Dear Editor,
According to the 2018 HerniaSurge guidelines, the Shouldice Repair is considered the best non-mesh suture repair for inguinal hernias [1, 2] and has been the strongly recommended non-mesh repair [1]. The 2018 guidelines also stated that “the use of open non-mesh repair in specific patients or types (e.g. young males with lateral hernia L1 and L2) of inguinal hernia as an acceptable alternative to a mesh technique has not been adequately investigated so far.” [1]. However, at the end of the guidelines there were recommendations for future research in this area due to limited available data. This research included randomized controlled trials or propensity score matching.
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In 2018 Köckerling et al. used the German Herniamed registry to perform a propensity score matching study, comparing the Shouldice Repair (n = 2608) to the Lichtenstein (n = 2115), TEP (n = 2225), and TAPP (n = 2400) procedures [3]. Patients who received the Shouldice Repair were mostly young (mean age: 40 years) males with a mean Body Mass Index of 24 kg/m2, and 85% of the defect sizes were not larger than 3 cm. This analysis revealed comparable one-year results between the Shouldice Repair and the Lichtenstein, TEP and TAPP procedures [3]. Based on the Kockerling et al. findings the HerniaSurge group stated in the 2023 updated guidelines that “In selected groups of patients with primary unilateral inguinal hernia repair, the Shouldice technique achieves one-year outcomes comparable to that of Lichtenstein, TEP and TAPP operations providing expertise and competence are available” [2].
However, four of the Shouldice Hospital’s recently published high-volume studies [4‐7] provides data that appears to be comparable to published high-volume registry data on mesh repair [3, 8]. From these four studies there were 27,751 patients who underwent surgery for groin (> 95% inguinal) hernias between 2013 and 2024 [4‐7]. The mean age of these patients ranged from 56.2 years (61–85; n = 25785 [4]) to 62 years (51–70; n = 1120 [6]) and the average Body Mass Index was 25.0 kg/m2. Two of the publications provided ASA information, with most patients having an ASA-Score of II and III [6, 7]. Approximately one third of the patients had a large hernia [4, 6]. One publication revealed a recurrence rate of 1.6% after a median follow-up of 16.5 months (n = 1120) and these recurrences were assessed by phone calls [6]. The findings are summarized in Table 1. They are also comparable to those of high-volume Herniamed registry data on the Lichtenstein procedure (n = 10.555; Body Mass Index: 25.7 kg/m2 (± 15.6); Age 63.2 years (± 15.4); one-year recurrence rate 0.83%) [8].
Table 1
Publications on groin hernia repair at the Shouldice Hospital in comparison to Herniamed data
Author/Year | Study N | Study Type | Study Period | Mean Age (years) | Body Mass Index (Kg/m2) | ASA | Primary Objective |
|---|---|---|---|---|---|---|---|
Spencer Netto/2023 | 25,785 | Retrospective | 2013–2017 | 56.2 (61–85) | 25.0 (14.5–42.9) | NA | Temporal pattern of recurrence |
Mainprize/ 2023 | 414 | Prospective | 2019–2020 | 57.5 (18–86) | 25.1 (17.7–31.9) | NA | Incidence of opioid use and pain |
Paasch/ 2024 | 1,120 | Prospective | 2021–2023 | 62.0 (51–70) | 25.2 (23.6–26.6) | I: 25.3% II: 39.7% III: 34.4% | Recurrence rate |
Mainprize/ 2024 | 500* | Prospective | 2023–2024 | 61.1 (25–89)* | 24.9 (16–34)* | I: 25.2%* II: 43.0%* III:31.8%* | Patient reported outcomes |
Kockerling/2018 | 2,600 | Retrospective | 2009–2015 | 43.7 ± 20.0 | 24.2 ± 3.5 | NA | Patient reported outcomes |
With this in mind and in contrast to the current guideline recommendations it is possible that even older patients with a higher BMI and more concomitant diseases could benefit from a Shouldice Repair.
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Declarations
Conflict of interest
Christoph Paasch, and Marguerite Mainprize declare that they have no conflict of interest.
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