See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/348843686

Shouldice standard 2020: review of the current literature and results of an

international consensus meeting

Article in Hernia · October 2021

DOI: 10.1007/s10029-020-02365-6

CITATIONS READS

20 25,509

9 authors, including:

Ralph Lorenz Joachim Conze

3+CHIRURGEN RWTH Aachen University
61 PUBLICATIONS 967 CITATIONS 126 PUBLICATIONS 6,324 CITATIONS

SEE PROFILE SEE PROFILE

René Fortelny Jurij Gorjanc

Sigmund Freud University Vienna University of Ljubljana
55 PUBLICATIONS 1,287 CITATIONS 25 PUBLICATIONS 236 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Ralph Lorenz on 28 January 2021.

The user has requested enhancement of the downloaded file.

Hernia
https://doi.org/10.1007/s10029-020-02365-6

ORIGINAL ARTICLE

Shouldice standard 2020: review of the current literature and results

of an international consensus meeting
R. Lorenz1 · G. Arlt2 · J. Conze3 · R. Fortelny4,10 · J. Gorjanc5 · A. Koch6 · J. Morrison7 · V. Oprea8 · G. Campanelli9

Received: 12 September 2020 / Accepted: 29 December 2020

© The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature 2021

Abstract
Introduction For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair
has been proven to entail better results in randomized trials. Since the first publication 1953 the Repair has been described in
detail in many textbooks, articles and You Tube videos. It appears that the original technique is used almost exclusively in
the Shouldice Hospital in Thornhill/ Canada and despite the success of the Shouldice Hospital many surgeons inexplicably
modify this original technique in their daily practice. In the last couple of years there appears to be an increasing interest
in pure tissue repairs for various reasons, often fear of mesh-related pain. The aim of the study was to review the current
evidence and to define an updated standard with key principles of the Shouldice repair.
Methods Because of unpublished evidence regarding many operative details the organizing group decided to create a tech-
nical update via a consensus meeting with 13 international designated hernia surgeons from six countries. In preparation of
the meeting a review of the current literature regarding Shouldice repair was done by the organizing group. A questionnaire
was prepared and sent to all participants before the meeting to get an independent answer on all critical aspects.
Results All questions regarding a detailed standard of the operation technique could be outlined. As result of the consensus
meeting the participants have formulated all key-points of preparation/dissection and repair of the Shouldice technique. For
5 of 6 critical technical surgical steps a strong consensuscould be defined in the group. There was no consensus among the
group regarding the cremaster resection and the ideal indication for Shouldice repair.
Conclusion After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all her-
nia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons
is proposed.

Keywords Shouldice repair · Groin hernia · Pure tissue repair

Introduction Edward Earl Shouldice, developed a novel method in 1945 to

The Shouldice repair is an open transinguinal suture proce-
dure to repair defects of the posterior wall of the inguinal
canal. The procedure is named after the Canadian surgeon
This paper is dedicated to MD Robert Bendavid (who died on
September, 30th, 2019) and MD Dennis R. Klassen (who died on
July 29th, 2020).
Supplementary Information The online version contains
supplementary material available at https​://doi.org/10.1007/s1002​
9-020-02365​-6.
treat inguinal hernia. Following modifications introduced by
Shouldice Hospital collaborators E. A. Ryan and N. Obney,
the procedure generally became known as the “Shouldice
repair” around the world [1–4]. In the United States, it was
also known as “Canadian repair” [5]. The procedure is the
gold standard for a mesh-free treatment of inguinal hernias
[6–10]. Over decades, the Shouldice clinic published excel-
lent results with a recurrence rate around 1% in non-com-
parative retrospective study [6]. There are also publications
with higher recurrence rates out there with recurrence rates
from 4.7 to 10.1% [11–16].

* R. Lorenz
lorenz@3chirurgen.de
Extended author information available on the last page of the article

