The Shouldice Method: an expert's consensus

Comparison and Standardisation of Various Open Preperitoneal Techniques in Inguinal Hernia Surgery-Results of a Review and Consensus

Introduction

Both open and laparoendoscopic preperitoneal mesh techniques are good options for the treatment of inguinal hernias. The 2023 updated HerniaSurge Guidelines recommend open preperitoneal mesh techniques as an acceptable alternative to Lichtenstein repair if a competent and experienced surgeon is available. However, although numerous open preperitoneal surgical techniques have been developed, only a few comparative studies comparing them are available. Because of the lack of scientific evidence and standardisation, the aim of this article is to define comparable standards and compare four frequently used open preperitoneal techniques.

Method

Using a Delphi-consensus process among both the authors and experts in the field, various key steps for each procedure, indications, and outcome parameters were set to allow adequate comparison of different open preperitoneal techniques.

Results

We present four different and frequently used open preperitoneal techniques: Minimal Open PrePeritoneal repair (MOPP), TransInguinal PrePeritoneal repair (TIPP), TransREctus sheat PrePeritoneal repair (TREPP), and Open New Simplifyed Total Extraperitoneal repair (ONSTEP). We provide a clear and comparable standard regarding the best indication, different procedural steps, the use of meshes and fixation, the learning curve involved, and possible complications and limitations. We also identify some similarities for the techniques but also specific differences on different topics.

Conclusion

Development, validation, and implementation of these standards for the various open preperitoneal techniques are necessary both for education and training as well as for future comparative studies.

The learning curve for the Shouldice Repair: a pilot analysis of post-training specialized surgeons at the Shouldice Hospital

PURPOSE

The aim of the study was to evaluate operative time and postoperative complications of 4 post-training specialized surgeons.

METHODS

This was a pilot retrospective chart review to determine the learning curve of a Shouldice primary inguinal hernia repair (Shouldice Repair) of 4 post-training specialized surgeons, at the Shouldice Hospital. The first 300 Shouldice Repairs (early learning block) were compared to their 900-1,000 repairs as the primary operating surgeon (late learning block). Data was collected from the hospital's database. The learning curve was examined using cumulative sum analysis (CUSUM).

RESULTS

During the early learning block cases, the surgeons had a mean operating time of 59.2 ± 11.2 min. The late learning block cases had significantly reduced operative time (53.4 ± 10.5 min, p = 0.001). According to the CUSUM analysis all four surgeons had a plateau after 78 to 88 operations in terms of operative time. A nonsignificant reduction in the rate of reported recurrences (n = 16 vs. n = 0) and surgical site occurrences (haematoma, seroma, infection; n = 27 vs. n = 2) was found between the early and late learning block cases.

CONCLUSION

The operating time plateaued after 78-88 Shouldice Repairs for the 4 surgeons trained and working at the Shouldice Hospital. A nonsignificant trend towards fewer complications were noted among late learning block cases.

Polypropylene vs. stainless-steel wire suture: short-term recurrence rate after shouldice primary inguinal hernia repair, a non-inferior analysis among 1120 patients. A case-control study

INTRODUCTION

Polypropylene material is commonly used for posterior wall reconstruction in hernia repair, in contrast with the classically described stainless-steel wire used at Shouldice Hospital. This study was conducted to evaluate possible differences in Shouldice Repair outcomes using polypropylene or stainless-steel wire sutures.

METHODS

A prospective follow-up of consecutive patients who underwent elective unilateral Shouldice primary inguinal hernia repair at Shouldice Hospital between December 6, 2021, and September 1, 2022, was conducted. Data was collected from follow-up telephone calls as well as manually reviewing patient's charts. The primary objective was to determine whether the use of polypropylene was non-inferior to the use of stainless-steel wire, regarding the recurrence rate reported by the patients with a minimum follow-up of 1 year after Shouldice primary inguinal hernia repair.

RESULTS

A total of 1120 patients were contacted by telephone (polypropylene: 560; stainless-steel wire: 560). The median follow-up period was 16 months (interquartile range: 15-18). In 22 (1.96%) cases a surgical site infection was diagnosed. There was a total of 18 recurrences reported by the patients (1.6%). There was no statistical difference between the groups (polypropylene: 7 (1.25%) vs. stainless steel wire: 11 (1.96%), p > 0.05) for the recurrence rate.

CONCLUSION

The use of polypropylene is non-inferior to the use of stainless-steel wire regarding recurrence rate at a median follow-up period of 16 months after elective unilateral Shouldice primary inguinal hernia repair. This finding may encourage other centers where stainless-steel wire is not easily available to perform the Shouldice Repair.

