canadian association of general surgeons association...

Review of all the available tech-niques in hernia surgery pre-sents a muddled picture.

The contentious issues have revolvedaround the use of prosthetic materialsand more recently the wisdom of laparoscopic herniorrhaphy. Both tension-free and laparoscopic tech-niques have serious drawbacks.

It is becoming imperative that

ethics, safety, economics and resultsbe objectively scrutinized. Further-more, the influence, precept and ma-nipulation of the manufacturers ofsurgical instruments must be scrupu-lously parried since they cannot, orwill not, appreciate the nature andimplications of invasive technologiclegerdemain on the living, humanpatient.

THE SHOULDICE TECHNIQUE

Evolution of the Shouldice tech-nique began with that of Bassini,through Halsted, Ferguson, Andrewsand to a certain degree, McVay.1,2 It in-corporates steps from all those opera-tions. The only drawback to theShouldice technique is that it must bedone integrally.3–5 Many surgeons over

Canadian Association of General SurgeonsAssociation canadienne de chirurgiens généraux

SYMPOSIUM ON THE MANAGEMENT OF INGUINAL HERNIAS

4. THE SHOULDICE TECHNIQUE: A CANON IN HERNIA REPAIR

Robert Bendavid, MD

From the Shouldice Hospital Ltd., Thornhill, Ont.

Symposium presented at the annual meeting of the Canadian Association of General Surgeons, Montreal, Que., Sept. 16, 1995

Accepted for publication Jan. 29, 1997

Correspondence to: Dr. Robert Bendavid, Shouldice Hospital Ltd., PO Box 370 Stn. Main, Thornhill ON L3T 4A3

© 1997 Canadian Medical Association (text and abstract/résumé)

Controversy exists on the merits of the various approaches to inguinal repair. Evolution of the classic openrepair has culminated in the Shouldice repair. Challenges from newcomers, namely, tension-free repair andlaparoscopy, are being examined. These two techniques have a number of disadvantages: the presence offoreign bodies (prostheses) and their implication in cases of infection; the cost of prosthetic material, whichis no longer negligible (particularly with expanded polytetrafluoroethylene); and problems of safety in thatthe laparoscopic approach is no longer a dependable asset except in the hands of a highly specialized anddextrous operator. Still, complications occur with laparoscopic repair that should not be associated with asurgical procedure that is considered benign, safe and cost-effective. Surgeons must recognize the perti-nent facts and decide according to their conscience which method of repair to use.

Les mérites des diverses méthodes de réparation inguinale suscitent la controverse. L’évolution de la réparationclassique a atteint son point culminant avec la méthode Shouldice. On examine à l’heure actuelle les défis poséspar de nouvelles méthodes, c’est-à-dire la réparation sans tension et la laparoscopie. Ces deux techniquesprésentent certains désavantages : la présence de corps étrangers (prothèses) et leurs répercussions en cas d’in-fection, le coût des prothèses, qui n’est plus négligeable (surtout dans le cas du polytétrafluoréthylène expansé)et les problèmes de sécurité posés par le fait que la laparoscopie n’est plus un moyen fiable, sauf entre les mainsd’un chirurgien très spécialisé et habile. La réparation par laparoscopie pose quand même des complicationsqu’il ne faudrait pas associer à une intervention chirurgicale jugée bénigne, sûre et peu coûteuse. Les chirurgiensdoivent reconnaître les faits pertinents et choisir la méthode à utiliser en fonction de leur conscience.

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the years have made a point of spend-ing 1 to 3 days at the Shouldice Hos-pital, where they can watch up to 30operations a day in 5 operating rooms.Too often, surgeons take short cuts,omit steps or improvise so much thatthe results bear no resemblance to theoriginal technique. I have yet to see asurgeon perform a Bassini repair as de-scribed by Bassini or his student, Cat-terina, whose monograph remains aclassic.6 The 3 crucial components ofthe Shouldice repair that contribute toits safety, efficacy and cost-effectivenessare local anesthesia, technical aspectsof the repair and early ambulation.

