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14845 June/97 CJS /Page 199

Canadian Association of General Surgeons


Association canadienne de chirurgiens gnraux

SYMPOSIUM ON THE MANAGEMENT OF INGUINAL HERNIAS


4. THE SHOULDICE TECHNIQUE:
A CANON IN HERNIA REPAIR

Robert Bendavid, MD

Controversy exists on the merits of the various approaches to inguinal repair. Evolution of the classic open
repair has culminated in the Shouldice repair. Challenges from newcomers, namely, tension-free repair and
laparoscopy, are being examined. These two techniques have a number of disadvantages: the presence of
foreign bodies (prostheses) and their implication in cases of infection; the cost of prosthetic material, which
is no longer negligible (particularly with expanded polytetrafluoroethylene); and problems of safety in that
the laparoscopic approach is no longer a dependable asset except in the hands of a highly specialized and
dextrous operator. Still, complications occur with laparoscopic repair that should not be associated with a
surgical procedure that is considered benign, safe and cost-effective. Surgeons must recognize the perti-
nent facts and decide according to their conscience which method of repair to use.

Les mrites des diverses mthodes de rparation inguinale suscitent la controverse. Lvolution de la rparation
classique a atteint son point culminant avec la mthode Shouldice. On examine lheure actuelle les dfis poss
par de nouvelles mthodes, cest--dire la rparation sans tension et la laparoscopie. Ces deux techniques
prsentent certains dsavantages : la prsence de corps trangers (prothses) et leurs rpercussions en cas din-
fection, le cot des prothses, qui nest plus ngligeable (surtout dans le cas du polyttrafluorthylne expans)
et les problmes de scurit poss par le fait que la laparoscopie nest plus un moyen fiable, sauf entre les mains
dun chirurgien trs spcialis et habile. La rparation par laparoscopie pose quand mme des complications
quil ne faudrait pas associer une intervention chirurgicale juge bnigne, sre et peu coteuse. Les chirurgiens
doivent reconnatre les faits pertinents et choisir la mthode utiliser en fonction de leur conscience.

THE SHOULDICE TECHNIQUE

R
eview of all the available tech- ethics, safety, economics and results
niques in hernia surgery pre- be objectively scrutinized. Further-
sents a muddled picture. more, the influence, precept and ma- Evolution of the Shouldice tech-
The contentious issues have revolved nipulation of the manufacturers of nique began with that of Bassini,
around the use of prosthetic materials surgical instruments must be scrupu- through Halsted, Ferguson, Andrews
and more recently the wisdom of lously parried since they cannot, or and to a certain degree, McVay.1,2 It in-
laparoscopic herniorrhaphy. Both will not, appreciate the nature and corporates steps from all those opera-
tension-free and laparoscopic tech- implications of invasive technologic tions. The only drawback to the
niques have serious drawbacks. legerdemain on the living, human Shouldice technique is that it must be
It is becoming imperative that patient. done integrally.35 Many surgeons over

From the Shouldice Hospital Ltd., Thornhill, Ont.


Symposium presented at the annual meeting of the Canadian Association of General Surgeons, Montreal, Que., Sept. 16, 1995
Accepted for publication Jan. 29, 1997
Correspondence to: Dr. Robert Bendavid, Shouldice Hospital Ltd., PO Box 370 Stn. Main, Thornhill ON L3T 4A3
1997 Canadian Medical Association (text and abstract/rsum)

