Shouldice technique is better than other open techniques, not using mesh

Inguinal hernia is a very common disease that mainly affects men in young and middle age and it's reparation is the most frequent operation in general surgery. Hernias present as bulges in the groin area that can become more prominent when coughing, straining, standing up and in all situation where the abdominal pressure grow. If uncomplicated they are rarely painful, and the bulge commonly disappears on lying down. There are various surgical strategies which may be considered in the planning of inguinal hernia repair. These include the consideration of mesh use (mesh is a prosthesis made up by net of synthetic material that help to contrast a abdominal wall tension). A tension free repair method have been proposed to achieve better results in terms of pain and infections and to avoid the problem to present again (recurrence).

We found that the Shouldice technique is the best way to cure an inguinal hernia without using a prosthesis in terms of recurrence. The use of prosthesis reduces the recurrence even more. The persisting pain, post-operative stay and complications after the intervention do not show significant differences between the techniques. Nevertheless the methodological quality of the most included studies is low, length of follow-up is different among studies and findings lacks in patients oriented outcome so the unwelcome results, particularly in patients with chronic disease, for example diabetic or patients under steroidal therapy, should be considered with caution.

Authors' conclusions: 

Shouldice herniorrhaphy is the best non-mesh technique in terms of recurrence, though it is more time consuming and needs a slightly longer post-operative hospital stay. The use of mesh is associated with a lower rate of recurrence. The quality of included studies, assessed with jaded scale, were low. Patients have similar characteristic in the treatment and control group but seems more healthy than in general population, this features may affect the dimension of effect in particularly recurrence rate could be higher in general population. Lost to follow-up were similar in the treatment and control group but the reasons were often not reported. The length of follow-up vary broadly among the studies from 1 year to 13.7 year.

Read the full abstract...

Inguinal hernia repair is the most frequent operation in general surgery. There are several techniques: the Shouldice technique is sometimes considered the best method but different techniques are used as the "gold standard" for open hernia repair. Outcome measures, such as recurrence rates, complications and length of post operative stay, vary considerably among the various techniques.


To evaluate the efficacy and safety of the Shouldice technique compared to other non-laparoscopic techniques for hernia repair.

Search strategy: 

We searched MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL), April 2008 and updated the searches September 2011, for relevant randomised controlled trials.

Selection criteria: 

Any randomised or quasi-randomised controlled trials (RCT) on the treatment of primary inguinal hernia in adults were considered for inclusion.

Data collection and analysis: 

All abstracts identified by the search strategies were assessed by two independent researchers to exclude studies that did not meet the inclusion criteria. The full publications of all possibly relevant abstracts were obtained and formally assessed. Missing or updated informations was sought by contacting the authors.

Main results: 

Sixteen trials contributed to this review. A total of 2566 hernias were analysed in the Shouldice group with 1121 mesh and 1608 non-mesh techniques. The recurrence rate with Shouldice techniques was higher than mesh techniques (OR 3.80, 95% CI 1.99 to 7.26) but lower than non-mesh techniques (OR 0.62, 95% CI 0.45 to 0.85). There were no significant differences in chronic pain, complications and post-operative stay. Female were nearly 3% of included patients.