Acta chir belg, 2004, 104, 418-421

Introduction
Inguinal hernia repair is the most frequently performed
operation in general surgery. Consequently, the outcome
is important for both the surgeon and the patient. Failure
of inguinal hernia repair leads to increased patient dis-
comfort, re-operations and sick leave, and so may result
in a considerable economic burden (1). Although many
methods have been described, choice of repair method
for inguinal hernia remains controversial. No consensus
has yet been reached about the best surgical approach to
inguinal hernia repair, which should show good cost-
effective clinical results (2,3). Of these some are more
difficult to perform, for instance the Shouldice method,
and some such as the Lichtenstein open mesh technique
are easier to do. These two methods are probably the
most widely used and their outcome has been reported to
be similar (4,5). The reported results have been excellent
which might be at least partly because all operations
were done by experts (6).
The purpose of this study is to compare the findings
of Lichtenstein repair, with those of Shouldice repair, for
primary unilateral inguinal hernia.
Patients and methods
Patients with primary unilateral inguinal hernia who
underwent a Shouldice repair (n : 120) and a Lichten-
stein open mesh techniques (n : 121) between 1994 and
1998 were evaluated retrospectively. We enrolled 241
male patients with primary unilateral inguinal hernia in
this study. Patients with primary unilateral inguinal her-
nia over the age of 18 years, who underwent a surgical
repair and with a follow-up period over three years were
included. Exclusion criteria were irreducible inguino-
scrotal hernia, recurrent hernia, femoral or bilateral her-
nia, female gender, coagulation abnormalities and
patients for whom anesthesia was contraindicated due to
cardiac status. The authors performed all operations.
There was no restriction on the type of anesthesia ;
local anesthesia, spinal or general anesthesia were em-
ployed depending on either surgeons or patients prefer-
ence or anesthesiologists opinion.
The Shouldice repair was performed as Bendavid (7)
using 2/0 polypropylene sutures (Prolene, Ethicon,
Johnson & Johnson). In the Shouldice repair, the sac
was dissected and ligated. The transversalis fascia was
Comparison of Shouldice and Lichtenstein repair for treatment of primary
inguinal hernia
B. Ayta*, K. S. akar**, A. Karamercan***
*Associate Professor, Department of General Surgery, TCDD Ankara Hospital ; **General Surgeon, Department of
General Surgery, TCDD Ankara Hospital ; ***Assistant Professor, Department of General Surgery, Gazi University
Medical Faculty.
Key words. Inguinal hernia, surgery.
Summary. Purpose : The purpose of this study was to compare the outcome following Lichtenstein open mesh repair
or Shouldice repair for the surgical treatment of primary unilateral inguinal hernias.
Patients and methods : Patients with primary unilateral inguinal hernia who underwent a Shouldice repair (n : 120) and
a Lichtenstein open mesh techniques (n : 121) between 1994 and 1998 were evaluated retrospectively. Operation time,
hospital stay, postoperative analgesic consumption and complications, return to work and recurrence after surgery were
assessed and compared.
Results : The two groups were comparable regarding age, types of hernia and the follow-up interval. There were no sig-
nificant differences in hospital stay and postoperative complications. The number of recurrences differed significantly
between the groups with five in the Shouldice group (4.1%) and one in the Lichtenstein group (0.8%) (p < 0.05). The
need of analgesic medication after mesh repair was significantly lower than the Shouldice group (3.9 1.4 vs. 4.9 1.6
gr. p < 0.05). The operation time was 3614 min. for Lichtenstein repair and 61 12 min. for Shouldice repair
(p < 0.05). The time for return to work was shorter in Lichtenstein group (17 4 days) compared to Shouldice group
(25 5 days) (p < 0.05).
Conclusion : Shorter operation time, faster return to work, less need to analgesia and lower recurrence rate, shows the
superiority of Lichtenstein repair against Shouldice repair in the surgical repair of primary unilateral inguinal hernia.