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BENDAVID

the years have made a point of spend- better displayed by the lower incidence, When the external oblique aponeurosis
ing 1 to 3 days at the Shouldice Hos- if not elimination, of pulmonary and has been divided along the direction of
pital, where they can watch up to 30 cardiac complications, urinary reten- its fibres and the edges freed and re-
operations a day in 5 operating rooms. tion and deep vein thrombophlebitis. tracted, these nerves are visualized and
Too often, surgeons take short cuts, The death rate has consistently been can be individually infiltrated with an-
omit steps or improvise so much that under 1/10 000.10 Local anesthesia re- other 2 or 3 mL of procaine hydrochlo-
the results bear no resemblance to the duces significantly the need for and ride. Other areas that will require anes-
original technique. I have yet to see a cost of preoperative consultations and thetizing during the procedure are the
surgeon perform a Bassini repair as de- investigations as well as postoperative edges of the internal ring (5 mL) and
scribed by Bassini or his student, Cat- care. Statistics at the Shouldice Hospi- the spermatic cord within its areolar tis-
terina, whose monograph remains a tal revealed that 52.1% of all patients sue at the level of the internal ring. An-
classic.6 The 3 crucial components of are older than 50 years (Table I). The other 5 to 10 mL of procaine hy-
the Shouldice repair that contribute to incidence of associated cardiac impair- drochloride is allowed to diffuse deep
its safety, efficacy and cost-effectiveness ment is shown in Table II. to the transversalis fascia along the edge
are local anesthesia, technical aspects To the majority of patients, local anes- of the myoaponeurotic arch (falx in-
of the repair and early ambulation. thesia is perceived as being associated guinalis). These additional areas are in-
with minor surgical procedures, so they nervated by sympathetic fibres from the
Local anesthesia will proceed more readily with elective renal and pelvic plexuses. The last site
repair rather than delay until an emer- to require infiltration will be a hernial
The desirability and feasibility of gency, with its attendant complications, sac, if indirect, with 5 to 10 mL around
herniorrhaphy under local anesthesia will force them to submit to surgery. the base of the sac and directly into the
were demonstrated by Halsted, Blood- The technical aspects of local anes- sac. Tension and dissection of the sac
good and Cushing as early as 18997 in thesia of the inguinal area are simple may otherwise be painful and bring
patients for whom ether and chloro- and do not require unusual dexterity. about a bradycardia.
form anesthesia represented a clear Procaine hydrochloride (1%) is still used
danger (33 cases). The introduction of up to a volume of 200 mL. Infiltration Surgical steps
local anesthesia on a widespread scale, of the skin is carried out from the level
however, began with Earle Shouldice, of the anterior superior iliac spine to the The Shouldice repair applies to di-
as seen in publications from this hospi- pubic crest 50 to 80 mL will suffice. rect and indirect inguinal hernias. It
tal: 2874 cases reported by Campbell Once the skin has been incised and does not apply to femoral hernias. The
in 19508 and 10 000 cases reported by bleeding vessels have been controlled, majority of recurrent inguinal hernias
Shouldice in 1953.9 an additional 20 to 30 mL are injected can be treated with a Shouldice repair.
Now that elderly patients undergo deep to the external oblique aponeuro- In a review of our statistics by Obney
hernia repair more frequently, the ad- sis in the general area of the ilioinguinal, and Chan,11 37% of 1057 patients who
vantages of local anesthesia are even iliohypogastric and the genital nerves. presented with a recurrent hernia had

Table II
Table I
Associated Cardiac Conditions in Patients Over 50 Years
Records of Patients at the Shouldice Hospital Over the of Age, From the Shouldice Hospital Records
Age of 50 Years Patients,
Condition %
Patients
Anticoagulation (with acetylsalicylic acid,
Age group, yr No. % Operations, no.
sulfinpyrazone, warfarin sodium) 12
< 50 2917 47.9 3424 History of
5059 1116 19.1 1369 Myocardial infarction 15
6069 1330 21.4 1533 Angina 15
7079 603 9.6 689 Congestive heart failure 17
8089 124 2.0 144 Hypertension 20
Total 6090 100.0 7159 Cardiac arrhythmia 50

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THE SHOULDICE TECHNIQUE

an indirect inguinal hernia. These re- ternal ring to the pubic crest, resulting Division of the posterior wall of the
currences may properly be termed in medial and lateral flaps. The medial inguinal canal
missed hernias. The majority of re- flap is essentially avascular and is resected
current direct hernias can also be entirely. The lateral flap, containing the This step, already emphasized by
treated in the same manner. The need external spermatic vessels and the geni- Bassini,13 is perpetuated in the Shouldice
for mesh is 1.3% for all groin hernias12 tal branch of the genitofemoral nerve, is repair. It consists of incising the trans-
(Table III). The essential steps of the divided between 2 clamps. Each result- versalis fascia from the medial aspect of
repair consist of the following. ing stump is doubly ligated with a re- the internal ring to the pubic crest. In
sorbable suture. In this manner, an indi- exceptional cases in which this fascia is
Resection of the cremaster muscle rect inguinal hernia can never be missed. substantial, division may be carried out
When such a hernia is absent, a peri- over 1 or 2 cm only, enough to insert
When the spermatic cord has been toneal protrusion can be identified, freed the index finger and palpate the femoral
exposed, the cremaster muscle is incised and pushed back into the preperitoneal opening. In female patients who rarely
longitudinally from the level of the in- space of Bogros (Fig. 1). have a direct inguinal hernia, the poste-
rior wall need not be incised. The trans-
Table III versalis fascia is then divided from the in-
ternal ring to the pubic tubercle. The
Need for Mesh in Hernia Repairs at the Shouldice Hospital logic behind this step is that it excludes
Mesh needed, the weakened transversalis fascia from
Hernia type No. of operations no. (%) being used again and, more importantly,
Abdominal wall 7529 154 (2.0) provides exposure of the more solid lay-
Groin 7085 98 (1.3) ers needed for the reconstruction, medi-
Direct inguinal 2890 26 (0.9) ally and laterally (Fig. 2).
Indirect inguinal 4028 4 (0.1)
Incision of the fascia cribriformis
Femoral 144 48 (33.3)
Inguinofemoral 23 20 (87.0)
The fascia cribriformis, an exten-

