The Shouldice Repair

Robert Bendavid, MD

Fate and evolution have reserved for the surgeon an interesting twist of irony in the treatment of hernias. In 1883, Edoardo Bassini ushered in the modern era of groin hernia treatment1; today, after 118 years and some 80 variations of his repair, 2 the premier operation, the "gold standard" of primary tissue repair, is the Shouldice procedure, which, except for its use of a continuous suture instead of an interrupted one, does not differ from the Bassini operation. The Shouldice repair, the Shouldice Hospital operation, the Canadian repair, and the Bassini-Shouldice3 all refer to the same procedure that has been performed since 1952. The Shouldice Hospital, which came into existence in 1945, thrived thanks to the concept of performing herniorrhaphies under local anesthesia and, importantly, early ambulation. In this case, early ambulation means that the patient walks away from the operating table. E. E. Shouldice (1890-1965) realized very early the significance 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 Company 1524-153X/99/0102-0004510.00/0

social problem (an impediment to army draft, work, etc). He also realized that only a specialized, dedicated team in a specialized facility would obtain the knowledge and skill necessary for the best results. Between 1945 and 1952, the results of the Shouldice Hospital were in line with reported series around the world. After 1952, Ernie Ryan (of the Shouldice Hospital) implemented the resection of the cremaster, as well as the splitting of the transversalis fascia. From 1952 on, the results have been rewarding, particularly in primary hernia repairs. In 1983, prosthetic materials were added to the armamentarium of the Shouldice Hospital, particularly for the difficult recurrences, inguinofemoral and femoral hernias. The Shouldice operations and the dissection in particular, is a key operation that every surgeon must be able to perform well, particularly today, when the pervasive use of prostheses imparts a false sense of security. No matter which operation surgeons ultimately prefer, chances are that at some time they will need to perform a Shouldice repair. The surgeon who understands the principles and acquires the skills to perform a flawless Shouldice repair can address every possibility, challenge, or emergency; it is an operation that does not need conversion to another technique and yet remains versatile enough to allow addition of prosthetic materials in every imaginable variation.

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Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 142-155

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SURGICAL TECHNIQUE

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1 Local anesthetic consists of 1% procaine hydrochloride (30 to 40 mL). Infiltration of the skin is along the line joining the anterior-superior fliac spine and the pubic crest. Infiltration raises a wheal about 5 cm wide over a length of l0 cm extending from the pubic crest to the anterior-superior iliac spine. Incision along this line is lower than that usually described by most authors writing on open techniques, who tend to perform an incision 2 to 4 cm above and parallel to the inguinal ligament. The lower approach allows clearer access to the groin without undue retraction, particularly near the medial portion of the posterior inguinal wall during reconstruction or while exploring for a femoral hernia below the inguinal ligament. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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Robert Bendavid

2 The incision has been made through the skin and subcutaneous tissues. Retraction of the skin edges reveals the external oblique aponeurosis as well as the 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 oblique aponeurosis, allowing extravasation of the anesthetic to reach the ilioinguinal and iliohypogastric nerves and the genital branch of the genitofemoral nerve. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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3 The external oblique aponeurosis is incised along the direction of its fibers from the superficial ring to a point 2 to 3 cm lateral to the deep inguinal ring. The undersurfaces of the two flaps of external oblique aponeurosis are freed from the underlying and adjacent structures to provide good exposure of the operative field, and also to mobilize the tissue layers that will form the eventual repair. The lower flap is freed from the adherent fibers of the internal oblique and cremaster until its reflected portion, the inguinal ligament, comes into full view. The femoral vein and artery can be identified by the translucency of the recurving portion of the external-oblique-aponeurotic fibers. The upper flap of the external oblique aponeurosis is also freed from the underlying internal oblique muscle as far medially as the lateral edge of the rectus muscle and sheath. At this stage, the trunks of the ilioinguinal, iliohypogastric, and genital nerves are easily seen and can be individually infiltrated with an additional 1 mL of procaine hydrochloride to insure complete anesthesia. (Reprinted with permission from Lippincott Williams and Wilkins.4)