Local anesthesia

The desirability and feasibility ofherniorrhaphy under local anesthesiawere demonstrated by Halsted, Blood-good and Cushing as early as 18997 inpatients for whom ether and chloro-form anesthesia represented a cleardanger (33 cases). The introduction oflocal anesthesia on a widespread scale,however, began with Earle Shouldice,as seen in publications from this hospi-tal: 2874 cases reported by Campbellin 19508 and 10 000 cases reported byShouldice in 1953.9

Now that elderly patients undergohernia repair more frequently, the ad-vantages of local anesthesia are even

better displayed by the lower incidence,if not elimination, of pulmonary andcardiac complications, urinary reten-tion and deep vein thrombophlebitis.The death rate has consistently beenunder 1/10 000.10 Local anesthesia re-duces significantly the need for andcost of preoperative consultations andinvestigations as well as postoperativecare. Statistics at the Shouldice Hospi-tal revealed that 52.1% of all patientsare older than 50 years (Table I). Theincidence of associated cardiac impair-ment is shown in Table II.

To the majority of patients, local anes-thesia is perceived as being associatedwith minor surgical procedures, so theywill proceed more readily with electiverepair rather than delay until an emer-gency, with its attendant complications,will force them to submit to surgery.

The technical aspects of local anes-thesia of the inguinal area are simpleand do not require unusual dexterity.Procaine hydrochloride (1%) is still usedup to a volume of 200 mL. Infiltrationof the skin is carried out from the levelof the anterior superior iliac spine to thepubic crest — 50 to 80 mL will suffice.Once the skin has been incised andbleeding vessels have been controlled,an additional 20 to 30 mL are injecteddeep to the external oblique aponeuro-sis in the general area of the ilioinguinal,iliohypogastric and the genital nerves.

When the external oblique aponeurosishas been divided along the direction ofits fibres and the edges freed and re-tracted, these nerves are visualized andcan be individually infiltrated with an-other 2 or 3 mL of procaine hydrochlo-ride. Other areas that will require anes-thetizing during the procedure are theedges of the internal ring (5 mL) andthe spermatic cord within its areolar tis-sue at the level of the internal ring. An-other 5 to 10 mL of procaine hy-drochloride is allowed to diffuse deepto the transversalis fascia along the edgeof the myoaponeurotic arch (falx in-guinalis). These additional areas are in-nervated by sympathetic fibres from therenal and pelvic plexuses. The last siteto require infiltration will be a hernialsac, if indirect, with 5 to 10 mL aroundthe base of the sac and directly into thesac. Tension and dissection of the sacmay otherwise be painful and bringabout a bradycardia.

Surgical steps

The Shouldice repair applies to di-rect and indirect inguinal hernias. Itdoes not apply to femoral hernias. Themajority of recurrent inguinal herniascan be treated with a Shouldice repair.In a review of our statistics by Obneyand Chan,11 37% of 1057 patients whopresented with a recurrent hernia had

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Table II

Associated Cardiac Conditions in Patients Over 50 Yearsof Age, From the Shouldice Hospital Records

Condition

Anticoagulation (with acetylsalicylic acid,sulfinpyrazone, warfarin sodium)

History ofMyocardial infarction

Angina

Congestive heart failure

Hypertension 20

17

15

15

12

Patients, %

Cardiac arrhythmia 50

Table I

Records of Patients at the Shouldice Hospital Over theAge of 50 Years

Age group, yr

< 50

50–59

60–69

70–79 603

1330

1116

2917

No.

Patients

9.6

21.4

19.1

47.9

%

689

1533

1369

3424

Operations, no.

80–89 124 2.0 144

Total 6090 100.0 7159

an indirect inguinal hernia. These re-currences may properly be termed“missed hernias.” The majority of re-current direct hernias can also betreated in the same manner. The needfor mesh is 1.3% for all groin hernias12

(Table III). The essential steps of therepair consist of the following.

Resection of the cremaster muscle

When the spermatic cord has beenexposed, the cremaster muscle is incisedlongitudinally from the level of the in-

ternal ring to the pubic crest, resultingin medial and lateral flaps. The medialflap is essentially avascular and is resectedentirely. The lateral flap, containing theexternal spermatic vessels and the geni-tal branch of the genitofemoral nerve, isdivided between 2 clamps. Each result-ing stump is doubly ligated with a re-sorbable suture. In this manner, an indi-rect inguinal hernia can never be missed.When such a hernia is absent, a peri-toneal protrusion can be identified, freedand pushed back into the preperitonealspace of Bogros (Fig. 1).