FIG. 1. Longitudinal incision of the cremaster muscle, resulting in two


leaves. The medial leaf is entirely resected. The lateral leaf is divided be- FIG. 2. Incision of the transversalis fascia from the deep inguinal ring to
tween clamps and doubly ligated, providing 2 stumps. (Reproduced with the pubis. Resection of the central elliptical portion is warranted in many
permission from: Nyhus LM, Baker RJ. Mastery of surgery. 2nd ed. Boston: cases. (Reproduced with permission from: Nyhus LM, Baker RJ. Mastery of
Little, Brown and Company; 1992.) surgery. 2nd ed. Boston: Little, Brown and Company; 1992.)

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BENDAVID

sion of the fascia lata of the thigh, is the medial myoaponeurotic arch nal ring. Four lines of sutures are thus
incised from the level of the femoral (transversalis fascia, transversus abdo- provided, sealing the posterior wall
vein to the pubic crest. The femoral minis and internal oblique muscles) and absorbing evenly any tension on
orifice below the inguinal ligament is and the lateral border of the rectus the repair. The spermatic cord is placed
demonstrated and with palpation of muscle, leaving a free border to this back in its normal anatomic position
the femoral ring from the preperi- arch (Fig. 3). This suture advances to- and the external oblique aponeurosis
toneal space confirms the presence or ward the internal ring, picking up the brought together anterior to the cord
absence of a femoral hernia. lateral stump of the cremaster, insert- with a running absorbable suture.
ing it deep to the muscular layer me-
Reconstruction dially. This same suture reverses its RESULTS
course back in the direction of the pu-
Reconstruction of the posterior bic crest and includes the shelving Before the introduction of pros-
wall is carried out with continuous edge of the ligament of Poupart on its thetic mesh in November 1983, the
stainless steel wire (gauge 32 or 34). way, to be finally tied near the pubic recurrence rate, globally, was less than
Steel is an ideal material, being nonre- spine (Fig. 4). The second suture pro- 1%. With mesh being used in chal-
active and nonallergenic. Further- vides lines 3 and 4 and begins later- lenging cases (less than 2%, ), the re-
more, it never needs to be removed in ally, picking up internal oblique and currence rate has been 0.7% (Tables
the presence of infection. The contin- transversus muscles, then crosses over III and IV14-19).20
uous suture is ideal because it elimi- to pick up the inner aspect of the Complications such as pneumonia,
nates the small defects between inter- lateral half of the external oblique atelectasis, pulmonary embolism, phleb-
rupted sutures and because it aponeurosis along a line just superior itis and urinary retention are practically
distributes the tension evenly on the and parallel to the inguinal ligament, nonexistent because of the aggressive
suture line. Two continuous sutures proceeding to the pubic tubercle, then encouragement of early ambulation,
are used, each going back and forth, reverses toward the internal ring, pick- which begins with the patient walking
thereby providing 4 lines. The first su- ing up again the external oblique away from the operating table after
ture begins near the pubic crest, pick- aponeurosis on its inner aspect just surgery. Other complications have been
ing up the iliopubic tract laterally, and above and along the previous third superficial hematomas (0.3%) and infec-
crosses over to be inserted through line to be knotted finally at the inter- tions (0.7%). The incidence of testicular

FIG. 3. Exposure of the structures that will contribute to a reliable repair. FIG. 4. The second line of the first suture incorporating the inguinal liga-
Note the vessels that must be identified and avoided. (Reproduced with ment, just before a knot is tied at the pubis. (Reproduced with permission
permission from: Nyhus LM, Baker RJ. Mastery of surgery. 2nd ed. Boston: from: Nyhus LM, Baker RJ. Mastery of surgery. 2nd ed. Boston: Little, Brown
Little, Brown and Company; 1992.) and Company; 1992.)

