Ultrasound-guided ilioinguinal-iliohypogastric nerve block with local anesthesia and fentanyl analgesia versus local anesthesia and fentanyl analgesia prior to Shouldice inguinal hernia repair in adults: a retrospective matched-pair analysis among 100 individuals.

PURPOSE: There is limited research on the impact of an ilioinguinal-iliohypogastric nerve block on intraoperative opioid consumption when conducting groin hernia repair in adults. Thus, the aim was to evaluate ilioinguinal-iliohypogastric nerve block for groin hernia patients at Shouldice Hospital. METHODS: The study was a pilot retrospective chart review on patients who underwent a Shouldice Repair from November 2023 to December 2023. This study compared individuals receiving an ilioinguinal-iliohypogastric nerve block with local anesthesia and fentanyl analgesia to those who received local anesthesia and fentanyl analgesia, by manually matching 1:1 on 12 demographic and intraoperative characteristics. Comparison between groups was performed using chi-square/Fisher Exact test for categorical and t-test/Mann-Whitney test for numerical variables depending on data distribution. Multivariable regression analysis was used to examine predictors of intraoperative use of fentanyl. RESULTS: In this study 50 matched pairs of unilateral primary inguinal hernia patients were analyzed. The ilioinguinal-iliohypogastric nerve block patients had lower recorded intraoperative fentanyl (85mcg less than control, p < .001) and dimenhydrinate (13 mg less than control, p < .001) than the control group patients. No differences were found in postoperative day 0 to 3 for acetaminophen, non-steroidal anti-inflammatory drug, and opioid consumption between the patients who did receive an ilioinguinal-iliohypogastric nerve block prior to surgery and those that did not. CONCLUSION: The administration of an ilioinguinal-iliohypogastric nerve block prior to primary inguinal hernia repair using a Shouldice Repair is associated with a significantly lower intraoperative fentanyl consumption compared to non-administration.

How to Article: Prehabilitation and postoperative treatment at Shouldice Hospital.

Shouldice Hospital has grown beyond its beginnings in the 1940s to become a leading centre of excellence for mesh-free hernia repair. Little is known to the international surgical community about the preoperative and postoperative care at Shouldice Hospital, and colleagues working at Shouldice Hospital have been repeatedly asked to provide more details at international and national congresses. Therefore, this article aims to summarize preoperative and postoperative care at Shouldice Hospital based on previously published literature. The authors believe that the long-standing tradition of prehabilitation and postoperative treatment may play a role in facilitating patient satisfaction and superior postoperative results after hernia surgery.

Inguinal hernia: Lichtenstein VS Shouldice technique repair: A randomized controlled trial.

Background: Inguinal hernia repair is the most frequent operation in general surgery. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27 % in men and 3 % in women. European Hernia Society guidelines state that the Lichtenstein technique (mesh-based repair) is the standard treatment of elective inguinal hernia in adults. Some authors consider the Shouldice technique (tissue-based repair) the best conventional method for open hernia repair. In this study, we compared these two methods. Methods: In This randomized study, 452 patients were randomly allocated into 2 groups. 51 patients were lost during follow-up period and were excluded from further analysis in the study. Finally, the analyzed patients were 183 patients in Shouldice technique group and 218 patients in Lichtenstein technique group. All patients were examined after 1 week, 1, 3 months, 1, 2, and 3 years after the operation date. Results: After 3 years follow up Recurrence of hernia in Shouldice technique group was 7.1 % and in Lichtenstein technique group was 3 % with significant differences (p-value 0.006). No statistically significant differences were found between the groups in wound infection, Seroma, hematoma, Hydrocele, Bladder damage, chronic pain in the inguinal region, and Patient Satisfaction level after surgery. Conclusion: It seems that inguinal hernia treatment by the Lichtenstein technique is better than the Shouldice technique in elective patients.

Temporal patterns for inguinal hernia recurrence operations after Shouldice Repair.

PURPOSE: Shouldice Repair for inguinal hernias results in a low recurrence rate; however, little is known about the risk factors for these relapses. In the present study, we reviewed all patient's undergoing a reoperation for recurrence after a primary Shouldice Repair. METHODS: Patients undergoing recurrent inguinal hernia repair from 2013 to 2017 were identified. The subgroup of patients with the first recurrence after a Shouldice Repair at this institution was selected and included. Data collection from the index and the reoperation surgery were performed, as well as statistical analysis. RESULTS: A total of 125 patients were included in the analysis. The mean age was 50.8 ± 13.9 (body mass index: 24.6 ± 2.6 kg/m2), 97% were male. The most common interval for a recurrence reoperation was in the first 5 years following the initial surgery (37.6% of patients; mode: 1 year; median: 7 years; mean: 13.7 ± 13.8 years). A temporal median pattern for recurrence reoperation according to age interval was noted (patients < 41 years old: 20 years; patients aged 41-60 years old: 10 years and patients > 61 years: 2 years)). CONCLUSION: Patients undergoing reoperations for recurrent inguinal hernias after a primary Shouldice Repair presented a pattern of temporal recurrence according to age. Older patients present with earlier recurrences than younger ones, an important consideration in the assessment of patients postoperatively.