13
Vol.:(0123456789)

Notwithstanding the good results in experienced hands,
the number of Shouldice repairs performed worldwide
has declined, and has only found a small niche mostly for
patients who refuse a mesh and/or after shared decision-
making within the International Guidelines for inguinal
hernia repair [17].
Nevertheless, there are still arguments for pure tissue
repair today [18–22]:
– Some patients explicitly wish to have a hernia repaired
with suture/tissue repair.
– Possible associations between synthetic mesh and chronic
pain,
– Unknown long-term effects of meshes with degradation,
migration, and recurrences
– “Ideal mesh” has not yet been invented.
– Strangulated or Incarcerated hernias with infected sur-
rounding tissues as a contradiction to use mesh
– Some recent registry studies have shown in selected cases
equal results for Shouldice repair comparing to TAPP,
TEP, and Lichtenstein technique.
Currently, one of the main problems is that the Shoul-
dice repair is not performed very frequently outside of the
Shouldice Hospital and few surgeons know how to perform
it exactly or have developed a personal modification of the
original technique [6]. It appears that specific training for
Shouldice repair is very rare and is no longer included in
general surgery training. To counter the neglect of teaching
this technique, the organizers of the German Hernia School
have implemented the Shouldice technique once again into
the training program Hernia Concrete.
If you personally had a midsize inguinal hernia
- What is your preference of technique?
13%
5%
SHOULDICE
36%
TAPP
TEP
24% LICHTENSTEIN
No Operaon
22%
Fig. 1  Hernia compact Survey 2018–2020 Cologne, Salzburg, Ber-
lin (n = 165)—if you personally had a midsize inguinal hernia with
minor symptoms—what is your preference of technique?
13
Hernia
How do you personally perform a Shouldice Repair? in %
4 lines wire 0
4 lines non-resorbable 32
4 lines resorbable 5,8
2 lines non-resorbable 47,1
2 lines resorbable 11
single stches 4,1
0 20 40 60
Fig. 2  Anonymous TED Voting by 280 Hernia Surgeons on Standard
Shouldice Technique during 4th Hernia Days 2010 Berlin, Germany
As further argument for teaching, the Shouldice repair
was the interest of younger surgeons for pure tissue repair.
During the standardized German and Austrian Hernia basic
education course—Hernia compact 2018 in Cologne, 2018
in Salzburg, 2019 in Berlin, and 2020 in Berlin, an anony-
mous survey of 165 participating young surgeons with a
median age of 33 years (27–53) has shown an ongoing inter-
est for pure tissue repairs. Asked for their personal prefer-
ence for their own inguinal hernia repair, 36% would choose
a pure tissue repair without mesh (Fig. 1).
The knowledge and understanding of inguinal hernia
anatomy are crucial to achieve long-term success and patient
satisfaction for tissue repair [6].
Since the original paper was published in 1953 [1] and
despite the current technique’s presentation in numerous
Textbooks and on-line videos, many surgeons do not follow
the original protocol, but have developed their own modifi-
cation. During the 4th Berlin Hernia Days, an anonymous
Tele-Dialog Voting (TED) among 280 interested German
hernia surgeons revealed the amount of modifications in
daily practice (Fig. 2). The most interesting fact was that
no one follows the original technique outside of Shouldice
Hospital. This leads to incomparable results.
The goal of this paper is to review the current evidence of
the Shouldice technique and to outline the key principles of
the Shouldice repair, including the dedicated pre-operative
preparation, the complete inguinal dissection and the four-
layered reconstruction of the posterior wall, the use of local
anesthesia, and last but not least the ideal indication with the
instrument of a consensus meeting.
Hernia
Methods
The main objective of the Shouldice Consensus Meeting
2019 was to bring together experts in Pure Tissue Hernia
Repair from around the world to assimilate the best available
experience to ultimately derive a consensus document. Dur-
ing the 41st International Congress of the European Hernia
Society (EHS) in Hamburg from September 11th to 14th,
2019, an international consensus meeting took place to cre-
ate an update of a standardized operative technique, which
should adapt the technique to the contemporary needs. The
group of surgeons was selected from an organizing group of
surgeons from Germany and Canada (RL, RB, AK, and JC),
and included interested and experienced surgeons across the
world who are dedicated in pure tissue repairs. Representa-
tives of the Shouldice Hospital in Thornhill, Canada, were
invited as observers and guests and were included in the
decision process. The surgeons in the Shouldice hospital fol-
low exactly the technique as it was developed and perfected.
A questionnaire regarding the standard techniques was send
out to each participant before the meeting.
The questions and sometimes also controversial responses
were discussed and further edited during the meeting. The
delegates who attended the meeting in person then voted to:
(1) agree; (2) disagree; or (3) abstain, on each response during
meeting, following a modified Delphi methodology. The vot-
ing results were rated as: a) simple majority (50.1–59%) = no
Consensus; b) majority (60–65%) = weak Consensus; c) super
Majority (66–99%) = Strong Consensus; and d) unanimous
(100%) = unanimous Consensus [23].
In preparation of the meeting, the recent published evi-
dence was reviewed in a PubMed search focusing on the latest
publications. From January 1st, 2015 till August 30th, 2019,
altogether, 33 articles were published. One Randomized-Con-
trolled Study, one Meta-analysis and 5 reviews were identified.
The Meeting took place in the Congress Center Hamburg
Messe, September 13th, 2019 with 12 participants from six
countries. Dr. Robert Bendavid, as part of the organizing team
preparing this meeting, could not join the meeting:
– Georg Arlt, MD—Park-Klinik Weissensee, Berlin (Ger-
many)
– Giampiero Campanelli, Prof. MD—University of Insubria,
Milano (Italy)
– Joachim Conze, MD—UM Hernia Center Dr. Conze,
Munich (Germany)
– René Fortelny, Prof. MD—Wilhelminenhospital, Sigmund
Freud University, Vienna (Austria)
– Jurij Gorjanc, MD, PhD—Krankenhaus der Barmherzigen
Brüder St. Veit an der Glan (Austria)
– Dennis R. Klassen, Prof. MD—Dalhousie University, Hali-
fax (Canada)
– Andreas Koch, MD—Chirurgische Praxis, Cottbus (Ger-
many)
– Ralph Lorenz, MD—3 + CHIRURGEN Hernia Center,
Berlin (Germany)
– John Morrison, MD—Chatham Kent Health Alliance,
Chatham (Canada)
– Valentin Oprea, MD—Military Hospital Cluj-Napoca,
Cluj-Napoca (Romania).
  As guests and observers from the Shouldice hospital:
– (Robert Bendavid, MD—Shouldice Hospital, Thornhill
(Canada)—invited, but could not join
– Peter Kalman, MD—Shouldice Hospital, Thornhill (Can-
ada)
– Edward Byrnes Shouldice, MD—Shouldice Hospital,
Thornhill (Canada).
  The Agenda of the Consensus Meeting included the fol-
lowing aspects:
– History of the Shouldice technique (EB Shouldice)
– Current scientific evidence (A Koch)
– Results of the questionnaire (R Lorenz)
– Discussion about technical steps of the preparation and the
repair (ALL).
Results
The results of the anonymous questionnaires regarding all
the critical points were introduced during the meeting and
were finally discussed with all participants (Table 1).
On basis of the current evidence and the surgeons’ experi-
ence, there was no consensus regarding the ideal indication
for Shouldice repair, but in summary, the majority of par-
ticipants gave a suggestion:
Suggestion on best indication for Shouldice repair
by the experts
1. Primary indirect and small direct inguinal hernias in
young adults (EHS-Classification LI, L II, M I)
2. Primary hernias in women after ruling out femoral her-
nia. (EHS-Classification LI, L II, MI, M II)
3. Indirect recurrent hernias following primary TAPP or
TEP (EHS-Classification LI, LII, R 1).
There was a strong consensus (75% agreement) in the
group for a clear preparation of all the patients. This stand-
ard should be followed by every surgeon:
Preoperative preparation
1. Marking of the side to be operated in conscious patients
13
 Hernia

