Shouldice is superior to Bassini inguinal herniorrhaphy

Abstract

The original Bassini and Shouldice methods for inguinal herniorrhaphy were tested against each other and against their respective variants that avoid permanent suturing of the internal oblique muscle. Seven hundred fifty inguinal hernia repairs were prospectively allocated to 1 of 4 groups: group A: Bassini with absorbable sutures (polyglycolic acid); group B: Bassini with nonabsorbable sutures (polyester); group C: Shouldice with four rows of polypropylene sutures; and group D: Shouldice with two rows of polypropylene sutures. Outcome was correlated to prospectively defined types and risk factors such as direct hernia, repair for recurrent hernia, hernial sac diameter greater than 8 cm, age greater than 70 years, overweight, and chronic bronchitis. Actual (not actuarial) recurrence rates were determined through clinical examination by hospital staff surgeons (not through information by letter or phone) for 93.6% of surviving patients. Local complications exclusive of recurrence, but including the redoubtable and litigious sequelae of testicular atrophy and chronic ilioinguinal pain, were significantly reduced from 6.3% (group B and C) to 2.3% by omitting permanent muscle sutures (groups A and D; P < 0.05). However, the use of slowly absorbable suture material resulted in a disproportionately high recurrence rate of 12.8% in the modified Bassini group A. The original Bassini method, ie, division of the transversalis fascia and repair with nonabsorbable sutures, as was used in group B, had an actual 2-year recurrence rate of 8.7%, still a highly significant difference compared with 3.6% and 2.3% for Shouldice groups C and D, respectively (P = 0.012). For repair of recurrent hernia, the superiority of the Shouldice technique was not statistically significant: re-recurrence rate 7.6% versus 13.5% for the original Bassini group B. Repair of recurrent hernia was the only patient-related risk factor of equal significance as the method of repair. The Shouldice technique is superior to and more than merely a reinvention of Bassini's original method. The omission of muscle sutures is physiologically sound and recommended for the Shouldice operation.