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Robert Bendavid

t line ating .'ision he pubic o femoral

4

The cribriform fascia is incised from the level of the pubic crest to that of the femoral artery (dotted line). This maneuver serves two purposes: (1) providing excellent exposure of the femoral orifice, where a protruding femoral hernia may be discovered; and (2) mobilizing the outer surface of the external oblique aponeurosis near its folding under to form the inguinal ligament; this provides a released, tension-free layer for the subsequent repair. Occasionally, a fat tab is present at the femoral orifice; one should not succumb to the temptation to dissect it. It serves as a "plug" and should simply be resected at its neck; a single suture of Prolene (Ethicon, Inc, Somerville, NJ) closes the edges of the defect. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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5 The cord, with its cremasteric muscle sheath, is clearly visible. A longitudinal incision is made along the direction of the fibers of the cremaster, from the pubis to the deep inguinal ring, resulting in two muscular flaps, a lateral and a medial. The medial flap is resected entirely from its base along the margin of the internal oblique or conjoined tendon. It will be avascular, although a bleeder near the deep ring may occasionally require ligation. The lateral flap of the cremaster is bulkier and contains the external spermatic vessels and the genital branch of the genitofemoral nerve. Two clamps are applied to the "cremaster bundle," which is divided between the clamps; each stump is doubly ligated with an absorbable suture. The lower medial stump will eventually be anchored near the pubis to avoid dropping of the testis due to the loss of cremasteric tone and reflex. The upper, lateral stump of the cremasteric will be used as a sling around the spermatic cord at the deep ring level, during reconstruction of the posterior inguinal wall. Should an indirect inguinal hernia be present, it will be easily identified at the medial side of the spermatic cord. The patient can be asked to strain or cough to show the hernia. At this stage, additional-procaine hydrochloride can be injected into the sac, at its base, within the loose areolar tissue of the cord near the deep ring, within the substance of the edges of the deep ring itself, and lastly within the transversalis fascia, from the level of the deep ring to the pubis, to infiltrate sympathetic pain fibers within the space of Bogros. The indirect hernia sac can now be freed from the cord and the deep ring. The dissection is carried deep to the ring. High dissection of the sac, not high ligation, is the important feature. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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Robert Bendavid

6 Perhaps the most important step of the repair is the incision of the posterior wall of the inguinal canal from the medial edge of the deep ring to the pubic crest. This maneuver allows access to the space of Bogros and, hence, examination of the femoral ring and the detection of direct inguinal (however small the defec0, supravesical, and Laugier hernias (hernias through the lacunar ligament). Above all, it allows identification of good tissue layers that will make up the repair: the substantial internal oblique, the transversus abdominis, the conjoined tendon (if present as such), and the edge of the rectus and its sheath. Division of the transversalis is not necessary in children or women, who rarely present with direct herniation. Omission of this incision of the transversalis fascia was the crucial error in the corruption of the Bassini technique and led to imbrication of the posterior inguinal wall, with dismal results. The success of the Shouldice repair depends largely on the performance of this incision of the transversalis fascia, as established by Bassini as early as 1883. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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7 The completed dissection shows an anatomy that will be conducive to a reliable repair with substantial tissues. Note that the transversalis fascia forms an integral part of the "triple layer" of Bassini (with the transversus abdominis and the internal oblique, anteriorly). It is never used as a single layer because it has no tensile strength and shreds readily. The lateral half of the divided transversalis fascia, near and parallel to the inguinal ligament, is referred to as the iliopubic tract or ligament of Thomson. The lateral half of this ligament is often of poor quality. The deeper surface of the iliopubic tract shows a marginal (iliopubic) vein, which is part of the venous network within the space of Bogros. Special care must be exercised to avoid injury to this vein because it can be the source of a substantial preperitoneal hematoma. The first suture of the reconstruction is inserted into the iliopubic tract laterally, then crosses to include the transversalis fascia, the edge of the rectus abdominis, transversus abdominis, and internal oblique, successively. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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Robert Bendavid

8 Stainless steel suture, held taut by a hook, is still used at the Shouldice Hospital, though many surgeons prefer 0 or 00 Prolene sutures (Ethicon, Inc). The suture is continuous and proceeds toward the deep ring by including full thickness of the triple layer medially and the iliopubic tract laterally. Halfway up the inguinal canal, the edge of the rectus, which lies vertically, is no longer available for inclusion in the repair of the inguinal wall. Note that the continuous suture goes through the triple layer 1 cm away from its border, creating a free border. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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9 The first line of the suture reaches the deep ring, picks up the lateral stump of the cremaster before crossing to include the triple layer, and, in so doing, carries the stump into the preperitoneal space, creating a sling about the cord at the deep ring. Throughout, the suture line picked up the triple layer medially in such a manner as to leave a free border. As the suture now reverses its course toward the pubis, the free border will be included in the suture and brought to the inguinal ligament, which will now be incorporated all the way to the pubis. (Reprinted with permission from Lippincott Williams and Wilkins.*)

