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  • 1. Introduction
  • 2. Surgical Approach
  • 3. Incision
  • 4. Exposure of External Oblique
  • 5. Mobilization of External Oblique
  • 6. Inguinal Dissection and Identification and Preservation of Nerves
  • 7. Skeletonize Cord Structure and Look for the Indirect Hernia Sac / Peritoneum
  • 8. Skeletonize Hernia Sac and Examine Internal Inguinal Ring and Peritoneum
  • 9. Division of Cremaster Muscle Fibers with Genital Branch of Genitofemoral Nerve
  • 10. Divide Floor of Inguinal Canal
  • 11. Four-Layer Shouldice Repair
  • 12. Closure
  • 13. Post-op Remarks

Shouldice Repair for Left Direct Inguinal Hernia


Divyansh Agarwal, MD1; Lauren Ott, PA-C2,3,4; Michael Reinhorn, MD, FACS2,3,4
1Massachusetts General Hospital
2Mass General Brigham - Newton-Wellesley Hospital
3Boston Hernia and Pilonidal Center
4Tufts University School of Medicine

Main Text

It is estimated that approximately one in four men, and one in 20 women will develop an inguinal hernia over the course of their lifetime. An inguinal hernia occurs when a hole in the lower abdominal wall allows abdominal contents to herniate into the groin. This may occur through a natural opening such as the internal ring, or through a weakness in transversalis fascia in the “direct” space, or a widening of the femoral canal. This abdominal wall defect can present as a burning, heavy, or aching sensation in the groin, and while watchful waiting can be an option for asymptomatic inguinal hernias, patients with significant symptoms of discomfort that affect their daily quality of living benefit from repair of the hernia. Surgery is most commonly performed as an elective procedure. Here we present the case of a 51-year-old male who presented with left groin pain and a bulge in the area, worsened while straining or after a long day of physical activity. The patient underwent a mesh-free hernia repair performed via the four-layer Shouldice technique as a 50-minute ambulatory/day-surgery procedure. This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.

Inguinal hernia repair remains one of the most common general surgical elective procedures in the U.S., with over 800,000 surgeries performed annually. An inguinal or groin hernia can be defined as herniation of the intra-abdominal or extraperitoneal organs through a defect or weakness in the abdominal wall muscles. Males account for approximately 90% of all inguinal hernia cases observed globally. These hernias can be further classified into three major categories – (i) direct: wherein the abdominal viscera protrude directly through a weakness of the posterior wall (transversalis fascia) of the inguinal canal medial to the inferior epigastric vessels, (ii) indirect: wherein the herniation occurs lateral to the Hesselbach's triangle and the inferior epigastric vessels, through the deep or internal inguinal ring into the inguinal canal, and (iii) femoral: wherein the peritoneal sac protrudes through a dilated femoral ring into the femoral canal, below the inguinal ligament and caudal to the emergence of the inferior epigastric vessels.

Inguinal hernias most commonly present as a burning, heavy, or painful sensation in the groin. Repair of symptomatic hernias is routinely performed to minimize the risk of downstream complications such as an incarcerated or strangulated hernia. The defect closure can be achieved via open or laparoscopic approaches. 

While the standard of care for inguinal hernia repair is a posterior mesh repair, anterior options are still commonly performed operations in the US. These anterior repairs have an unacceptably high incidence of chronic pain lasting up to a year at 5–15% and a 3% incidence of permanent disability postoperatively.1 Modern culture has attributed this high incidence of chronic pain to mesh repairs as evidenced by advertisements on TV and internet.2,3 The Authors as well as most hernia surgeons understand that while mesh itself may be inert and safe to use, it is the variability in a surgeon’s knowledge and technique with the use of mesh that leads to complications more frequently than the prosthetic itself.  

Because of patient demand, and clear need to further the understanding of hernia anatomy, the authors traveled to the Shouldice hospital in Thornhill, Ontario in Canada to observe the process of patient selection and technical steps required. 

