The Shouldice technique for the treatment of inguinal hernia

Abstract

The Shouldice repair has been refined over several decades and is the gold standard for the prosthesisfree treatment of inguinal hernias. A recurrence rate around 1% has been consistently demonstrated over the years. The objective of this paper is to outline and highlight the key principles, including the dedicated pre-operative preparation, the use of local anesthesia, a complete inguinal dissection and the eponymous four-layered reconstruction. A knowledge and understanding of inguinal hernia anatomy and the patho-physiology of recurrence are vital to achieving a long-term success and patient satisfaction for a pure tissue repair.

Keywords: Inguinal hernia; Shouldice repair; recurrence.

Figure 1

Right inguinal hernia repair: dissection of cremasteric muscle. Mobilization of the spermatic cord through the cremasteric muscle and creation of medial and lateral flaps for transection

Figure 2

Dissection of femoral space A) Cooper's ligament seen through the preperitoneal space, deep to the tips of the clamp; and B) Incision of the cribiformis ligament below the inguinal ligament

Figure 3

Reconstruction: the first layer. A) Starting at the pubic tubercle, the lateral flap of transversalis fascia is taken to the edge of rectus sheath underneath the medial flap; and B) The layer is completed with the reconstruction of internal ring. The lateral stump of cremasteric muscle is taken with the bite of transversalis to buttress its medial edge of the new internal ring, prior to emerging with a full thickness bite of internal oblique.

Figure 4

Reconstruction: the second layer Using the same suture, it is continued from the internal ring back, taking the medial flap of transversalis fascia to the shelving portion of the inguinal ligament. Overlapping layers are created.

Figure 5

Reconstruction: the third layer. Starting at the medial side of the internal ring, the external and internal oblique are used to imbricate the first two layers. Small bites of external oblique are taken just above the inguinal ligament.

Figure 6

Reconstruction: the fourth layer. The second layer of imbrication using the external and internal oblique. The benefit of incising the cribiformis fascia and the mobilization of the lateral flap of external oblique is realized as a small flap of external oblique remains after the four layers. This small flap is used to reconstruct the inguinal canal and restore the natural anatomic position of the cord structures.