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Robert Bendavid

10 The first suture, after reversing its course at the deep ring, proceeds toward the pubis by approximating the free border of the triple layer to the inguinal ligament. For the purpose of illustration, the suture shows a loose approximation of the tissues. At the pubis, the ends of the suture are tied, ending what the surgeons of the Shouldice Hospital refer to as lines 1 and 2 of the first suture. Figure 11 will show lines 3 and 4 of the second suture. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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l 1 A new suture now starts at the deep ring. It will proceed through the internal oblique, transversus abdominis, and transversalis fascia, medially, then cross over to include the inner aspect of the external oblique aponeurosis along a line parallel to the inguinal ligament as far as the pubis. Here again, for illustrative purposes, the suture is shown to approximate the apposed layers loosely. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

1 2 The suture reaches the level of the pubis, where it will reverse its course toward the deep ring. About the pubis, the wide medial portion of the lateral flap of the external oblique aponeurosis is used to cover the medial 2 to 3 cm of the posterior inguinal wall. This maneuver reinforces a portion of the wall known to be prone to direct recurrences. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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13 The suture proceeds back toward the deep ring, approximating medially the triple layer again (although blindly) to the inner aspect of the external oblique aponeurosis, along a line parallel (again) to the inguinal ligament but more superficially The two ends of the suture are tied at the deep ring. At this stage, the medial (distal) stump of the cremaster is anchored near the pubis to prevent dropping of the testicle and scrotum. The spermatic cord is now placed back in its normal anatomical position. (Reprinted with permission from Lippincott Williams and Wllkins. 4)

14 Approximation of the external oblique aponeurosis over the spermatic cord. An absorbable suture is used for this purpose. The superficial ring will be displaced 1 to 3 cm laterally, as a result of the suture of the medial portion of the external oblique aponeurosis onto the medial portion of the posterior inguinal wall. The subcutaneous tissues are approximated with Vicryl (Ethicon, Somerville, NJ) sutures. The skin is dosed with Michel dips, half of which are removed in 24 hours, and the remainder in 48 hours. The patient is able to stand and walk at the end of surgery. (Reprinted with permission from Lippincott Williams and Wilkins. 4)

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Comments
The results published from the Shouldice Hospital confirm the efficacy of the operation, as measured by the incidence of recurrence: 0.5% or less for primary hernias. For recurrences, however, when mesh is not used, the incidence varies between 2:3% and 11.4%. Global recurrence rates are now seen at 2.20/0.5 There are no major complications associated with this procedure. Mortality has been 0.009% and never attributable to the act of hernia surgery (cerebrovascular accidents, myocardial infarcts, acute mesenteric thrombosis, spontaneous rupture of the gall bladder). Incidence of hematoma is 0.3%, infection <1%, hydrocele formation 0.7%, testicular atrophy after primary repair 0.036%, and after recurrent repair 0.46%. 6 Large series by Wantz (3,454 cases), 7 Bocchi (1,640 cases), 8 Myers (903 cases), 9 and many others 5 have yielded recurrence rates of 1% or less. In conclusion, the Shouldice operation is a must in the proper formation of the general surgeon.

REFERENCES
1. Bocchi P: Bassini: The man, the soldier, the surgeon. Postgrad Gen Surg 4:175-178, 1992 2. Bendavid R: New techniques in hernia repair. World J Surg 13:522-531, 1989 3. Wantz G: The operation of Bassini as described by Attilio Catterina. Surg Gynecol Obstet 168:67-80, 1989 4. Nyhus LM, Baker RJ, Fischer JE: Shouldice method of inguinal herniorrhaphy, in Mastery of Surgery (ed 3). Boston, MA, Little Brown & Co, 1996, pp 1828-1836 5. Bendavid R: The Shouldice repair, in Nyhus LM, Condon RE (eds): Hernia (ed 4). Philadelphia, PA, J. B. Lippincott & Co, 1995, pp 217-226 6. Bendavid R, Andrews DF, Gilbert A: Testicular atrophy: Incidence and relationship to the type of hernia and to multiple recurrent hernias. Probl Gen Surg 12:225-237, 1995 7. ~vVantz G: The Canadian repair of inguinal hernias, in Nyhus LM, Condon RE (eds): Hernia (ed 3). Philadelphia, PA, J. B. Lippincott & Co, 1989 8. Bocchi P: The Shouldice operation: Can it be done by the average surgeon in an average surgical service? An analysis of the recurrences. Probl Gen Surg 12:101-104, 1995 9. Myers RN, Shearburn EW: The problems of the recurrent inguinal hernias. Surg Clin North Am 53:555-558, 1973

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