The Shouldice Procedure:
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If you are interested in a non-mesh repair for your inguinal hernia, our surgeons are experts in the Shouldice procedure. Each receiving training in this specialized repair, it is an excellent option for patients who want to avoid mesh placement for inguinal hernias.
Read more about it below.
The Shouldice procedure has been around and well studied since 1945 and is an excellent alternative to the traditional open inguinal hernia repair with mesh. The concept of the Shouldice repair is to restore the abdominal wall and groin region to normal anatomy using only sutures (stitches). This is performed through a groin incision and the repair brings 4 separate layers of tissue together, dispersing the tension over 4 different layers, thereby reducing the chances of recurrence versus a 1 or 2 layered closure.
Why Choose the Shouldice Procedure?
You might want to choose the Shouldice procedure for your hernia repair if you:
Do not want implantable mesh
You have a small or medium inguinal hernia
You are otherwise healthy and want to remain active
You might not be a candidate if your hernia is larger, you have a femoral or obturator hernia, or you have multiple other medical problems. The Shouldice procedure may also not be ideal for recurrent hernias, as you may need additional reinforcement in the form of a synthetic mesh. Discuss your options with one of our Experts.
The Procedure
The Shouldice procedure involves an incision through the groin and then isolation of the outermost oblique muscle, which overlies the inguinal canal, the external oblique. The oblique is cut to enter the canal and then the spermatic cord (in men) or the round ligament (in women) is seen.
The inguinal floor and the hernia are seen at this point. The hernia sac (the lining of the hernia contents) is separated from all nearby structures and is reduced back into your abdominal cavity. Then the repair can begin. The theory behind the Shouldice repair is to restore your anatomy to almost normal. The first step involves cutting through the floor of the canal, which frees up the innermost oblique muscle and connective tissue, the transversus abdominis.
Then, the 2 parts of the innermost oblique are seen and the goal is to tighten them to restore the floor of the inguinal canal. This is done by bringing one the lowermost leaflet to the connective tissue of the underside of the rectus abdominis muscle (the six pack muscles) and eventually the underside of the innermost 2 oblique muscles (the internal oblique and transversus abdominis).
This part is typically done with a continuous suture line (The First Row). Then the uppermost leaflet of the innermost oblique (transversus abdominis) is sutured to the tough connective tissue of the outermost oblique (external oblique)
The second suture line is tied back onto itself to finish the first step and The Second Row.
The Third and Fourth Row utilize another suture line in order to bring the muscle and tendon of the internal oblique and tranversus abdominis to the strong connective tissue of the external oblique. By doing so, it disperses the tension across 2 more suture lines and fully recreates the inguinal floor.
Then the cut edge of the external oblique is sewn back togather and the skin is closed. A cross section shows us how the repair looks, with each of the 4 layers of the Shouldice, along with the skin closure layers
The Recovery
The recovery for the Shouldice procedure is very similar to a regular inguinal hernia repair. We do like to restrict vigorous physical activity for 6 weeks instead of 4, however discomfort is similar between repairs.
The only real difference between a Shouldice Repair and a traditional inguinal hernia repair, in our philosophy, is the recurrence rate being slightly higher (Quoted in the literature from 4-5%). While our recurrence rate is quite lower (1-2%) we still recommend that our patients be vigilant about notifying us when they think they might have a new symptom or bulge.