Role of the Should ice technique in inguinal hernia repair: A systematic review of controlled trials and a meta-analysis

Abstract

The Shouldice technique for inguinal hernia repair has been suggested by some authors as the best conventional method against which other methods using prostheses should be compared. The paper which follows is a systematic review involving a comprehensive search of the medical literature to identify all clinical trials (article or abstract) evaluating the Shouldice repair. After assessment of certain quality criteria, the best studies were pooled in a meta-analysis. Nine publications were found with 11 study arms. In ten studies the results of the Shouldice technique were better than the results of the control arm. Six studies could be pooled in a meta-analysis of 2500 patients; Shouldice was significantly better than control methods (relative risk 0.62 (95 per cent confidence interval 0.45-0.85)). In spite of possible bias caused by different variables (modifications in operative technique, suture material, level of surgeon, follow-up methods and outcome measurement), the results of this systematic review suggest that the Shouldice method is the best current conventional technique for inguinal hernia repair.

Inguinal hernia repair: current surgical techniques

“…In 1994, in a randomized controlled trial (RCT) comparing modified Bassini versus Shouldice inguinal hernia repair, the recurrence rates after 3.3 years were 9.6% for the Bassini technique and only 1.7% for a Shouldice operation [3]. In 1996, in a systematic review of controlled trials and a meta-analysis, Simons et al [4] found that the relative risk ratio (risk of developing a recurrence) for pooled studies (n=2,500) was 0.62 (95% confidence interval, 0.44-0.87) in favor of the Shouldice technique. Thus, the Shouldice technique should be used when a non-mesh repair is considered (grade A).…”

Recurrence risks in randomized trials of laparoscopic versus open inguinal hernia repair: to pool or not to pool (this is not the question)

“…At specialized centres like the Shouldice Hospital, reported recurrence rates are fewer than 1% [5,6]. Those excellent results hardly reflect the reality of general health care [7,8] but underline surgical expertise as an important risk factor.…”

A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit

“…Under trial circumstances, the traditional open repairs (Bassini, McVay, Shouldice) have recurrence rates of 0-11% [15]. The time for return to work after these operations tends to be as long as 4-9 weeks after surgery [12,17].…”