Table 1  Results of the questionnaire among the 10 participants of the consensus meeting (GA, GC, JC, RF, JG, PK, DK, AK, RL, JM, and VO)
and two guests from the Shouldice hospital (RB and PK). Half votes are given for that participants who gave two instead of one answer
Topic Options Results of voting Strength

Ideal Indication for Shouldice

Which is the ideal indication for Shouldice repair? A: only by request for pure tissue A:1,5 a
B: All small hernias L I, II, M I in young patients below B:4
50 C:4,5
D:2
C: All small hernias L I, II, M I, M II
D: All hernias
What should we do in case of small or medium sized A: Mc Vay repair A: 1,5 a
femoral hernias instead of an inguinal hernia? B: Open mesh repair B: 4,5
C: 6
C: Endoscopic mesh repair
Preparation/dissection of open inguinal hernia surgery
How should we handle iliohypogastric and ilioinguinal A: No Identification A: 0 d
nerves? B: Identification and neurectomy/neurolysis on demand B: 12
C: 0
C: Neurectomy always
Should be included a Cremaster resection? A: Always A: 5 a
B: sometimes B: 5
C: 2
C: Never
How should we handle the hernia sac, Lipomas? A: Resection always A: 2 c
B: Resection sometimes B: 10
C: 0
C: Resection never
Specific Shouldice—repair
Which suture material should be allowed? A: only wire A: 0 c
B: wire or non-resorbable suture B: 9
C: 3
C: wire or non- or long-term absorbable suture
D: 0
D: any suture
How many lines should be done? A: always 4 continuous suture lines A: 9 c
B: always 3 or more continuous suture lines B: 2
C: 1
C: always 2 or more continuous suture lines
Which tissues exactly? A: exact original protocol always A: 9 c
B: small modifications allowed B: 3
C: 0
C: modifications allowed

a) Simple majority (50.1–59%); no consensus; b) majority (60–65%); weak consensus; c) super majority (66–99%); strong consensus; d) unani-
mous (100%); unanimous consensus