Recent publications have demonstrated a low recurrence rate of 1.15% and very low risk of chronic pain when the Shouldice repair is performed at the Shouldice hospital, by a trained surgeon there.4 In this case, we describe the Shouldice technique, a pure tissue/no mesh approach in which the entire groin region is dissected out and secondary hernias and weakness are searched for, and subsequently a unique laminated closure allows the repair to be performed without tension.5

Our patient in this case was a 51-year-old overweight male (BMI: 27) who presented with a two-year history of a left inguinal hernia. He had first noticed a bulge near the left groin region that would become painful after a strenuous day at work, but over the past six months, his symptoms began to interfere with his daily activities. In particular, the patient was a regular golfer, and the left inguinal bulge interfered with his ability to play golf. He noticed that his pain would worsen while playing, and over the last three months he has been unable to play. He also reported this discomfort and unmanageable pain while lifting heavy boxes or mechanical equipment at home.

He had no other past medical history, and his only past surgical history was notable for a right-sided no mesh inguinal hernia repair four years ago. The patient had remained symptom-free on the right side since his prior surgery and expressed his desire to now undergo a no mesh left inguinal hernia repair, understanding the risks of surgery including bleeding, infection, recurrent hernia, and chronic pain. He denied any recent dyschezia, hematochezia, dysuria, or hematuria.

The focused physical examination in this case was performed with the patient in standing position, and visually inspecting the inguinal area. A prior well-healed inguinal surgical scar was evident on the right side, but we did not appreciate any bulges or asymmetry in the groin or scrotum bilaterally. 

We then began palpating over the groin and scrotum bilaterally, and towards the external inguinal ring. The patient was then instructed to cough to simulate increased intra-abdominal pressure. A bulge tender to palpation was observed in the left inguinal region but not on the right. We also assessed for the presence of a femoral hernia on both the ipsilateral and contralateral sides by palpating below the inguinal ligament and just lateral to the pubic tubercle, however, we could not appreciate one on either side.

The patient’s CBC and electrolytes were within normal limits, and no imaging studies were necessary or obtained in this case.

After sedation and local anesthesia was administered, a left lower quadrant oblique incision was made and carried down through the subcutaneous tissues and through the external oblique. Local anesthetic was infiltrated along each layer, and an ilioinguinal nerve block was performed. Then, the external oblique was separated along the length of its fibers. The anterior cremaster muscle fibers were divided, and the cord was retracted laterally. The iliohypogastric nerve was mobilized and placed in situ. The cremaster muscle covering of the spermatic cord is then opened longitudinally in order to identify the indirect hernia sac component and dissected free from the cord completely. Any preperitoneal fat component is also dissected, divided, or returned to the preperitoneal space. A Penrose drain was then placed around the cord to allow its mobilization and protection in subsequent steps of the operation. 

Next, we cleaned the posterior floor by dividing the posterior cremaster fibers and partially excising the genital branch of the genitofemoral nerve. The transversalis fascia was intentionally opened to look for a possible femoral hernia. The intentional investigation for a femoral hernia is important while repairing inguinal hernias as there is a non-insignificant chance of detecting an occult, concomitant femoral hernia in patients who preoperatively received a diagnosis of inguinal hernia, the incidence ranging between 4–14% across various studies.6–9 

In cases where there is a significant direct hernia, the redundant transversalis fascia is excised and a moist sponge is place in the retroperitoneum to help keep the hernia contents from interfering with the repair.

After verifying the absence of any concomitant femoral hernia in this case, a four-layer Shouldice hernia repair was performed using 0–0 polypropylene sutures. The first layer was constructed by suturing the transversalis fascia near the pubic tubercle together with the underside of the internal oblique–transversus abdominis combination, often known as conjoined tendon. The remnant of the posterior cremasteric muscle was then used to wrap around the cord and create a new internal ring. The second layer of the repair was then run back towards the pubic tubercle, including the shelving edge of the inguinal ligament as well as the internal oblique–transversalis combination laterally, and the rectus sheath medially. Once this was accomplished, another layer was sutured starting from the internal ring carried all the way down to the pubic tubercle, taking the external oblique and internal oblique, and then run back taking additional external oblique layer to the rectus medially and the internal oblique laterally. This was tied, the wound was irrigated, and then the external oblique was closed over the spermatic cord and the ilioinguinal nerve. Finally, we closed the incisional wound with 3-0 Vicryl suture for Scarpa's fascia, and with 4-0 Monocryl for skin.