Quality of life following Shouldice Repair: a prospective cohort study among inguinal hernia patients

PURPOSE

The aim of this study was to evaluate quality of life from the preoperative time to six months after surgery of patients who underwent a Shouldice Repair for primary inguinal hernia.

METHODS

After ethical approval, consent was obtained, and data collected from surveys and chart review. The study population was composed of male and female patients aged 16-90 years of age, who had a Shouldice Repair of a primary unilateral inguinal hernia. The EQ-5D-3L, a questionnaire applied to hernia surgery in Canada, was used to determine quality of life at the preoperative and 1 week, 1- and 6-month postoperative time. Data analysis included descriptive statistics, as well as inferential analysis.

RESULTS

From January 2023 to February 2024, 532 participants met the criteria, completed and returned the preoperative survey, and underwent primary inguinal hernia repair. The participants were mostly male (94%) with an average age of 62.18 years and BMI of 24.93 kg/m2. The EQ-5D-3L health index scores and EQ-VAS health status at preoperative were 0.83 ± 0.13 and 79.5 ± 12.59. At the 1-month postoperative time, health index scores and health status had significantly increased from preoperative (score:0.91 ± 0.12, p = .001; status 83.56 ± 12.93, p = .001), and continued to significantly increase from baseline at the 6-month postoperative time (score:0.95 ± 0.10, p = .001; status:85.25 ± 12.17, p < .001).

CONCLUSION

Quality of life, as measured by the ED-5D-3L health index score, significantly improved for patients that underwent a Shouldice Repair for an inguinal hernia.

Non-mesh inguinal hernia repair: Review

Hernioplasty stands as one of the most common abdominal surgical interventions. The "gold standard" treatment for inguinal hernias remains Lichtenstein mesh hernioplasty. Nonetheless, clinical practice continues to grapple with issues concerning complications such as recurrence, chronic postoperative pain, and infection. The myriad types of surgery lead to conflicting opinions regarding the superiority and drawbacks of inguinal canal plastic surgery methods. This article presents current data on the surgical treatment of non-mesh inguinal hernias, delineating the most prevalent techniques while exploring their respective advantages and disadvantages. Additionally, the researchers' experiences are analyzed in detail.

Ultrasound-guided ilioinguinal-iliohypogastric nerve block with local anesthesia and fentanyl analgesia versus local anesthesia and fentanyl analgesia prior to Shouldice inguinal hernia repair in adults: a retrospective matched-pair analysis among 100 individuals

PURPOSE

There is limited research on the impact of an ilioinguinal-iliohypogastric nerve block on intraoperative opioid consumption when conducting groin hernia repair in adults. Thus, the aim was to evaluate ilioinguinal-iliohypogastric nerve block for groin hernia patients at Shouldice Hospital.

METHODS

The study was a pilot retrospective chart review on patients who underwent a Shouldice Repair from November 2023 to December 2023. This study compared individuals receiving an ilioinguinal-iliohypogastric nerve block with local anesthesia and fentanyl analgesia to those who received local anesthesia and fentanyl analgesia, by manually matching 1:1 on 12 demographic and intraoperative characteristics. Comparison between groups was performed using chi-square/Fisher Exact test for categorical and t-test/Mann-Whitney test for numerical variables depending on data distribution. Multivariable regression analysis was used to examine predictors of intraoperative use of fentanyl.

RESULTS

In this study 50 matched pairs of unilateral primary inguinal hernia patients were analyzed. The ilioinguinal-iliohypogastric nerve block patients had lower recorded intraoperative fentanyl (85mcg less than control, p < .001) and dimenhydrinate (13 mg less than control, p < .001) than the control group patients. No differences were found in postoperative day 0 to 3 for acetaminophen, non-steroidal anti-inflammatory drug, and opioid consumption between the patients who did receive an ilioinguinal-iliohypogastric nerve block prior to surgery and those that did not.

CONCLUSION

The administration of an ilioinguinal-iliohypogastric nerve block prior to primary inguinal hernia repair using a Shouldice Repair is associated with a significantly lower intraoperative fentanyl consumption compared to non-administration.

Matching males and females undergoing non mesh primary unilateral inguinal hernia repair: evaluating sex differences in preoperative and acute postoperative pain

PURPOSE

The objective was to compare pain and related psychological factors during the preoperative and acute postoperative period between male and female patients, who underwent non mesh primary unilateral inguinal hernia repair.

METHODS

After ethics approval, informed consent was obtained, and data were collected. Male and female participants were compared by manually matching one-to-one on 10 variables. Descriptive statistics (mean ± standard deviation and frequency) as well as numerical rating scales from 0 to 10 were used. Comparison tests were performed using Chi-square or Fisher's Exact test for categorical data and independent samples t-test or non-parametric equivalent tests for numerical scores. p < 0.05 is reported as statistically significant. To control type I error, Bonferroni correction was used.