2. Supine position with a slight hyperextension in the hip
area using a cushion or in a flex position
3. Skin disinfection and sterile covering
4. Single-shot antibiotic i.v. (up to the skin incision) in risk
patients
5. Team Time out!
During preparation, all possible hernia orifices should
be inspected—unanimous consensus (100% agreement).
There was also unanimous consensus (100% agreement) in
the group to identify all the nerves in all cases. In almost all
cases, a nerve resection should be avoided to limit postop-
erative pain. Only in case of any nerve damage, a neurolysis
or neurectomy should be allowed—strong consensus (75%
agreement).
Table 2  Description of four-layered reconstruction of the Shouldice
repair
Line Suture direction Suturing anatomical structures
1 Medial–lateral Conjoint tendon to transversal fascia
2 Lateral–medial Transversal fascia to inguinal ligament
3 Lateral–medial Internal oblique to inguinal ligament
4 Medial–lateral Internal oblique to inguinal ligament
The group has formulated a strong consensus (75%
agreement) regarding the handling with the hernia sac: the
hernia sac should be reduced if possible. Only in case of
huge scrotal hernias, there is an option to remain part of the
distal hernia sac (because of the risk of testicular atrophy).
Preperitoneal lipomas should be resected in the majority if

13
Hernia

possible, but not in all cases—strong consensus (75% agree-

ment). There was no consensus regarding the handling with
the cremaster muscle. Half of the group preferred the com-
plete resection of the cremaster muscle in all cases, the other
half only in selected cases—no consensus. There is a strong
argument for resecting the cremaster which lowers the risk
of indirect recurrences as shown by EE Shouldice and oth-
ers (in their data) [24, 25]. Some surgeons argue against a
complete resection of the cremasteric muscle because of an
increased risk of nerve damage, the loss of the cremasteric
reflex, and the risk of lowered testicle position.
There was a strong consensus (75% agreement) in the
group to follow the original technique, which includes a
complete opening of the transversalis fascia from the pubic
tubercle to the internal ring and following four-layered
reconstruction of the abdominal wall (75% agreement)
(Table 2). The splitting of the transversal fascia should be
performed as medially as possible to maintain a reason-
able size of the inferolateral flap for further suturing. Inci-
sions that are too lateral do not enable to suture four layers Fig. 4  Second line of Shouldice repair ( © W. Hope Textbook of Her-
properly. nia)
The first two layers represent an overlapped reconstruc-
tion. It begins medially, anchoring over the pubic tubercle, internal ring and should include the superior stump of the
leaving a sufficient end to tie the returning suture after the divided lateral flap of cremasteric muscle. This buttresses
second layer. The inferolateral flap of transversalis fascia the internal ring should help to prevent an indirect recur-
is sutured to the lateral edge of the rectus sheath by reach- rence. The suturing is then reversed to begin the second
ing underneath the deep portion of the superior–medial flap layer. The superior flap of transversalis fascia is sutured to
of the transversalis fascia. The reconstruction then moves the posterior portion of the inguinal ligament then tied at
laterally to the aponeurosis of the transversus abdominis the pubic tubercle (Fig. 4). The periosteum should not be
and the edge of the internal oblique muscle (conjoined ten- included in any bite as this can result in a painful osteitis. In
don) (Fig. 3). The lateral extent of this layer redefines the

Fig. 5  Third line of Shouldice repair ( © W. Hope Textbook of Her-

Fig. 3  First line of Shouldice repair ( © W. Hope Textbook of Hernia) nia)

13
 Hernia

The next step of reconstruction creates a two-layered

Fig. 6  Forth line of Shouldice repair ( © W. Hope Textbook of Her-
nia)
case that the inferolateral flap is big enough, the 2nd layer
can also be performed as connection of transversals fascia
with transversalis fascia.
imbrication to provide reinforcement. The third and the
fourth line: the third starts at the newly reconstructed inter-
nal ring picking up some more large bites of internal oblique
and approximated inferiorly to the inguinal ligament allow-
ing the laminated closure of the floor of the inguinal canal.
This further minimize tension and reconstruct the internal
ring in a cylindrical fashion. The fourth line ends at the
internal ring where the second knot is placed. (Fig. 5).
In addition, small bites, no more than 5 mm are rec-
ommended. Excessively large bites might increase ten-
sion. At the pubic tubercle, the direction is reversed for
the fourth layer and taken back to the internal ring and
affixed (Fig. 6). The importance of mobilizing the inferior
flap of external oblique by previously incising the cribri-
form fascia or superficial thigh fascia is realized here.
The additional mobility allows the external oblique to be
used in the third and fourth layers to cover the medial
portion of the repair. The inguinal canal is reconstructed
by re-approximating the remaining external oblique fas-
cia, returning the cord to its anatomical position. In case
of cremaster resection, the inferior stump of the medial
flap of cremasteric muscle should be included in the first
suture line medially to stabilize the position of the testes
and prevent drooping [7].
There was also a strong consensus in the group (75%
agreement) using a 2–0 monofilament non-resorbable

