Shouldice Repair

Shouldice Repair

David Ray Velez, MD

Definition

Definition: An Open Tissue Repair that Reconstructs the Posterior Wall in Multiple Layers by Imbrication of the Transversalis Fascia and Approximation of the Conjoined Tendon to the Inguinal Ligament

Essentially a Four-Layer Modification of the Bassini Repair.

Significantly Improved Recurrence Rates (as Low as 1-2%) Have Been Reported at High Volume Centers Such as the Shouldice Hospital in Ontario, Canada but it Has Been Less Reproducible Elsewhere

See Also:
*See Inguinal Hernia
*See Inguinal Hernia Repair (IHR)

Technique

Skin Incision: 6-8 cm Oblique Incision Parallel and Just Superior to the Inguinal Ligament

Dissection

  • Carry Incision Down Through the Subcutaneous Tissue and Scarpa’s Fascia
  • Expose and Longitudinally Incise the External Oblique Aponeurosis to Enter the Inguinal Canal
    • Preserve the Ilioinguinal Nerve
  • Mobilize and Isolate the Spermatic Cord and Encircle it with a Penrose Drain
  • Dissect the Hernia Sac from the Spermatic Cord and Reduce It
  • Consider High Ligation and Resection of the Sac vs Reduction Alone

Repair

  • Incise the Posterior Wall (Transversalis Fascia) from the Internal Ring to the Pubic Tubercle to Expose the Preperitoneal Space and Facilitate Reduction of the Hernia Sac
    • Develop the Preperitoneal Plane
    • Create Medial and Lateral Flaps of the Transversalis Fascia
  • Close Layer #1: Suture the Inferolateral Flap of the Transversalis Fascia to the Undersurface of the Superomedial Flap
    • Begin Medially Anchoring at the Pubic Tubercle and Proceed Laterally
  • Close Layer #2: Reverse Direction and Overlap the Superomedial Flap of the Transversalis Fascia onto the Shelving Edge of the Inguinal Ligament
    • Creates a Double-Breasted (Imbricated) Reconstruction of the Transversalis Fascia
  • Close Layer #3: Approximate the Conjoined Tendon to the Inguinal Ligament
    • Begin Laterally and Proceed Medially
  • Close Layer #4: Reverse Direction and Imbricate the Conjoined Tendon to the Inguinal Ligament Over the Previous Layer
    • Recreate the Internal Ring Around the Spermatic Cord without Constriction

A Four Layered Repair Traditionally Using Two Sutures: First for Layers #1-2 and Second for Layers #3-4

Modern Repairs Use Running Nonabsorbable Suture (Polypropylene) for All Layers – Original Description Used Stainless Steel Wire

May Create a “Relaxing Incision” of the Anterior Rectus Sheath if Under Perceived Tension

Closure

  • Return the Spermatic Cord to the Inguinal Canal
  • Close the External Oblique Aponeurosis Over the Spermatic Cord
    • Preserve the Ilioinguinal Nerve
  • Close Scarpa’s Fascia and Skin

Incision

Incise the Posterior Wall

Layer #1: Inferolateral Flap of the TF to the Undersurface of the Superomedial Flap

Layer #2: Superomedial Flap of the TF onto the Shelving Edge of the Inguinal Ligament

Layer #3: Conjoined Tendon to the Inguinal Ligament

Layer #4: Imbricate the Conjoined Tendon to the Inguinal Ligament