Original papers
Repair of Primary Inguinal Hernia 419
doubled with a running monofilament non-absorbable
suture on two layers taking small and closely placed
bites of tissue. A second continuous suture started at the
internal ring fixing the transversalis muscle (third layer)
and the oblique muscle (fourth layer) to the inguinal
ligament.
The tension-free hernioplasty was performed as
described by Lichtenstein et al (8), using a 6 11 cm
polypropylene mesh (Prolene, Ethicon, Belgium) and a
2/0 prolene suture to fix mesh in the desired position. In
the Lichtenstein procedure, the sac was dissected and
inverted into the abdomen without ligation. The medial
end of the mesh was rounded to fit the shape of the
medial corner of the inguinal canal. It was sutured to the
inguinal ligament from the medial side of the tubercle to
a point just lateral to the internal ring. A slit was made
in the lateral end creating two tails that surrounded the
spermatic cord. The tails were sutured to the inguinal
ligament creating a new internal ring. The mesh was
sutured loosely to ensure a true tension-free repair. The
aponeurosis of the external oblique muscle was then
closed over the cord with a non-absorbable suture.
The operations were done strictly in accordance with
the descriptions in previous papers and no individual
variations were allowed.
Prophylactic antibiotics were not used.
The hernias were classified as types I, II, III accord-
ing to the classification of Nyhus (9). The operation time
was defined as the time from the skin incision to the
placement of the last suture. We compared the findings
between the two groups regarding postoperative pain
by comparing the administered amounts of metamizol
sodium. We collected information about postoperative
hematoma, seroma, infection and other complications.
The length of hospitalization is defined as the number
of days in hospital after surgery was recorded. Conval-
escence and return to work periods were noted.
Follow-up evaluation was performed by physical
examination and personal interview after 1 week,
6 months and yearly. The endpoint of follow-up was a
recurrence defined as a detectable bulge or weakness in
the inguinal area by the patient himself or by the exam-
ining doctor.
Fishers exact test was used to assess the significance
of the difference in the number of recurrence. For the
analysis of differences between two groups we used
students t-test. The Chi-square test was used to compare
proportions and p values of less than 0.05 were regarded
as significant.
Results
A total number of 241 patients were included in the
study. Shouldice repair was performed in 120 patients
and Lichtenstein repair in 121. The groups were compa-
rable regarding patient characteristics and types of her-
nia (Table 1).
The mean operation time was significantly longer in
Shouldice group. It was 61 12 min. in the Shouldice
repair group and 36 1.4 min. in the Lichtenstein
repair group (P < 0.05). The mean hospital stay was
3.1 1.4 days in the Lichtenstein group and 3.2
1.5 days in the Shouldice group, which was not statisti-
cally significant.
The need of analgesic medication after Lichtenstein
repair was significantly lower than that after the
Shouldice repair (3.9 + 1.4 vs. 4.9 + 1.6 gr. p < 0.05).
Patients who had a mesh repair returned to work after a
mean of 17 4 days. This was significantly shorter than
after the Shouldice repair for which the corresponding
figures 25 5 days (p < 0.05). The rate of postoperative
complications did not differ significantly between the
two groups. The number of hematomas, seromas and
infections were similar for mesh and Shouldice repairs.
The patients with hematoma or seroma were treated with
aspiration when needed.
Five patients in the Shouldice repair group had recur-
rence (4.1%), in comparison with one patient in
Lichtenstein group (0.8%). In the Shouldice group, two
patients had recurrences during the first year, and three
after the first year. The only recurrence in the
Lichtenstein repair group was six months after surgery.
There was no association between postoperative compli-
cations and recurrence.