Table 3  Key-points: preparation/dissection for open inguinal hernia surgery

Key-points: preparation/dissection for open inguinal hernia surgery

1. A transverse incision in the lower abdomen or an oblique incision paralleling the groin crease is possible as incision depending on preference,
4–6 cm long. It begins 1 cm cranial and 1 cm lateral to the pubic tubercle
2. External oblique is incised along the direction of its fibers to about 2.5 cm medial to its junction with thigh fascia, through the external ring,
extending the incision from about 2 cm above the internal ring. The aponeurosis should be splitted with scissors (note: nerve exit points fre-
quently medial). A wet dissection with using local anesthesia intraoperatively is very useful. Cribriform fascia is incised to give flexibility of the
inguinal ligament for repair
3. All three nerves (iliohypogastric and ilioinguinal nerves and genital branch of the genitofemoral nerve) are safely demonstrated if possible,
safe sparing, resection in the risk of nerve sheath injury
4. Cord coverings are divided longitudinally to mobilize the cord and to allow freeing and division of cremasteric tissues. Isolation of the sper-
matic cord or round ligament, splitting or resecting the cremaster muscle, and high preparation of the deep inguinal ring, the triangle of doom is
visualized in indirect inguinal hernia, the hernia sac reduced and retained, and, where appropriate, additional cord lipomas should be removed
5. Optional: cremasteric muscles, vessels, and genital branch of the genital femoral nerve are taken and both stumps doubly ligated. Division
and ligation of the cremasteric tissue is essential to give clear exposure of floor of inguinal canal and prevents missed hernias, controls tissue
oozing and permits reconstruction of the floor
6. In the case of incarceration, the hernia sac is opened with management of sac content, subsequent closure of the peritoneum afterward
7. Identify the epigastric vessels for the purpose of hernia classification and reflect them safely away. The medial posterior wall of the inguinal
canal is visualized and the transverse fascia is split. Posterior wall of the inguinal canal is opened from internal ring to the point where firm
tissue is encountered, freeing pre-peritoneal fat from the deep surface of transversalis fascia. The edge of the rectus is exposed. The pectineal
“Cooper” ligament is visualized (note: corona mortis—venous and/or arterial vessels in almost 20% of cases). The femoral canal should be
digitally examined. Check for interstitial and femoral hernias
8. Cord is separated from internal ring. Indirect hernias and/or peritoneal protrusions and lipomas are identified and dissected from cord. Sliding
hernias reduced, broad based sacs reduced, long narrow sacs can be excised or reduced and lipoma stumps reduced. Direct hernias are reduced
9. The hernia is classified according to European Hernia Society (EHS) criteria: M I/II/III, L I/II/III, F I/II/III; C I/II/III, R X, photographic
documentation of the hernia, if applicable

13
Hernia

Table 4  Key-points: specific Shouldice repair

Key-points: specific Shouldice repair

1. Dissection could be completed with a resection of the cremaster muscle on demand into two portions close to the deep inguinal ring and
sectioning of the vasa cremasterica (“blue line”) on the floor of the inguinal canal
2. The pre-peritoneal space is systematically dissected starting from the medial or lateral aspect according to the type of hernia. Preperitoneal fat
is reduced and retained with the assistance of a compress
3. Reconstruction of the floor with non-absorbable running sutures-four lines
4. The Reconstructed starts with the first line medially, beginning with the caudal flap of the transverse fascia close to the pubic bone. Suture
material: monofilament, permanent synthetic suture, size: 2–0, 3–0 (e.g., polypropylene) or 34 or 32 gauge stainless steel wire, both preferably
with a small needle. The cranial suture line for the first three stitches consists of the edge of the rectus sheath, and then the dorsal fascia of the
transverse abdominal muscle. This suture is continued laterally as long as the newly created deep inguinal ring can still be entered with the point
of the forceps. Here, the caudal stump of the cremaster musculature is included in the final stitch (note: the fascial tissue is only adapted, no trac-
tion on the suture, the deep epigastric vessels are preserved)
6. In the second line the suture returns by attaching the cranial flap of the transverse fascia along with the muscle to the base of the inguinal liga-
ment. The suture descends medial to the femoral vessels to reach the deeper fibers of the inguinal ligament and continues over the medial origin
up to the pubic tubercle (note: the distal suture line is close to yet by no means within the periost). Renewed suture reversal and knotting with
the origin of the suture kept long
7. The posterior wall is now reconstructed and, in interventions under local or regional anesthesia, can be tested by the patient’s releasing a
heavy cough
8. Third and fourth lines—the suture starts at the internal ring, reinforcing the previous lines by carrying the lateral flap of the external oblique
aponeurosis on to the internal oblique covering the previous suture line. It is reversed at the pubic tubercle and is returned to the internal ring,
continuing to carry the external oblique on to the internal oblique. Enough tissue is left behind to completely cover the cord as it is replaced.
Sparingly, the first row accommodates the deep parts and the second row includes the superficial parts of the caudal edge of the muscle
9. The musculature is infiltrated laterally to the deep inguinal ring (e.g., 5–10 ml local anesthetic) to infiltrate the ilioinguinal and iliohypogastric
nerves
10. Closure: spermatic cord replaced in anatomical position beneath external oblique and closed over with single continuous suture line of
absorbable suture size 3–0 or 2–0
11. Distal cremasteric stump (if resected) should be included in closure at external ring or in subcutaneous tissue to prevent a dependent testis.
The intervention is concluded by suturing the subcutaneous fascia of Scarpa by resorbable running suture and closing the skin. Redon drainage
is normally not necessary