Open preperitoneal inguinal hernia repair has superior 1-year patient-reported outcomes compared to Shouldice non-mesh repair.

INTRODUCTION: The Shouldice method for inguinal hernia repair remains the gold standard for prosthesis-free repairs. Nonetheless, international guidelines have favored posterior mesh reinforcement as the standard of care for inguinal hernia repair due to lower risk of recurrence and chronic pain, avoidance of general anesthesia, and favorable biomechanical properties. Recent publications have shown the benefits of an open approach to posterior repairs. Herein, we use the Abdominal Core Health Quality Collaborative (ACHQC) registry to compare patient-reported outcomes after a Shouldice no-mesh repair versus open preperitoneal (OPP) mesh repair. METHODS: We performed a propensity score matched analysis to compare patient-reported quality of life (QoL) and peri/postoperative outcomes after a Shouldice repair versus OPP. Data from 2012 to 2022 were obtained from the ACHQC, and 1:1 optimal matching was performed. EuraHS scores were used to estimate QoL, and further analysis on the EuraHS domains of pain, aesthetics, and activity restriction were performed between the two cohorts. RESULTS: Matching resulted in 257 participants in each, Shouldice and OPP cohorts. OPP was associated with a better QoL score compared to Shouldice at 30 days after surgery (Median (IQR) 7.75 (2.0-17.0) vs 13.0 (4.0-26.1); OR 0.559 [0.37, 0.84]; p = 0.003). This difference persisted at 6 months and 1 year postoperatively (OR 0.447 [0.26, 0.75] and 0.492 [0.26, 0.93], respectively). We did not observe any significant differences in hernia recurrence risk at 1-year, or rates of 30-day SSOs/SSIs, postoperative bleeding, peripheral nerve injury, DVTs, or UTIs. CONCLUSION: Our data suggest that OPP is associated with significantly better patient-reported QoL, in the first month after surgery and up to 1 year postoperatively, especially with respect to lesser pain, when compared to the Shouldice repair. In specialized inguinal hernia practices, open posterior mesh repairs may lead to better outcomes than non-mesh repairs. We encourage more training in both repairs to facilitate larger prospective studies and evaluation of the generalizability of these results to all surgeons performing IHR.

Primary Tissue Repair for Inguinal Hernias: The Shouldice Repair Technique and Patient Selection.

It is estimated that approximately one in four men and one in 20 women will develop an inguinal hernia over the course of their lifetime. A non-mesh inguinal hernia repair via the Shouldice technique is a unique approach that necessitates dissection of the entire groin region as well as careful assessment for any secondary hernias. Subsequently, a pure tissue laminated closure allows the repair to be performed without tension. Herein, the authors describe a brief overview of inguinal hernias and discuss the relevant patient evaluation, operative steps of the Shouldice procedure, and postoperative considerations.

The Shouldice Method: an expert's consensus.

BACKGROUND: Hernia repairs are a commonly performed surgical procedure and the Shouldice Repair of inguinal hernias has been well described before in terms of its outcomes. However, the purpose of this paper was to understand what experts from Shouldice Hospital consider to be the essential steps to the Shouldice Method. METHODS: Utilizing a Delphi Methodology, surgeons at Shouldice Hospital who are considered content experts, provided their answers on what is essential to the Shouldice Method. The median, interquartile range, and percent agreement from the responses as well as the Delphi's overall Cronbach's Alpha were determined. All Delphi items were ranked on a five-point Likert scale and consensus was reached when Cronbach's Alpha was ≥ 0.8. The items from the survey that ranked as 5-completely agree or 4-partially agree by ≥ 80% of participants on the five-point Likert scale were included in the final framework. RESULTS: The final consensus for the Shouldice Method included 39 items with 7 overarching steps: preoperative preparation of the patient, anesthetic component, incision and nerve identification, treatment of the cremasteric muscles, hernia identification and treatment, reconstruction of the posterior wall, and post-operative management of patients. CONCLUSION: The results of this consensus provide a step-by-step approach to the Shouldice Method, as well as information that is timely and can be utilized by surgeons incorporating non-mesh hernia repairs into their practice.

Results of Shouldice hernia repair after 18 years of follow-up in all the patients.

