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Should Ice

Should Ice

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Published by: marquete72 on Jan 21, 2009
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The Shouldice Repair
Robert Bendavid, MD
Fate and evolution have reserved for the surgeon aninteresting twist of irony in the treatment of hernias. In1883, Edoardo Bassini ushered in the modern era of groinhernia treatment1; today, after 118 years and some 80variations of his repair, 2 the premier operation, the "goldstandard" of primary tissue repair, is the Shouldiceprocedure, which, except for its use of a continuoussuture instead of an interrupted one, does not differ fromthe Bassini operation.The Shouldice repair, the Shouldice Hospital opera-tion, the Canadian repair, and the Bassini-Shouldice3 allrefer to the same procedure that has been performedsince 1952. The Shouldice Hospital, which came intoexistence in 1945, thrived thanks to the concept ofperforming herniorrhaphies under local anesthesia and,importantly, early ambulation. In this case, early ambula-tion means that the patient walks away from the operat-ing table.E. E. Shouldice (1890-1965) realized very early thesignificance of the hernia as a pathological, surgical, and
From the Department of Surgery, University of Toronto, Toronto, Canada.Address reprint requests to Robert Bendavid, MD, 1208-18 Cedarcroft Blvd,Toronto, M2R 2Z2 Canada.Copyright 9 1999 by WB. Saunders Company1524-153X/99/0102-0004510.00/0
social problem (an impediment to army draft, work, etc).He also realized that only a specialized, dedicated team ina specialized facility would obtain the knowledge andskill necessary for the best results. Between 1945 and1952, the results of the Shouldice Hospital were in linewith reported series around the world. After 1952, ErnieRyan (of the Shouldice Hospital) implemented the resec-tion of the cremaster, as well as the splitting of thetransversalis fascia. From 1952 on, the results have beenrewarding, particularly in primary hernia repairs. In1983, prosthetic materials were added to the armamen-tarium of the Shouldice Hospital, particularly for thedifficult recurrences, inguinofemoral and femoral her-nias.The Shouldice operations and the dissection in particu-lar, is a key operation that every surgeon must be able toperform well, particularly today, when the pervasive useof prostheses imparts a false sense of security. No matterwhich operation surgeons ultimately prefer, chances arethat at some time they will need to perform a Shouldicerepair. The surgeon who understands the principles andacquires the skills to perform a flawless Shouldice repaircan address every possibility, challenge, or emergency; itis an operation that does not need conversion to anothertechnique and yet remains versatile enough to allowaddition of prosthetic materials in every imaginablevariation.142
Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 142-155
The Shouldice Repair
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Local anesthetic consists of 1% procaine hydrochloride (30 to 40 mL). Infiltration of the skin is alongthe line joining the anterior-superior fliac spine and the pubic crest. Infiltration raises a wheal about 5 cmwide over a length of l0 cm extending from the pubic crest to the anterior-superior iliac spine. Incisionalong this line is lower than that usually described by most authors writing on open techniques, who tendto perform an incision 2 to 4 cm above and parallel to the inguinal ligament. The lower approach allowsclearer access to the groin without undue retraction, particularly near the medial portion of the posterioringuinal wall during reconstruction or while exploring for a femoral hernia below the inguinal ligament.(Reprinted with permission from Lippincott Williams and Wilkins. 4)
144 Robert Bendavid2 The incision has been made through the skin and subcutaneous tissues.Retraction of the skin edges reveals the external oblique aponeurosis as well asthe cribriform fascia, an extension of the fascia lata of the thigh. At this stage,procaine hydrochloride (20 to 30 mL) is injected deep to the external obliqueaponeurosis, allowing extravasation of the anesthetic to reach the ilioinguinaland iliohypogastric nerves and the genital branch of the genitofemoral nerve.(Reprinted with permission from Lippincott Williams and Wilkins. 4)

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