suture or wire for all the four layers of the Shouldice
repair. There was no evidence to use a long-term absorb-
able suture instead of non-resorbable suture or wire
[26–28].
Key-points of the Standard Technique for open surgery
in inguinal hernia repair are essentially classified into two
steps: Preparation/Dissection for open inguinal hernia sur-
gery (Table 3) and specific Shouldice repair (Table 4). As
Inguinal Preparations/Dissections among most open tech-
niques in inguinal hernia repair are usually quite similar,
they are presented here separately. Femoral hernia, although
a groin hernia, are not part of the Shouldice repair for ingui-
nal hernias.
Discussion
According to the International Guidelines for Inguinal
Hernia Repair, the Shouldice repair is considered to be the
best non-mesh technique, but should only be used for those
patients, who reject mesh repair following informed consent
[17, 29]. There is also an indication for pure tissue repair
in emergent groin hernia repair with contaminated or dirty
surgical fields [17].
The scientific evidence for the International Guidelines
ends on January 1st, 2015 for systematic reviews and on July
1st, 2015 for randomized-controlled studies [17].
Currently, some scientific papers have shown the equiva-
lence of the Shouldice repair to mesh-based operation tech-
niques for inguinal hernia repair. In a recent study, using
propensity score-matching, the German Hernia Database
(Herniamed) has shown in a selected group of patients
(younger age, smaller defects, lower BMI, and no risk fac-
tors) that the Shouldice technique has comparable outcomes
in terms of pain, recurrence, and local complications with
Lichtenstein, TEP, and TAPP operations [21]. Only for
female patients, a multivariate analysis gave the recommen-
dation that female groin hernia repair should be performed
with laparo-endoscopic technique (TEP or TAPP) or alterna-
tively with the Shouldice technique if there is no evidence of
a femoral hernia [22]. The equivalence of Shouldice Repair
comparing to Lichtenstein repair regarding long-term results
after 6–9 years was shown in a prospective trial [30]. Shoul-
dice repair may also decrease the risk of chronic groin pain
after open inguinal herniorrhaphy [30].
The recently published review of the Cochrane Library
arrives at the following conclusion: mesh and non-mesh
repairs appear to be effective surgical approaches in treating
hernias. Mesh repairs reduce the rate of hernia recurrence,