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THE SHOULDICE TECHNIQUE

atrophy after primary repair of an in- With reference to the first, there is als is high, especially in the case of ex-
guinal hernia is 0.036% and after repair no doubt that it is extremely easy to ex- panded polytetrafluoroethylene. Post-
of a recurrent hernia, 0.46%.21 The death ecute. However, it overlooks basic operative comfort and earlier return to
rate of 1/10 000 within 30 days of sur- principles in surgery, namely, the need work are factors that depend greatly on
gery has not been a direct result of to know the anatomy of an area that patient personality, motivation and in-
surgery (e.g., cerebrovascular accident, may present other problems than a sim- surance status rather than the particular
perforated gallbladder, duodenal ulcer, ple, primary, elective repair. This is par- herniorrhaphy.
mesenteric or coronary thrombosis). The ticularly applicable to incarcerated or If one remains detached and truly
postoperative period (48 to 72 hours) is strangulated hernias. A tension-free re- has the patients interest as an objec-
considered one of rehabilitation during pair is of no value in inguinofemoral tive, objections to laparoscopic hernior-
which patients are encouraged to resume hernias or in the absence of an inguinal rhaphy appear to be increasing with
normal activities. A study of 1200 pa- ligament, hence potential failures are each published report. There is ample
tients carried out by Mr. Alan ODell, eliminated, contributing to a success evidence that laparoscopic herniorrha-
the administrator of Shouldice Hospital, rate that is deceiving. The proper site phy is feasible, but it must be remem-
revealed that on average, patients re- for a prosthetic mesh is the preperi- bered that the average general surgeon
turned to work in 8.2 days.12 toneal space, applied as widely as possi- performs 50 herniorrhaphies a year (A.
Increasingly, cost is becoming a ma- ble, deep to the transversalis fascia as ODell, Administrator, Shouldice Hos-
jor factor in medical economics. In the prescribed by Stoppa, Soler and Ver- pital, Thornhill, Ont.: personal com-
same study by ODell, the cost of all haeghe,22 Wantz23 and Flament, Rives munication, 1995), a number that is
disposable items, per patient, and Palot.24 The weakness of the trans- not likely to endow anyone with ex-
amounted to Can$24.58. These items versalis fascia is the result of a metabolic pertise in a challenging technique. Ob-
included: syringes, dressings, swabs, etiology that reaches beyond the in- jections therefore beg to be cata-
scrub solutions, drugs (midazolam, guinal floor to the adjacent tissues.25 logued: exclusions include patients at
promethazine, meperidine hydrochlo- Mesh infection always represents a cat- high anesthetic risk, those with multi-
ride, morphine, prochlorperazine, di- astrophe, and though the incidence ple previous abdominal operations,
azepam, procaine hydrochloride), caps, may be low (0.5% to 3.5%),26 the actual incarcerated or strangulated hernias,
masks, gowns, tubings, needles, gloves, cases provide an indelible experience peritonitis, coagulopathy, severe obe-
blades, sponges, sutures and oxygen. that should temper their use. I have sity, immune deficiency and a history
seen infections present up to 2 years af- of recent infection, females of child-
DISCUSSION ter the original surgery; Stoppa26 re- bearing age and those with recurrent
ported 3 to 18 months, Flament and hernia after laparoscopy.3234 Also the
The simplicity, the excellent results associates27 6 and 8 years. Should a re- use of laparoscopic techniques for her-
and the cost-effectiveness of the current hernia follow a wound infec- nia repair in the pediatric patient has
Shouldice repair make it difficult to tion, subsequent repair must exclude not been well accepted35 and for the
emulate. What are the objections to the use of a prosthesis because surviv- simple, nonrecurrent unilateral inguinal
the tension-free repair and to laparo- ing organisms can be detected years hernias, the use of a laparoscopic ap-
scopic herniorrhaphy? later.2831 The cost of prosthetic materi- proach is controversial.32 Such exclu-
sions make up 90% of the surgery done
Table IV at the Shouldice Hospital!
Results of the Shouldice Repair From Various Series
Complications
Follow-up Recurrence
Series No. of cases % Length, yr rate, % Long-term complications are not
Shearburn and Myers, 1969 14
550 100 13 0.2 yet known, but some can be predicted,
Wantz, 198915 2087 5 0.2 particularly with any technique that
Bocchi, 199516 2119 80 7 0.75 leaves prosthetic material within the
Devlin et al, 198617 350 6 0.8 peritoneal cavity (the intraperitoneal
onlay method [IPOM]). This tech-
Moran et al, 196818 104 6 2.0
nique must be considered an experi-
Berliner, 1983 19
591 25 2.7
mental operation and patients must be

