a moist sponge in the retroperitoneum to prevent interference with the repair.

Performing the Shouldice Repair

Four-Layer Hernia Repair:
- First Layer: Suturing of the transversalis fascia near the pubic tubercle with the underside of the internal oblique–transversus abdominis (conjoined tendon).
- Creating a New Internal Ring: Using the remnant of the posterior cremasteric muscle.
- Second Layer: Running back towards the pubic tubercle, including inguinal ligament, internal oblique–transversalis combination laterally, and rectus sheath medially.
- Subsequent Layers: Suturing from the internal ring to the pubic tubercle, involving external oblique and internal oblique, and back with an additional external oblique layer.

Closure and Finishing Steps

Closure:
- External oblique closed over the spermatic cord and ilioinguinal nerve.
- Incisional wound closed using 3-0 Vicryl for Scarpa’s fascia and 4-0 Monocryl for skin.
- Wound irrigation performed.

Complications of Shouldice Repair for Inguinal Hernia

Overview

While the Shouldice repair technique for inguinal hernias is known for its low complication rates, like any surgical procedure, it carries inherent risks.

Hernia Recurrence

Incidence Rate: The recurrence rate post-Shouldice repair is between 1% and 3%, which is relatively low compared to other hernia repair methods.

Infection Risks

Occurrence Rate: Infection occurs in about 1 in 200 cases.
Nature of Infections: Commonly, these are skin infections, treatable with antibiotics.

Chronic Pain

Probability: Chronic pain affects about 1 in 50 patients.
Cause: This complication may arise due to nerve entrapment or irritation during the suturing process.

Postoperative Pain

Expectation: Postoperative pain is a common, short-term issue.
Management: Typically managed with over-the-counter pain medications like Tylenol and ibuprofen.

Risk of Strangulation

Concern for Untreated Hernias: Strangulation is a serious risk if a hernia is not treated, potentially necessitating emergency surgery.

Patient Suitability

Ideal Candidates: Best suited for thin, healthy individuals with smaller hernias and strong groin tissue.
Limitations: Not recommended for patients with a high Body Mass Index (BMI) due to increased risk of complications.

Conclusion

The Shouldice repair, noted for its efficacy and safety, still poses certain risks. Appropriate patient selection is crucial to minimize the likelihood of recurrence, infection, and chronic pain.