13

but non-mesh repair should be favored in low-income coun-
tries due to low cost and reduced availability of mesh mate-
rials [31].
The surgeon’s expertise has always an underestimated
influence on the results of the hernia repair [32]. Regard-
ing an independent health insurance data analysis, in
Ontario, Canada, the recurrence rate seems to be lower for
the extremely high-volume Shouldice hospital (using for
the majority of inguinal hernias a non-mesh repair (98%)
than in all other low, mid- and high-volume hospitals in
Ontario which for the majority of inguinal hernias use a
mesh repair [33]). A recent study from Australia has shown
first a 20-year long-term follow-up between different hernia
operation techniques. In this study, were significantly more
recurrences after TEP (25.7%) comparing to the Shouldice
repair (9.7%) [34].
In 2018, Murphy et al. have looked at the reoperation rate
for hernia recurrences in the US. In a timeframe between
2005 and 2014, it seems that, though using meshes in most
of the inguinal hernia repairs, the frequency of hernia reop-
erations due to recurrence remains high and has not really
decreased. Based on their data, the authors summarize that
the recurrence rates after inguinal hernia repair seem to be
skewed and overly optimistic [35].
Conclusion
The purpose of this publication is to review the current lit-
erature and to build a consensus on the essential elements
of the Shouldice repair. Individual surgical modifications in
hernia repair are common, but are seldom described or dif-
ferentiated in the surgical notes. To avoid this limitation and
to increase the comparability of the results of the Shouldice
procedures performed, a binding standard of the techniques,
including the intraoperative exploration of all potential her-
nia gaps, is essential and summarized in the key-points
(Tables 3 and 4). The results should be reviewed by future
randomized-controlled studies but also in large‑scale register
studies.
Compliance with ethical standards
Conflict of interest RL, GA, JC, RF, JG, AK, JM, VO, and JC have no
conflicts of interest.
Ethical approval This study was performed in line with the principles
of the Declaration of Helsinki and its later amendments or comparable
ethical standards.
13
Hernia
Human and animal rights All procedures performed in this study
involving human participants were in accordance with the ethical stand-
ards of the institutional and/or national research committee and with
the 1964 Helsinki declaration and its later amendments or comparable
ethical standards.
Informed consent For this type of study, no informed consent is
required.
References
1. Shouldice EE (1953) The treatment of Hernia. Ontario Med Rev
20:670–684
2. Shouldice EB (2003) The Shouldice repair for groin hernias. Surg
Clin North Am 83:1163–1187
3. Shearburn EW, Myers RN (1969) Shouldice repair for inguinal
hernia. Surgery 66:450–459
4. Obney N, Chan CK (1984) Repair of multiple time recurrent
inguinal hernias with reference to common causes of recurrences.
Contemp Surg 25:25–32
5. Wantz GE (1989) The Canadian repair: personal observations.
World J Surg 13:516–521
6. Bendavid R (2016) Re: Recurrence of inguinal hernias repaired in
a large surgical specialty hospital and general hospitals in Ontario,
Canada. Can J Surg 59(1):E3. https​://doi.org/10.1503/cjs.01771​5
7. Chan CK, Chan G (2006) The Shouldice technique for the treat-
ment of inguinal hernia. J Minim Access Surg 2(3):124–128
8. Gorjanc J (2011) The Shouldice repair—experience with first 50
patients. Zdrav Vestn 80:668–675
9. Kux M, Fuchsjäger N, Schemper M (1995) Shouldice is superior
to Bassini inguinal herniorhaphy. Am J Surg 168:15–18
10. Schumpelick V, Treutner K-H, Arlt G (1994) Inguinal hernia
repair in adults. Lancet 344:375–379
11. Hay JM et al (1995) Shouldice inguinal hernia repair in the male
adult a multicenter controlled trial in 1578 patients. Ann Surg
22:719–727
12. Treutner KH, Arlt G, Schumpelick V (1999) Shouldice repair for
recurrent hernia—a ten-year follow-up. In: Schumpelick V (ed)
Incisional hernia, 9th edn. Springer, Berlin, Heidelberg, p 359
13. Nordin P et al (2002) Randomised trial of Lichtenstein vs Shoul-
dice hernia repair in general surgery practice. Br J Surg 89:45–49
14. Danielsson P et al (2003) Randomised study of Lichtenstein with
Shoudice inguinal hernia repair by surgeons in training. Eur J
Surg. https​://doi.org/10.1080/11024​15997​50007​504
15. Arvidsson D et al (2005) Randomised clinical trial comparing
5-year recurrence rate after laparoscopic versus shouldice repair
of primary Inguinal hernia. Br J Surg 92:1085–1091
16. Amato B, Moja L, Panico S et al (2012) Shouldice technique
versus other open techniques for inguinal hernia repair. Cochrane
Database Syst Rev 2012(4):01543. https​://doi.org/10.1002/14651​
858.CD001​543.pub4 (Published 2012)
17. HerniaSurge Group (2018) International guidelines for groin her-
nia management. Hernia 22:1–65
18. Fischer JE (2013) Hernia repair: why do we continue to perform
mesh repair in the face of the human toll of inguinodynia? Am J