Division of the posterior wall of theinguinal canal

This step, already emphasized byBassini,13 is perpetuated in the Shouldicerepair. It consists of incising the trans-versalis fascia from the medial aspect ofthe internal ring to the pubic crest. Inexceptional cases in which this fascia issubstantial, division may be carried outover 1 or 2 cm only, enough to insertthe index finger and palpate the femoralopening. In female patients who rarelyhave a direct inguinal hernia, the poste-rior wall need not be incised. The trans-versalis fascia is then divided from the in-ternal ring to the pubic tubercle. Thelogic behind this step is that it excludesthe weakened transversalis fascia frombeing used again and, more importantly,provides exposure of the more solid lay-ers needed for the reconstruction, medi-ally and laterally (Fig. 2).

Incision of the fascia cribriformis

The fascia cribriformis, an exten-


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CJS, Vol. 40, No. 3, June 1997 201

FIG. 1. Longitudinal incision of the cremaster muscle, resulting in twoleaves. The medial leaf is entirely resected. The lateral leaf is divided be-tween clamps and doubly ligated, providing 2 stumps. (Reproduced withpermission from: Nyhus LM, Baker RJ. Mastery of surgery. 2nd ed. Boston:Little, Brown and Company; 1992.)

FIG. 2. Incision of the transversalis fascia from the deep inguinal ring tothe pubis. Resection of the central elliptical portion is warranted in manycases. (Reproduced with permission from: Nyhus LM, Baker RJ. Mastery ofsurgery. 2nd ed. Boston: Little, Brown and Company; 1992.)

Table III

Need for Mesh in Hernia Repairs at the Shouldice Hospital

Hernia type

Abdominal wall

Groin

Direct inguinal

Indirect inguinal

Femoral 144

4028

2890

7085

7529

No. of operations

48

4

26

98

154

Mesh needed,no. (%)

(33.3)

(0.1)

(0.9)

(1.3)

(2.0)

Inguinofemoral 23 20 (87.0)

sion of the fascia lata of the thigh, isincised from the level of the femoralvein to the pubic crest. The femoralorifice below the inguinal ligament isdemonstrated and with palpation ofthe femoral ring from the preperi-toneal space confirms the presence orabsence of a femoral hernia.

Reconstruction

Reconstruction of the posteriorwall is carried out with continuousstainless steel wire (gauge 32 or 34).Steel is an ideal material, being nonre-active and nonallergenic. Further-more, it never needs to be removed inthe presence of infection. The contin-uous suture is ideal because it elimi-nates the small defects between inter-rupted sutures and because itdistributes the tension evenly on thesuture line. Two continuous suturesare used, each going back and forth,thereby providing 4 lines. The first su-ture begins near the pubic crest, pick-ing up the iliopubic tract laterally, andcrosses over to be inserted through

the medial myoaponeurotic arch(transversalis fascia, transversus abdo-minis and internal oblique muscles)and the lateral border of the rectusmuscle, leaving a free border to thisarch (Fig. 3). This suture advances to-ward the internal ring, picking up thelateral stump of the cremaster, insert-ing it deep to the muscular layer me-dially. This same suture reverses itscourse back in the direction of the pu-bic crest and includes the shelvingedge of the ligament of Poupart on itsway, to be finally tied near the pubicspine (Fig. 4). The second suture pro-vides lines 3 and 4 and begins later-ally, picking up internal oblique andtransversus muscles, then crosses overto pick up the inner aspect of the lateral half of the external obliqueaponeurosis along a line just superiorand parallel to the inguinal ligament,proceeding to the pubic tubercle, thenreverses toward the internal ring, pick-ing up again the external obliqueaponeurosis on its inner aspect justabove and along the previous thirdline to be knotted finally at the inter-

nal ring. Four lines of sutures are thusprovided, sealing the posterior walland absorbing evenly any tension onthe repair. The spermatic cord is placedback in its normal anatomic positionand the external oblique aponeurosisbrought together anterior to the cordwith a running absorbable suture.

