What is the recommended treatment for a middle-aged adult patient with a symptomatic inguinal hernia, considering the Shouldice repair?

Shouldice Repair for Inguinal Hernia

Mesh repair is the recommended standard approach for symptomatic inguinal hernias in middle-aged adults, as it provides significantly lower recurrence rates (0% vs 19% with tissue repair like Shouldice) without increased infection risk. 1, 2

Current Standard of Care

The Shouldice repair, while historically significant as a pure tissue technique, is no longer the first-line recommendation for inguinal hernia repair based on contemporary guidelines:

• Mesh repair is strongly recommended by the European Hernia Society and American Hernia Society as the standard approach for all non-complicated inguinal hernias 1, 2
• Laparoscopic approaches (TAPP or TEP) offer comparable outcomes to open mesh repair with additional benefits including reduced postoperative pain, lower wound infection rates, and faster return to activities 1, 2

Evidence Comparing Shouldice to Modern Techniques

The most recent systematic review demonstrates clear superiority of mesh over tissue repairs:

• Shouldice has a 3.8-fold higher recurrence rate compared to mesh techniques (OR 3.80,95% CI 1.99 to 7.26) 3
• Shouldice performs better than other non-mesh techniques (OR 0.62,95% CI 0.45 to 0.85) but this is clinically irrelevant when mesh is available 3
• No significant differences exist in chronic pain, complications, or postoperative stay between Shouldice and mesh repairs 3

When Shouldice May Be Considered

The Shouldice technique has limited contemporary indications and should only be considered in highly selected circumstances:

• Primary hernias in young, healthy patients who specifically decline mesh after informed discussion of higher recurrence risk 4, 5
• Patients with absolute contraindications to mesh (extremely rare in clean surgical fields) 1
• Settings where mesh is unavailable (resource-limited environments) 4

Technical Requirements for Shouldice

If Shouldice is performed, specific technical expertise is mandatory:

• Complete inguinal dissection with identification and preservation of all three inguinal nerves 4
• Resection of cremaster muscle and exposure of all three hernial sites (lateral, medial, femoral) 4
• Four-layer reconstruction of transversalis fascia using monofilament running suture 4, 6
• Can be performed under local anesthesia in 95% of compliant adults 4, 6

Critical Pitfalls to Avoid

• Do not offer Shouldice as equivalent to mesh repair - the recurrence data clearly demonstrates inferiority 3
• Do not use Shouldice for recurrent hernias - mesh is mandatory in this setting, with Shouldice showing 6.9% recurrence rates even in selected recurrent cases 4
• Do not use Shouldice for large medial or combined hernias - mesh prosthesis is necessary 4

Recommended Algorithm for Middle-Aged Adults

For a symptomatic inguinal hernia in a middle-aged adult:

1. First-line: Laparoscopic mesh repair (TAPP or TEP) - provides lowest recurrence with minimal invasiveness 1, 2
2. Alternative: Open mesh repair - if laparoscopic expertise unavailable or patient has contraindications to general anesthesia 1
3. Shouldice repair: Not recommended - only consider if patient refuses mesh after detailed counseling about 3.8-fold higher recurrence risk 3

The historical success of Shouldice at specialized centers (1% recurrence) 6, 5 reflects highly selected patients and exceptional surgical expertise that is not generalizable to routine practice 3.