Guide to Shouldice Procedure (Non-Mesh Hernia Repair)
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The Shouldice procedure is an option to repair inguinal hernias without the need of mesh placement.
Key Facts
- The Shouldice procedure uses sutures (stitches) instead of the mesh material used in more traditional hernia repairs
- It is an option for people with small-to-medium sized hernias who are otherwise healthy and active
- Patients can typically go home 1-2 hours after surgery
What is the Shouldice Procedure?
The Shouldice procedure has been around and well-studied since 1945 and is a proven alternative to the traditional open inguinal hernia repair with mesh. The concept of the Shouldice repair is to restore the abdominal wall and groin region to normal anatomy using only sutures (stitches).
How is the Shouldice Procedure Performed?
The Shouldice procedure is performed through a small incision in the groin. The repair brings four separate layers of tissue together, dispersing the tension over each of them and thereby reducing the chances of recurrence versus a one- or two-layered closure.
- The procedure starts with an incision through the groin and then isolation of the outermost oblique muscle, which overlies the inguinal canal, the external oblique. The oblique is cut to enter the canal and then the spermatic cord (in men) or the round ligament (in women) is seen.
- The inguinal floor and the hernia are seen at this point. The hernia sac (the lining of the hernia contents) is separated from all nearby structures and is reduced back into the abdominal cavity. Then the repair can begin.
- The first step of the repair involves cutting through the floor of the inguinal canal, which frees up the innermost oblique muscle and connective tissue, the transversus abdominis.
- Then, the two parts of the innermost oblique are seen, and the goal is to tighten them to restore the floor of the inguinal canal. This is done by bringing one the lowermost leaflet to the connective tissue of the underside of the rectus abdominis muscle (the six pack muscles) and eventually the underside of the innermost two oblique muscles (the internal oblique and transversus abdominis).
- This part is typically done with a continuous suture line. Then the uppermost leaflet of the innermost oblique (transversus abdominis) is sutured to the tough connective tissue of the outermost oblique (external oblique)
- A second suture line is tied back onto itself to finish the first step and the second layer.
- The third and fourth layers utilize another suture line to bring the muscle and tendon of the internal oblique and transversus abdominis to the strong connective tissue of the external oblique. By doing so, it disperses the tension across two more suture lines and fully recreates the inguinal floor.
- Then the cut edge of the external oblique is sewn back together, and the skin is closed.
What Type of Anesthesia is Used?
The Shouldice procedure is done with minimal anesthesia, which includes some minor sedation and mostly local anesthesia or injectable numbing medicine in the area that the surgery is performed.
What are the Risks?
During the Shouldice procedure, in certain cases, tiny nerves near the hernia can get stuck in scar tissue which is formed by the hernia and must be taken in order to prevent chronic pain. In many cases patients do not experience any numbness at all, however leaving the injured nerve in place has a high chance of leading to chronic pain. To prevent this, the nerve is taken and implanted into nearby muscle to get it working again.
What is Recovery Like?
Patients typically go home 1-2 hours after the procedure is complete.
The recovery for the Shouldice procedure is very similar to a regular inguinal hernia repair. Patients should expect pain for only a day or so and then soreness for 2-3 weeks. Walking is encouraged as much as possible. Pain control is usually Tylenol and Ibuprofen. Rarely do we prescribe narcotic pain medicine for this procedure.
Often the area near the incision swells, which is expected after surgery, and the area can appear bruised. Both resolve usually in 2-3 weeks. It is also not uncommon to get testicular discomfort on the same side as the hernia. This is also from swelling from the surgery and resolves over time.
Of note, the recurrence rate for a Shouldice procedure is slightly higher than a mesh repair. Patients should be vigilant about notifying their surgeon if they think they might have a new symptom or bulge.
Why Choose the Shouldice Procedure?
People in need of inguinal hernia repair may prefer the Shouldice procedure over other options if:
- They do not want implantable mesh
- They have a small or medium inguinal hernia
- They are otherwise healthy and want to remain active
Why Not Choose the Shouldice Procedure?
Patients may not be good candidates for the Shouldice procedure if:
- Their hernia is large
- They have a femoral or obturator hernia
- They have multiple other medical problems.
The Shouldice procedure may also not be ideal for people with recurrent hernias, as that may require additional reinforcement in the form of a synthetic mesh.
Next Steps
If you are interested in hearing more about the Shouldice procedure or seeing if this is the right surgery for you, the Columbia Hernia Center can help.
- Our team is highly experienced in all the most advanced treatment options, including enhanced recovery protocols for all our patients to help reduce complications from surgery and reduce the length of both your hospital stay and recovery.
- We also believe strongly that the best recovery begins before you ever enter the operating room. As part of this “pre-habilitation” approach, our team of specialists will check in with you every step of the way and make sure your body is optimized for your procedure ahead of time.
- We use permanent or semi-permanent mesh for all major abdominal wall reconstructions. This has been proven in the literature to drastically reduce the risk of recurrence in the future, as it assists with scar tissue formation to form your “new” abdominal wall. We also utilize techniques which do not expose any abdominal wall nerves to provide a natural barrier between any intestine and the mesh.
- Our precise attention to detail has allowed us to reduce the rates of chronic pain after surgery to less than 1%. We also pride ourselves in our ability to avoid post-operative narcotics.
- Our specialized pain management protocols have allowed us to avoid narcotics in over 95% of our minimally-invasive repairs.
- Our job doesn’t end after surgery. We’ll be with you throughout your recovery, monitoring your progress and answering any questions you have. If any complications come up, we’ll be there to get your recovery back on track.
To set up a consultation, please call us at (212) 305-5947 or use our online appointment request form. We look forward to answering your questions and meeting your hernia care needs.