Shouldice Repair

The Refinements of Dr. Shouldice

Before the mesh-era, there were numerous techniques and nuances to tissue repairs of inguinal hernias. Inguinal hernias and inguinal anatomy are so variable that there are many different types of anatomic situations encountered during inguinal hernia surgery. This is partly why there were so many techniques and modifications over the years. The Bassini repair was perhaps the most commonly used technique in the pre-mesh era owing to its durability. Do note that there have been many likely unintentional modifications over the years which probably led to some of the discouraging recurrence rates seen in several series.

In essence, there are two main common categories of inguinal hernias. One is the direct type, where there is a defect in the inguinal floor where normally there is connective tissue commonly described as the transversalis fascia although some have put forth the notion that it is truly aponeurotic extensions of the conjoint tendon. The other is the indirect hernia, where there is a dilation of the internal inguinal ring. Within each type are multiple subtypes. Direct hernias can be a very defined and sometimes small defect. Many times it can be a general laxity. And sometimes it can come from a total tearing of the tissue of Hasselbach's triangle. Indirect hernias likewise can be quite well-defined, but sometimes can be large and transition into healthy muscular tissue further away. Of interest, hernias from the posterior view (as seen more commonly with modern techniques of laparoscopy) appear much more well-defined than they can appear from anteriorly (as is seen in most open repairs).

The Bassini operation sought to bring the good muscular tissue of the conjoint tendon superiorly down to the strong tendinous tissue of the inguinal ligament. Note that this is not the native configuration of the inguinal canal. Therefore there is a degree of tension on this repair above what is seen in native inguinal regions. This was thought to lead to some of the recurrences as the mechanical forces over time would stretch the tissues back to their original weakness. The Bassini operation was essentially a single layered suture line to accomplish this (not to be confused with the technique being described as "triple layer" -- that simply refers to getting three distinct muscle and fascial layers in one suture bite).

To refine this technique, Dr. Shouldice broke the Bassini operation into smaller parts and did add one ingenious addition. In the subtypes of inguinal hernias were some good transversalis fascia tissue remains just superior (or cephalad) to the inguinal ligament, the transversalis fascia is double-breasted in two layers. Then a third and fourth layer bring the conjoint tendon down to the inguinal ligament using the external oblique itself to buttress the repair and distribute tension over a broader area. Dr. Shouldice himself was a master surgeon and showed much lower recurrence rates than had been seen before. Many surgeons did however find his technique technically challenging and hard to reproduce. And thus when Dr. Lichtenstein described his famous tension-free mesh repair, the surgical community breathed a collective sigh of relief as it was much more reproducible by non-expert hernia surgeons.

Dr. Shouldice furthermore advanced the field by establishing a dedicated hernia hospital where staff developed expertise taking care of hernia patients. and postop routines were developed to optimize the recovery process.

Dr. Cober learned about the Shouldice operation as a resident as it was performed by a few hernia experts in his training center. His favorite aspects of the Shouldice repair is that it takes the traditional principles of reinforcing the floor of the inguinal canal but distributes the tension over multiple layers of tissue and uses the external oblique itself to almost in a way "patch" the repair. In his practice, he will sometimes combine different aspects of the Shouldice repair with other repairs owing to the different subtypes of hernia anatomy encountered at time of operation.

There are numerous articles in peer-reviewed journals. See the References section here.