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BENDAVID

so informed,32 and we do not recom- rence rate, showed the highest inci- 4. Nyhus LM, Baker RJ. Mastery of
mend the IPOM procedure outside of dence of complications.40,44,57 surgery. 2nd ed. Boston: Little, Brown
and Company; 1992:1584-94.
a controlled trial.32 Can the patient re-
5. Bendavid R. Loperation de Shouldice.
ally be expected to make the right de- Cost In: Encyclopdie mdico-chirurgicale.
cision? Complications that may occur Techniques chirurgicales appareil diges-
at the time of surgery or shortly there- Exclusive of fixed equipment and tif. Paris: Encyclopdie mdico-chirur-
after are presently well documented set-up expenses, the cost of laparo- gicale; 40112 4.11.12:5 pages.
and range from 0% to 53.3%.32,3657 scopic herniorrhaphy may vary but will 6. Catterina A. Loperation de Bassini.
These complications include the fol- always be far more onerous than the Paris: Librairie Felix Alcan; 1934.
lowing: perforation of bowel or urinary open repair. An example may be seen 7. Cushing H. The employment of local
bladder; major vascular injuries (exter- in the figures provided by Arregui: anaesthesia in the radical cure of cer-
tain cases of hernia, with a note upon
nal iliac, circumflex iliac profunda, ob- US$1656.00,58 versus the Shouldice
the nervous anatomy of the inguinal
turator and inferior epigastric vessels); Hospital: US$17.45.59 Another cost is- region. Ann Surg 1900;31:1-34.
nerve injury (the genitofemoral nerve, sue raised by laparoscopic surgeons is 8. Campbell EB. Anesthesia in the re-
the femoral nerve and the lateral one of hospital stay, as the patients are pair of hernia. Can Med Assoc J 1950;
femorocutaneous nerve of the thigh) discharged on the same day, but this is 62:364-6.
(nerves cannot be readily identified no longer a particular feat as many in- 9. Shouldice EE. The treatment of her-
with certainty); adhesive, obstructive stitutions also discharge patients on the nia. Ont Med Rev 1953;October:1-14.
and erosive events and fistula formation same day as for an open repair. The is- 10. Nyhus LM, Baker RJ. Mastery of
surgery. 2nd ed. Boston: Little, Brown
requiring subsequent abdominal sur- sue of earlier return to work after la-
and Company; 1992:1593.
gery; bleeding with or without the paroscopic repair has not been convinc-
11. Obney N, Chan CK. Repair of multi-
need for transfusion; abdominal wall ing. Our own patients return to work ple time recurrent inguinal hernias with
hematomas; trocar site hernias; persis- on average, 8.2 days after surgery.5961 reference to common causes of recur-
tent leg, groin and testicular pain; sero- rence. Contemp Surg 1984;25:25-32.
mas; hydroceles; orchitis; epididymitis; CONCLUSIONS 12. Bendavid R. Prosthetics in hernia
spermatic cord transection; mesh infec- surgery: a confirmation. Postgrad Gen
tion; lost clips or needles; inadequate At best, the tension-free and la- Surg 1992;April:166-7.
peritoneal closure leading to bowel paroscopic herniorrhaphies may ap- 13. Bassini E. Nuovo metodo operativo per
la cura radicale dellernia inguinale.
slipping into the extraperitoneal space proach the good results of the
Padova (Italy): R. Stabilimento Pros-
and obstruction (shower curtain ef- Shouldice repair in terms of recur- perini; 1889.
fect); right lower quadrant pain, rence. With respect to cost, neither 14. Shearburn EW, Myers RN. Shouldice
Richters hernia involving a trocar site of those two techniques may com- repair for inguinal hernia. Surgery
opening. Control of some of these pare, least of all laparoscopy. In terms 1969;66(2):450-9.
complications may require immediate of actual and potential complications, 15. Wantz GE. The Canadian repair for in-
conversion to an open procedure5,52,56 laparoscopic herniorrhaphy leaves me guinal hernia. In: Nyhus LM, Condon
or an urgent laparotomy. with a very uneasy feeling. I have no RE, editors. Hernia. 3rd ed. Philadel-
phia: J.B. Lippincott; 1989:236-47.
doubt that eventually, common sense
16. Bocchi P. The Shouldice operation.
Recurrence and reason will prevail. Can it be done by the average sur-
geon in an average surgical service?
Recurrence rates vary with the An analysis of the recurrences. Probl
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C.V. Mosby; 1960:11-33. Shouldice operation, 19701982. Br
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2. Nyhus LM, Baker RJ. Mastery of J Surg 1986;73(2):123-4.
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