RESULTS

Before the introduction of pros-thetic mesh in November 1983, therecurrence rate, globally, was less than1%. With mesh being used in chal-lenging cases (less than 2%, ), the re-currence rate has been 0.7% (TablesIII and IV14-19).20

Complications such as pneumonia,atelectasis, pulmonary embolism, phleb -itis and urinary retention are practicallynonexistent because of the aggressiveencouragement of early ambulation,which begins with the patient walkingaway from the operating table aftersurgery. Other complications have beensuperficial hematomas (0.3%) and infec-tions (0.7%). The incidence of testicular

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202 JCC, Vol. 40, No 3, juin 1997

FIG. 3. Exposure of the structures that will contribute to a reliable repair.Note the vessels that must be identified and avoided. (Reproduced withpermission from: Nyhus LM, Baker RJ. Mastery of surgery. 2nd ed. Boston:Little, Brown and Company; 1992.)

FIG. 4. The second line of the first suture incorporating the inguinal liga-ment, just before a knot is tied at the pubis. (Reproduced with permissionfrom: Nyhus LM, Baker RJ. Mastery of surgery. 2nd ed. Boston: Little, Brownand Company; 1992.)

atrophy after primary repair of an in-guinal hernia is 0.036% and after repairof a recurrent hernia, 0.46%.21 The deathrate of 1/10 000 within 30 days of sur -gery has not been a direct result ofsurgery (e.g., cerebrovascular accident,perforated gallbladder, duodenal ulcer,mesenteric or coronary thrombosis). Thepostoperative period (48 to 72 hours) isconsidered one of rehabilitation duringwhich patients are encouraged to resumenormal activities. A study of 1200 pa-tients carried out by Mr. Alan O’Dell,the administrator of Shouldice Hospital,revealed that on average, patients re-turned to work in 8.2 days.12

Increasingly, cost is becoming a ma-jor factor in medical economics. In thesame study by O’Dell, the cost of alldisposable items, per patient,amounted to Can$24.58. These itemsincluded: syringes, dressings, swabs,scrub solutions, drugs (midazolam,promethazine, meperidine hydrochlo-ride, morphine, prochlorperazine, di-azepam, procaine hydrochloride), caps,masks, gowns, tubings, needles, gloves,blades, sponges, sutures and oxygen.

DISCUSSION

The simplicity, the excellent resultsand the cost-effectiveness of theShouldice repair make it difficult toemulate. What are the objections tothe tension-free repair and to laparo-scopic herniorrhaphy?

With reference to the first, there isno doubt that it is extremely easy to ex-ecute. However, it overlooks basicprinciples in surgery, namely, the needto know the anatomy of an area thatmay present other problems than a sim-ple, primary, elective repair. This is par-ticularly applicable to incarcerated orstrangulated hernias. A tension-free re-pair is of no value in inguinofemoralhernias or in the absence of an inguinalligament, hence potential failures areeliminated, contributing to a successrate that is deceiving. The proper sitefor a prosthetic mesh is the preperi-toneal space, applied as widely as possi-ble, deep to the transversalis fascia asprescribed by Stoppa, Soler and Ver-haeghe,22 Wantz23 and Flament, Rivesand Palot.24 The weakness of the trans-versalis fascia is the result of a metabolicetiology that reaches beyond the in-guinal floor to the adjacent tissues.25

Mesh infection always represents a cat-astrophe, and though the incidencemay be low (0.5% to 3.5%),26 the actualcases provide an indelible experiencethat should temper their use. I haveseen infections present up to 2 years af-ter the original surgery; Stoppa26 re-ported 3 to 18 months, Flament andassociates27 6 and 8 years. Should a re-current hernia follow a wound infec-tion, subsequent repair must excludethe use of a prosthesis because surviv-ing organisms can be detected yearslater.28–31 The cost of prosthetic materi-

als is high, especially in the case of ex-panded polytetrafluoroethylene. Post-operative comfort and earlier return towork are factors that depend greatly onpatient personality, motivation and in-surance status rather than the particularherniorrhaphy.

