Overview
Definition:
The Shouldice repair is a tension-free surgical technique for repairing primary inguinal hernias, focusing on anatomical reconstruction of the posterior inguinal wall by suturing the transversalis fascia to Cooper's ligament and the inguinal ligament
It is considered a gold standard for direct inguinal hernias.
Epidemiology:
Inguinal hernias are common, affecting 1-5% of the general population, with men being significantly more affected than women
Primary inguinal hernias are those that occur without a prior hernia repair history
Recurrence rates vary with technique, but Shouldice repair historically demonstrates low recurrence.
Clinical Significance:
Inguinal hernias can cause pain, discomfort, and cosmetic concerns
Untreated hernias carry the risk of strangulation and bowel obstruction, necessitating prompt surgical intervention
Understanding different repair techniques like Shouldice is crucial for surgical trainees preparing for DNB and NEET SS examinations, impacting patient quality of life and reducing surgical complications.
Indications
Indications For Repair:
Symptomatic inguinal hernias
Asymptomatic inguinal hernias in young, active individuals or those with a risk of incarceration/strangulation
Hernias that are enlarging or causing significant cosmetic deformity.
Contraindications:
Absolute contraindications are rare but include severe co-morbidities that make any surgery unsafe
Relative contraindications may include active infection at the surgical site or uncontrolled coagulopathy.
Patient Selection:
Ideal candidates are those with primary inguinal hernias without significant tissue laxity or previous surgical complications
Patient comorbidities influencing anesthetic risk are also considered.
Preoperative Preparation
History And Physical:
Detailed history of hernia symptoms, duration, and progression
Physical examination to confirm hernia type (direct/indirect, reducible/irreducible) and assess for signs of complications.
Preoperative Assessment:
Routine blood tests (CBC, coagulation profile, electrolytes)
ECG and chest X-ray for patients with cardiac or pulmonary issues
Assessment of anesthetic risk.
Informed Consent:
Detailed explanation of the procedure, including risks, benefits, alternatives, and potential complications like recurrence, infection, hematoma, nerve injury, and chronic pain
Discussion of anesthesia options.
Bowel Preparation:
Typically not required for elective inguinal hernia repair unless there is a specific surgeon preference or perceived risk of bowel manipulation.
Procedure Steps
Anesthesia:
Usually performed under general anesthesia, but spinal or local anesthesia with sedation can also be employed depending on patient factors and surgeon preference.
Incision And Dissection:
A curvilinear incision is made 2-3 cm superior to the inguinal ligament, extending laterally
The external oblique aponeurosis is incised longitudinally
The inguinal canal contents are dissected and identified
The hernia sac is identified, reduced, or ligated and divided.
Posterior Wall Reconstruction:
The transversalis fascia is incised laterally to medially
It is then meticulously sutured to Cooper's ligament on the pectineal line with a continuous non-absorbable suture (e.g., Prolene)
The medial edge of the transversalis fascia is then sutured to the inguinal ligament (Poupart's ligament) posterior to the spermatic cord or round ligament in females, creating a double-layered repair.
Spermatic Cord Management:
In males, the spermatic cord is elevated and placed anterior to the reconstructed posterior wall
In females, the round ligament is managed similarly.
Fascial Closure And Skin Closure:
The external oblique aponeurosis is closed in a layered fashion
Subcutaneous tissue and skin are closed with absorbable sutures or staples
No mesh is used in the traditional Shouldice repair.
Postoperative Care
Pain Management:
Postoperative pain is managed with oral analgesics (e.g., paracetamol, NSAIDs, opioids if necessary)
Early mobilization is encouraged.
Wound Care:
Dressings are usually kept clean and dry
Patients are advised to monitor for signs of infection or wound dehiscence.
Activity Restrictions:
Patients are advised to avoid heavy lifting (>5-10 kg) and strenuous activities for 4-6 weeks postoperatively to allow for adequate tissue healing and reduce tension on the repair.
Discharge Criteria:
Discharge typically occurs within 24 hours if the patient is pain-controlled, ambulating, and tolerating oral intake
Follow-up appointment is scheduled within 2-4 weeks.
Complications
Early Complications:
Hematoma formation
Seroma formation
Wound infection
Urinary retention
Anesthesia-related complications
Recurrence (early if suture breakdown).
Late Complications:
Chronic pain (e.g., ilioinguinal nerve entrapment)
Scar tenderness
Persistent swelling
Recurrence (late due to inadequate repair or tissue degeneration)
Testicular atrophy (rare).
Recurrence Rate:
The recurrence rate for Shouldice repair is reported to be around 5-10% in various studies, generally considered higher than mesh-based repairs for certain hernia types, but acceptable for primary hernias with good technique.
Key Points
Exam Focus:
The Shouldice repair reconstructs the posterior inguinal wall by suturing transversalis fascia to Cooper's ligament and inguinal ligament
It is a tension-free repair
Crucial for DNB/NEET SS to differentiate from Lichtenstein (mesh) and other techniques
Understanding anatomical landmarks is key.
Clinical Pearls:
Meticulous dissection of the transversalis fascia is essential for a tension-free repair
The continuous non-absorbable suture should be placed accurately to avoid tearing tissue
Ensuring adequate overlap when suturing transversalis fascia to Cooper's and inguinal ligaments is critical for preventing recurrence
Proper identification and management of the spermatic cord (or round ligament) are paramount.
Common Mistakes:
Inadequate mobilization of the transversalis fascia
Placing sutures too far from the edge, leading to tearing
Insufficient overlap of fascial edges
Suturing the external oblique aponeurosis instead of the transversalis fascia to Cooper's ligament
Premature resumption of strenuous activity leading to suture failure.