RESULTS

72 participants with 36 matched pairs were included. Sex differences were found for operation length (p = .006), side of operation (p = .002), and hernia type (p = .013). Significant differences between the sexes were not found at the preoperative or postoperative time for resilience, pain interference or pain severity related measures, postoperative hernia pain incidence, pain catastrophizing, depression and anxiety symptoms, or return to normal activities.

CONCLUSION

When controlling for known confounders and using a conservative Type I error rate, pain and related factors between the sexes did not differ significantly.

Temporal patterns for inguinal hernia recurrence operations after Shouldice Repair

PURPOSE

Shouldice Repair for inguinal hernias results in a low recurrence rate; however, little is known about the risk factors for these relapses. In the present study, we reviewed all patient's undergoing a reoperation for recurrence after a primary Shouldice Repair.

METHODS

Patients undergoing recurrent inguinal hernia repair from 2013 to 2017 were identified. The subgroup of patients with the first recurrence after a Shouldice Repair at this institution was selected and included. Data collection from the index and the reoperation surgery were performed, as well as statistical analysis.

RESULTS

A total of 125 patients were included in the analysis. The mean age was 50.8 ± 13.9 (body mass index: 24.6 ± 2.6 kg/m2), 97% were male. The most common interval for a recurrence reoperation was in the first 5 years following the initial surgery (37.6% of patients; mode: 1 year; median: 7 years; mean: 13.7 ± 13.8 years). A temporal median pattern for recurrence reoperation according to age interval was noted (patients < 41 years old: 20 years; patients aged 41-60 years old: 10 years and patients > 61 years: 2 years)).

CONCLUSION

Patients undergoing reoperations for recurrent inguinal hernias after a primary Shouldice Repair presented a pattern of temporal recurrence according to age. Older patients present with earlier recurrences than younger ones, an important consideration in the assessment of patients postoperatively.

How to Article: Prehabilitation and postoperative treatment at Shouldice Hospital

Shouldice Hospital has grown beyond its beginnings in the 1940s to become a leading centre of excellence for mesh-free hernia repair. Little is known to the international surgical community about the preoperative and postoperative care at Shouldice Hospital, and colleagues working at Shouldice Hospital have been repeatedly asked to provide more details at international and national congresses. Therefore, this article aims to summarize preoperative and postoperative care at Shouldice Hospital based on previously published literature. The authors believe that the long-standing tradition of prehabilitation and postoperative treatment may play a role in facilitating patient satisfaction and superior postoperative results after hernia surgery.

Surgical aspects and early morbidity of patients undergoing open recurrent inguinal hernia repair

PURPOSE

This study aims to characterize the patterns of recurrence associated with specific types of primary inguinal hernia repair techniques used for and their respective correlations with early morbidity, in patients undergoing open repair for their first hernia recurrence.

METHODS

After ethics approval was obtained, a retrospective review of charts from patients who underwent open surgery for repair of a first recurrence after a previous inguinal hernia repair during 2013-2017 was completed. Statistical analyses were performed and p-values < .05 are reported as statistically significant.

RESULTS

1393 patients underwent 1453 surgeries for recurrent inguinal hernias at this institution. Operations for recurrence were longer (61.9 ± 21.1 vs. 49.3 ± 11.9; p < .001), required more frequent intra-operative surgical consultation (1% vs. 0.2%; p < .001) and had a higher incidence of surgical-site infections (0.8% vs. 0.4%; p = .03) than primary inguinal hernia repairs. When comparing the patterns of recurrence among different techniques of primary repairs, patients undergoing laparoscopic hernia repair presented with a higher incidence of indirect recurrences. Reoperations after a Shouldice repair and open mesh repair represented markers for higher surgical difficulty in the recurrent operation (longer operative time, higher identification of heavy scarring, less nerve identification, and higher frequency of intra-operative consultation), but not higher rates of complications when compared with other techniques.

CONCLUSIONS

Open reoperations for inguinal hernia first recurrences are more complex, with noticeable differences according to the index operation, and associated with higher morbidity when compared with primary hernia repairs. This complexity varies according to the type of primary surgery, with a previous Shouldice repair and open hernia repair with mesh presenting higher surgical difficulties although this did not translate to higher incidence of early complications. This information may allow adequate allocation of surgeons with an expertise in recurrent hernias and choice of recurrent repair method (laparoscopic or open) based on the primary surgery.

Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital

PURPOSE

This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital.

METHODS

After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary.

RESULTS

A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005.

CONCLUSION

Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.