If one remains detached and trulyhas the patients’ interest as an objec-tive, objections to laparoscopic hernior -rhaphy appear to be increasing witheach published report. There is ampleevidence that laparoscopic herniorrha-phy is feasible, but it must be remem-bered that the average general surgeonperforms 50 herniorrhaphies a year (A.O’Dell, Administrator, Shouldice Hos-pital, Thornhill, Ont.: personal com -mu nication, 1995), a number that isnot likely to endow anyone with ex-pertise in a challenging technique. Ob-jections therefore beg to be cata-logued: exclusions include patients athigh anesthetic risk, those with multi-ple previous abdominal operations,incarcer ated or strangulated hernias,peritonitis, coagulopathy, severe obe-sity, immune deficiency and a historyof recent infection, females of child-bearing age and those with recurrenthernia after laparoscopy.32–34 Also “theuse of laparoscopic techniques for her-nia repair in the pediatric patient hasnot been well accepted”35 and “for thesimple, nonrecurrent unilateral inguinalhernias, the use of a laparoscopic ap-proach is controversial.”32 Such exclu-sions make up 90% of the surgery doneat the Shouldice Hospital!

Complications

Long-term complications are notyet known, but some can be predicted,particularly with any technique thatleaves prosthetic material within theperitoneal cavity (the intraperitonealonlay method [IPOM]). This tech-nique “must be considered an experi-mental operation and patients must be



CJS, Vol. 40, No. 3, June 1997 203

Table IV

2.7

2.0

0.8

0.75

0.2

0.2

Recurrencerate, %

Results of the Shouldice Repair From Various Series

Series

Shearburn and Myers, 196914

Wantz, 198915

Bocchi, 199516

Devlin et al, 198617 350

2119

2087

550

No. of cases

—

80

—

100

%

Follow-up

6

7

5

13

Length, yr

Moran et al, 196818 104 — 6

Berliner, 198319 591 — 2–5

so informed,”32 and “we do not recom-mend the IPOM procedure outside ofa controlled trial.”32 Can the patient re-ally be expected to make the right de-cision? Complications that may occurat the time of surgery or shortly there-after are presently well documentedand range from 0% to 53.3%.32,36–57

These complications include the fol-lowing: perforation of bowel or urinarybladder; major vascular injuries (exter-nal iliac, circumflex iliac profunda, ob-turator and inferior epigastric vessels);nerve injury (the genitofemoral nerve,the femoral nerve and the lateralfemorocutaneous nerve of the thigh)(nerves cannot be readily identifiedwith certainty); adhesive, obstructiveand erosive events and fistula formationrequiring subsequent abdominal sur -gery; bleeding with or without theneed for transfusion; abdominal wallhematomas; trocar site hernias; persis-tent leg, groin and testicular pain; sero-mas; hydroceles; orchitis; epididymitis;spermatic cord transection; mesh infec-tion; lost clips or needles; inadequateperitoneal closure leading to bowelslipping into the extraperitoneal spaceand obstruction (“shower curtain ef-fect”); right lower quadrant pain,Richter’s hernia involving a trocar siteopening. Control of some of thesecomplications may require immediateconversion to an open procedure5,52,56

or an urgent laparotomy.

Recurrence

Recurrence rates vary with thetechnique, and though earlier reportsshowed a range from 6% to 22%, thosefigures have in the best of series, im-proved to 0% to 0.4% for the totallyextraperitoneal repair, 0.7% to 0.8%for the transabdominal preperitonealrepair and 2.2% to 3.2% for theIPOM.39,41,44,46,50–52,54,55,57 It is interestingto note that the totally extraperitonealrepair, which has the lowest recur-

rence rate, showed the highest inci-dence of complications.40,44,57

Cost

Exclusive of fixed equipment andset-up expenses, the cost of laparo-scopic herniorrhaphy may vary but willalways be far more onerous than theopen repair. An example may be seenin the figures provided by Arregui:US$1656.00,58 versus the ShouldiceHospital: US$17.45.59 Another cost is-sue raised by laparoscopic surgeons isone of hospital stay, as the patients aredischarged on the same day, but this isno longer a particular feat as many in-stitutions also discharge patients on thesame day as for an open repair. The is-sue of earlier return to work after la-paroscopic repair has not been convinc-ing. Our own patients return to workon average, 8.2 days after surgery.59–61

CONCLUSIONS

At best, the tension-free and la-paroscopic herniorrhaphies may ap-proach the good results of theShouldice repair in terms of recur-rence. With respect to cost, neitherof those two techniques may com-pare, least of all laparoscopy. In termsof actual and potential complications,laparoscopic herniorrhaphy leaves mewith a very uneasy feeling. I have nodoubt that eventually, common senseand reason will prevail.

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