Several basic options are available to patients for inguinal hernia repair. Traditional anterior mesh or no mesh repairs are possible approaches, while open, laparoscopic, and robotic posterior mesh repairs are also available to most patients. Patient body habitus, previous ipsilateral hernia surgery, patient preference, previous retroperitoneal hernia surgery, and history of thromboembolic events all play a role in determining which operation might be the most optimal for each person.

Our choice of the Shouldice repair over other options was primarily motivated by the patient’s previous experience, lower incidence of acute and chronic pain, and the fact that the patient had an appropriate abdominal girth. Most overweight individuals with larger abdomens have a higher likelihood of hernia recurrence as there is increased pressure on the repair, and thus are not good candidates for this procedure.  Furthermore, while chronic pain has been reported in 5–20% of patients undergoing traditional surgical approaches10–12, those undergoing a Shouldice repair are likely to experience lower rates of chronic pain, and a 1–3% risk of hernia recurrence.13,14

Other complications shared across hernia repair approaches include hemorrhage, urinary retention, atelectasis, infection, and postoperative testicular atrophy. Whilst existing data show that most of these complications are exceptionally rare after a Shouldice repair, it is important to note that trauma to the cord vessels and more rarely, a tight internal ring, can result in testicular atrophy in up to 1 in 1000 cases.5,15 A major benefit of the Shouldice repair is also that a substantial proportion of these surgeries can be performed under local anesthesia with sedation, which can also allow the patient to strain on the operating room table in cases wherein a smaller hernia defect might be tricky to locate. An important consideration for patients undergoing inguinal hernia repair to allow the incisions to heal optimally and minimize postoperative complications such as a recurrence and bleeding is that they avoid strenuous exercise and heavy lifting of anything over 10 kg for up to a month after surgery.

Hernia repair remains a major elective surgical procedure that comes with important socioeconomic challenges. Here we describe the Shouldice technique for herniorrhaphy, which is particularly advantageous from a cost-effectiveness perspective since it does not rely on any foreign materials or technology, and therefore is relatively easy to perform and inexpensive. Further still, many specialized centers can perform these open surgeries under local anesthesia with sedation with few postoperative complications. In this case, the patient was able to recover and go home two hours later. He remains free of symptoms without any evidence of recurrence and with minimal pain postoperatively that was managed with over-the-counter non-opioid medications.

As is true for most surgical procedures, its outcomes are proportional to the surgeon’s experience. This is particularly true for the Shouldice repair, whose outcomes from the Shouldice Hospital, Ontario, Canada, over the past 50 years have documented a cumulative recurrence rate of less than 1%, with an even smaller proportion of patients experiencing any significant long-term complications.5,16 Globally, the Shouldice technique for inguinal hernia repair remains a valid option in a variety of settings; for instance, the HerniaSurge Group recently recommended the Shouldice approach in uncomplicated hernias in people under 30 years of age, without obesity or other risk factors, and for those with an indirect hernia defect of less than 3 cm.13,17 Additionally, in countries without access to meshes or in individuals who because of a clinical or personal reason are intolerant to a mesh, this pure tissue repair provides for a favorable option. 

No special equipment, tools, or implants used in the procedure.

No relevant disclosures of conflicts of interest.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

We thank the patient for giving us the permission to present this case in JoMI.


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Cite this article

Agarwal D, Ott L, Reinhorn M. Shouldice repair for left direct inguinal hernia. J Med Insight. 2022;2022(340). doi:10.24296/jomi/340.

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Publication Date
Article ID340
Production ID0340