Doctors undergoing inguinal hernia repair with the three-layer Shouldice technique: The PRO*Shouldice retrospective cohort study

Abstract

PURPOSE: The Shouldice method has shown promising outcomes in reconstruction of the inguinal canal without mesh. However, measuring actual recurrence rates is difficult in clinical practice. Some studies have been applying algorithms based on Patient-Reported Outcomes (PRO) to facilitate the detection of recurrence. The aims of this study were to assess the medium- to long-term recurrence rate of the three-layer Shouldice technique in a population composed solely of doctors, validate the PRO questionnaire compared to clinical examination and ultrasound, and measure the patients’ degree of satisfaction.

MATERIALS AND METHODS: This retrospective cohort study investigates the medium- to long-term outcomes of the three-layer Shouldice technique, with a minimum follow-up of 12 months postoperatively. Patients were evaluated by comparing clinical examination results, PRO questionnaire, and ultrasound.

RESULTS: Sixty-one patients comprising 76 hernias underwent primary inguinal hernia repair with a minimum follow-up of 12 months. Results indicate a low recurrence rate of 1.3%, with one patient requiring reoperation after 18.5 years. Self-perception of recurrence through the PRO questionnaire correlated well with clinical examination findings. Ultrasonographic evaluation detected incidental findings in three cases, highlighting the selective role of imaging in postoperative care. Patient satisfaction, assessed by the Net Promoter Score (NPS), was notably high, at 96, underscoring the procedure’s acceptability among this cohort.

CONCLUSION: Overall, the three-layer Shouldice technique demonstrates comparable efficacy to that of standard methods, with minimal complications and high patient satisfaction, suggesting its viability as a suitable alternative in inguinal hernia repair.

Keywords

Herniorrhaphy / inguinal hernia / patient-reported outcomes / recurrence rate / Shouldice repair

References

[1] Murphy BL , Ulb DS , Zhang J , Habermann EB , Farley DR , Paley K , et al. Trends of inguinal hernia repairs performed for recurrence in the United States. Surgery 2018; 163: 343- 50.

[2] Tervaert JWC , Martinez-Lavin M , Jara LJ , Halpert G , Watad A , Amital H , et al. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) in 2023. Autoimmun Rev 2023; 22: 103287.

[3] Welsh DRJ , Alexander MAJ . The Shouldice repair. Surg Clin North Am 1993; 73: 451- 69.

[4] Malik A , Bell CM , Stukel TA , Urbach DR . Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg 2016; 59: 19- 25.

[5] Bendavid R . Re: Recurrence of inguinal hernias repaired in a large surgical specialty hospital in Ontario, Canada. Can J Surg 2016; 59: E3.

[6] Agarwal D , Sinyard RD , Ott L , Reinhorn M . Primary tissue repair for inguinal hernias — the Shouldice repair technique and patient selection. Surg Clin N Am 2023; 103: 859- 73.

[7] Berliner SD . An approach to groin hernia. Surg Clin North Am 1984; 64: 197- 213.

[8] Kux M , Fuchsjäger N , Schemper M . Shouldice is superior to Bassini inguinal herniorrhaphy. Am J Surg 1994; 168: 15- 8.

[9] Schumpelick V , Tittel A . Shouldice repair. In: Schumpelick V, Arlt G, Conze J, Junge K, editors. Hernia Surgery, 5th ed. Thieme: Stuttgart; 2019. p. 107- 11.

[10] Simons MP , Smietanski M , Bonjer HJ , Bittner R , Miserez M , Aufenacker TJ , et al. The Hernia surge group International guidelines for groin hernia management. Hernia 2018; 22: 1- 165.

[11] Stabilini C , van Veenendaal N , Aasvang E , Agresta F , Aufenacker T , Berrevoet F , et al. Update of the international HerniaSurge guidelines for groin hernia management. BJS Open 2023; 7: zrad080.

[12] Lorenz R , Arlt G , Conze J , Fortelny R , Gorjanc J , Koch A , et al. Shouldice standard 2020: Review of the current literature and results of an international consensus meeting. Hernia 2021; 25: 1199- 207.

[13] Szasz P , Spencer Netto F ; Shouldice Hospital . Shouldice Hospital comments on “Shouldice standard 2020: Review of current literature and results of an international consensus meeting. Hernia 2021; 25: 1375- 6.

[14] Hawn MT , Itani KM , Giobbie-Hurder A , McCarthy M , Jonasson O , Neumayer LA . Patient-reported outcomes after inguinal herniorrhaphy. Surgery 2006; 140: 198- 205.

[15] Baucom RB , Ousley J , Feurer ID , Holzman MD , Sharp KW , Poulose BK , et al. Patient reported outcomes after incisional hernia repair: Establishing the ventral hernia recurrence inventory. Am J Surg 2016; 212: 81- 8.

[16] Melo RM , Cozadi AO , Matias IS , Moreira CC . Modified shouldice technique in primary groin hernia repair. Rev Col Bras Cir 1998; 25: 167- 71.

[17] Reichheld , Frederick F . The One Number you Need to Grow. Brighton: Harvard Business Review; 2008.

[18] Robinson P , Hensor E , Landsdown M , Ambrose NS , Chapman AH . Inguinofemoral hernia: Accuracy in patients with indeterminate clinical features. Am J Roentgenol 2016; 187: 1168- 78.

[19] Chiu MK , Hadied MO , Klochko C , van Holsbeeck MT . Comparison of patient characteristics and treatment approaches for femoral and inguinal hernias utilizing dynamic ultrasound at a single institution. Hernia 2023; 27: 1245- 52.

[20] Plumb AA , Rajeswaran G , Abbasi MA , Masci L , Warren O , Wilson J . Contemporary imaging of inguinal hernia and pain. Br J Radiol 2022; 95: 20220163.

[21] Liu N , Prout TM , Xu Y , Smith J , Funk LM , Greenberg JA , et al. Unnecessary use of radiology studies in the diagnosis of inguinal hernias: A retrospective cohort study. Surg Endosc 2021; 35: 4444- 51.

[22] Ridha H , de Vries RPH , Nijholt IM , Abbes S , Boomsma MF , Nijveldt RJ . Positive predictive value of ultrasound in correctly identifying an inguinal hernia: A single-centered retrospective pilot study. Insights Imaging 2022; 13: 133.

[23] Turaga K , Fitzgibbons RJ , Puri V . Inguinal hernias: Should we repair? . Surg Clin North Am 2008; 88: 127- 38, ix.

RIGHTS & PERMISSIONS

International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow on behalf of Higher Education Press