Table I
The comparison of Lichtenstein and Shouldice technques in
primary inguinal hernia repairs
Lichtenstein Shouldice p Value
Number of cases 121 120
Age (year) 46 14 49 14
Hernia type (Nyhus)
Type I 14 15
Type II 74 72
Type III 33 33
Anaesthesia
General 30 31
Spinal 44 46
Local 47 43
Operating time (min) 36 14 61 12 < 0.05
Analgesia (Metamizol/gr) 3.9 1.4 4.9 1 .6 < 0,05
Postoperative Complications
Wound Infections 2 2
Seroma 2 2
Hematoma 3 3
Urinary retention 2 2
Recurrence 1 5 < 0,05
Hospital Stay (day) 3.1 1.4 3.2 1.5
Return to work (day) 17 4 25 5 < 0,05
Follow up period (month) 44 8 43 6
420 B. Ayta et al.
Discussion
Since the days of the Bassini inguinal hernia repair,
which failed only seven times in 251 cases, various tech-
niques have been described with excellent results in
terms of recurrences. The ideal method of hernia repair
should cause minimal discomfort to the patient, both
during the surgical procedure and the postoperative
course. It would be technically simple to perform and
easy to learn, would have a low rate of complications
and recurrence and would require only a short period of
convalescence. Finally, cost effectiveness is important, as
10-15 percent of patients with hernia are admitted for
the repair of recurrence (10,11). One of the most accept-
ed methods for several years was the Shouldice repair,
with a recurrence rate of roughly 1-6% (12,13). This
method was considered to be the gold standard with
which other techniques should be compared. Inguinal
hernia repair performed by suturing and displacement of
anatomic structures may lead to excessive tension on the
suture line and surrounding tissue. Subsequently, tissue
ischaemia and suture cut out may occur, resulting in
recurrence. The use of prosthetic mesh allows tension-
free repair of inguinal hernia and better results (14).
In recent years, Shouldice methods superiority has
been challenged by the introduction of mesh techniques,
of which the Lichtenstein method has been the most
popular.
In the present study, the results following either
Lichtenstein or Shouldice repair clearly favor the first
method. The perioperative variables such as length of
hospital stay, and complications were similar in two
groups. Return to work, postoperative analgesia require-
ments, the duration of operation, sick leave, post-opera-
tive discomfort and in particular, the number of recur-
rences differed significantly. The shorter duration of
surgery in mesh technique is due to its technical specifi-
cations itself, where there is no disturbance of the nor-
mal anatomy and preservation of the sphincter mecha-
nism of the internal ring and shutter mechanism of the
inguinal canal. This is also known as tension free
repair(15,16,17,18). This might be the cause of shorter
time to return to work and low dose analgesia require-
ment postoperatively.
The difference in the rates of recurrence in the
Shouldice and Lichtenstein repairs appears to be clini-
cally important. Five patients had recurrences during
follow-up period in the Shouldice group. On the other
hand, there was only one case of recurrence in the
Lichtenstein repair group. The difference in the recur-
rence rates between the groups is also expected to
increase over period of time. There was no late recur-
rence after Lichtenstein repair in our series, since the
mesh completely covers the hernia port and reinforces
the groin region. The interstices of polypropylene mesh
were completely infiltrated with fibroblasts, and the
repair also remained permanently strong (19).
Though the Lichtenstein repair seems to be more
expensive due to the extra cost of mesh, shorter time for
return to work and lower recurrence rate repays its cost
(10). In conclusion, patients with primary unilateral
inguinal hernias who undergo a Lichtenstein repair have
shorter operation time, recover more rapidly and have
fewer recurrences in comparison with those who under-
go a Shouldice repair. The Lichtenstein repair is also
much simpler to perform than the conventional Shoul-
dice repair and therefore, Lichtenstein tension free mesh
technique must be the open method of choice for prima-
ry inguinal hernia repair (3,6,14).
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Dr. Blent Ayta
Emek Mahallesi, Yes
.
iltepe Bloklar 79.sokak, 2/16
Ankara, Turkey
Phone : +90 312 222.80.56
Fax : +90 312 434 02 57
E-mail : bulentaytac2002@yahoo.com
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