Surg 206:619–623. https:​ //doi.org/10.1016/j.amjsur​ g.2013.03.010
19. Lorenz R (2018) Do we really need a renaissance of pure tissue
repair? Invited comment to: Desarda’s technique versus Lichten-
stein technique for the treatment of primary inguinal hernia: a
systematic review and meta-analysis of randomized controlled
trials Emile S, Elfeki H. Hernia 22:397–398
Hernia
20. Lorenz R (2019) Outside of guidelines: successful desarda tech-
nique for primary inguinal hernias. Int J Abdom Wall Hernia Surg
2:23–24
21. Köckerling F, Koch A, Adolf D et al (2018) Has shouldice repair
in a selected group of patients with inguinal hernia comparable
results to lichtenstein, TEP and TAPP techniques? World J Surg
42(7):2001–2010. https​://doi.org/10.1007/s0026​8-017-4433-5
22. Köckerling F, Lorenz R, Hukauf M, Grau H, Jacob D, Fortelny
R, Koch A (2019) Influencing factors on the outcome in female
groin hernia repair: a registry-based multivariable analysis of
15,601 patients. Ann Surg 270(1):1–9. https​://doi.org/10.1097/
SLA.00000​00000​00327​1
23. WHO handbook for guideline development—2nd ed. (ISBN 978
92 4 154896 0) © World Health Organization 2014, https​://www.
who.int/publi​catio​ns/guide​lines​/Chp16​_May20​16.pdf (accessed
1 Nov, 2019)
24. Ris HB, Aebersold P, Küpfer K, Stucki U, Stirnemann H, Doran J
(1987) 10 years’ experience using a modified Shouldice surgical
technic for inguinal hernia in adults. II. Which factors modify the
recurrence of inguinal hernia? Chirurg 58(2):100–105
25. Töns C, Klinge U, Kupczyk-Joeris D, Rötzscher VM, Schumpelick
V (1991) Controlled study of cremaster resection in Shouldice
repair of primary inguinal hernia. Zentralbl Chir 116(12):737–743
26. Hilgert RE, Dörner A, Wittkugel O (1999) Comparison of polydi-
oxanone (PDS) and polypropylene (Prolene) for Shouldice repair
of primary inguinal hernias: a prospective randomised trial. Eur
J Surg 165:333–338
27. Nordin P, Haapaniemi S, Kald A, Nilsson E (2003) Influence of
suture material and surgical technique on risk of reoperation after
non-mesh open hernia repair. Br J Surg 90:1004–1008
28. Peiper C, Junge K, Füting A, Conze J, Bassalay P, Schumpelick V
(1998) Intraoperative Messung der Nahtkräfte bei der Shouldice-
Reparation primärer Leistenhernien. Chirurg 69:1077–1081
29. Weyhe D, Conze J, Kuthe A, Köckerling F, Lammers BJ, Lor-
enz R, Niebuhr H, Reinpold W, Zarras K, Bittner R (2018)
Authors and Affiliations
R. Lorenz1 · G. Arlt2 · J. Conze3 · R. Fortelny4,10 · J. Gorjanc5 · A. Koch6 · J. Morrison7 · V. Oprea8 · G. Campanelli9
1 6
3+CHIRURGEN Hernia Center, Klosterstrasse 34/35,
13581 Berlin, Germany
2 7
Department for General- Visceral and Minimal-Invasive
Surgery, Park‑Klinik Weissensee, Schönstraße 80,
13086 Berlin, Germany
3
UM Hernienzentrum Dr. Conze, Arabellastraße 17,
81925 München, Germany
4
Department of General Surgery, Wilhelminenhospital,
Montleartstraße 37, 1160 Vienna, Austria
5
Department of Surgery, Krankenhaus der Barmherzigen
Brüder, St. Veit an Der Glan, Spitalgasse 26,
9300 St. Veit an der Glan, Austria
View publication stats
HerniaSurge: international guidelines on treatment of inguinal
hernia in adults : comments of the Surgical Working Group Hernia
(CAH/DGAV) and the German Hernia Society (DHG) on the most
important recommendations. Chirurg 89(8):631–638. https​://doi.
org/10.1007/s0010​4-018-0673-7
30. Miedema BW, Ibrahim SM, Davis BD, Koivunen DG (2004) A
prospective trial of primary inguinal hernia repair by surgical
trainees. Hernia 8:28–32
31. Lockhart K, Teo S, Ng JY, Dhillon M, Teo E, van Driel ML
(2018) Mesh versus non-mesh for inguinal and femoral hernia
repair. Cochrane Database Syst Rev 9:CD011517. https​://doi.
org/10.1002/14651​858.CD011​517.pub2
32. Bocchi P (1993) Shouldice’s operation: can results in a general
surgical unit be the same as those in a highly specialized surgical
unit? J Chir (Paris) 130:275–277
33. Malik A, Bell CM, Stukel TA, Urbach DR (2016) Recurrence
of inguinal hernias repaired in a large hernia surgical specialty
hospital and general hospitals in Ontario, Canada. Can J Surg
59:19–25
34. Barbaro A, Kanhere H, Bessell J, Maddern GJ (2017) Laparo-
scopic extraperitoneal repair versus open inguinal hernia repair:
20-year follow-up of a randomized controlled trial. Hernia
21(5):723–727. https ​ : //doi.org/10.1007/s1002 ​ 9 -017-1642-7
(Epub 2017 Sep 1)
35. Murphy BL, Ubl DS, Zhang J, Habermann EB, Farley DR, Paley
K (2018) Trends of inguinal hernia repairs performed for recur-
rence in the United States. Surgery 163(2):343–350. https​://doi.
org/10.1016/j.surg.2017.08.001 (Epub 2017 Sep 15)
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Hernia Center Cottbus, Gerhard‑Hauptmann‑Strasse 15,
03044 Cottbus, Germany
Chatham Kent Health Alliance, 78 Victoria Avenue,
Chatham, ON N7L 3A1, Canada
8
Department of Surgery, Military Hospital Cluj-Napoca,
Strada General Traian Moșoiu 22, Cluj‑Napoca, Romania
9
Department of Surgical Science, University of Insubria,
Istituto Clinico Santambrogio, Milano, Italy
10
Medical Faculty, Sigmund Freud University, Freudplatz 3,
1020 Vienna, Austria
13