PURPOSE: Evaluate the long-term efficacy of the Shouldice technique performed by non-specialized surgeons and also to reflex on the quality parameters necessary to safely assess hernia recurrence rates. METHODS: During 3 years, a prospective study was conducted in 243 adult men who underwent surgery for primary inguinal hernias by 13 junior surgeons with an interest in hernia surgery. Using local anesthesia, a classic 4 step Shouldice repair, with polypropylene or polyester, was performed. All patients were followed for 18 years. The follow-up met the nine quality criteria proposed by the authors. RESULTS: At 18 years, 80.2% of patients were followed and only 6.5% were lost. There were 7 recurrences in the first 10 years, 5 of them secondary to a direct hernia, and the same after 18 years. The recurrence rate was 2.88%. Tolerance of the local anesthesia was excellent in 91.4%of patients and, after 3 years, the pain was considered moderate or severe in 4 patients (1.8%). CONCLUSIONS: It is necessary to incorporate more demanding criteria in the assessment of recurrence, to give more valid results. The Shouldice technique remains a useful technique today not only in patients under 30 years of age, and in the absence of risk factors, but also in cases of intolerance, patient rejection or absence of mesh. In addition, it provides the clinical and economic advantages of being possible to perform it under local anesthesia.

Shouldice standard 2020: review of the current literature and results of an international consensus meeting.

INTRODUCTION: For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair has been proven to entail better results in randomized trials. Since the first publication 1953 the Repair has been described in detail in many textbooks, articles and You Tube videos. It appears that the original technique is used almost exclusively in the Shouldice Hospital in Thornhill/ Canada and despite the success of the Shouldice Hospital many surgeons inexplicably modify this original technique in their daily practice. In the last couple of years there appears to be an increasing interest in pure tissue repairs for various reasons, often fear of mesh-related pain. The aim of the study was to review the current evidence and to define an updated standard with key principles of the Shouldice repair. METHODS: Because of unpublished evidence regarding many operative details the organizing group decided to create a technical update via a consensus meeting with 13 international designated hernia surgeons from six countries. In preparation of the meeting a review of the current literature regarding Shouldice repair was done by the organizing group. A questionnaire was prepared and sent to all participants before the meeting to get an independent answer on all critical aspects. RESULTS: All questions regarding a detailed standard of the operation technique could be outlined. As result of the consensus meeting the participants have formulated all key-points of preparation/dissection and repair of the Shouldice technique. For 5 of 6 critical technical surgical steps a strong consensus could be defined in the group. There was no consensus among the group regarding the cremaster resection and the ideal indication for Shouldice repair. CONCLUSION: After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.

Tipp versus the Lichtenstein and Shouldice techniques in the repair of inguinal hernias - short-term results.

OBJECTIVE: The Lichtenstein mesh technique is recommended as the standard surgical procedure for inguinal hernias. Shouldice is the best non-mesh technique. However, there are reports that the transinguinal preperitoneal technique (TIPP), which uses a preperitoneal mesh, has potential advantages in relation to the Lichtenstein and the Shouldice techniques. PATIENTS AND METHODS: Three hundred patients with inguinal hernias were randomized into three groups of hundred patients each: Group 1 whose inguinal hernia repair was performed using the Lichtenstein technique; Group 2 using the Shouldice technique; and Group 3 using TIPP. The parameters for monitoring were: length of operation, blood loss, length of hospitalization, length of incision, post-operative pain, and the patient's satisfaction level. RESULTS: The visual analog scale (VAS) score after 6, 12, 24 and 48 h, and 14 d was lower in TIPP than the Lichtenstein and Shouldice groups (p < .0001). The satisfaction level was higher in TIPP than in the Lichtenstein and Shouldice groups (p < .0001). CONCLUSIONS: TIPP technique has advantages in comparison with the Lichtenstein and Shouldice techniques. This method takes a shorter time, the skin incision is smaller, the VAS score is lower and the patient satisfaction level is higher. These advantages are in balance with the higher costs of this procedure.

Primary unilateral not complicated inguinal hernia: our choice of TAPP, why, results and review of literature.

BACKGROUND: Currently, three different techniques are favored for repair of an inguinal hernia: (1) The suture repair described by Shouldice. (2) An open mesh repair according to Lichtenstein. (3) Laparo-endoscopic techniques TAPP and TEP. The aim of the presented paper was to describe the ranking of the Transabdominal Preperitoneal Patch Plasty (TAPP) in comparison to the other techniques for inguinal hernia repair. METHODS: The manuscript is based on the experiences gained in more than 15,000 TAPPs and numerous own studies as well. The technique of TAPP is described in detail and also the results which can be achieved with special reference to primary unilateral inguinal hernias in male patients. Moreover, a systematic review of the literature is done for the comparison with the other techniques. RESULTS: According to own experiences, 98% of all patients with an inguinal hernia admitted for surgery to Marienhospital Stuttgart could be operated on using the TAPP technique. The recurrence rate and the rate of severe chronic pain in this setting were below 1%. Due to the limited quality of most of the published studies an evidence-based comparison which is the best of the currently most recommended techniques is questionable. Therefore, when comparing TAPP with TEP, no definite conclusion about superiority of one technique over the other is possible. Both techniques are safe and effective if properly performed. The guidelines recommend that the surgeon should use the technique he had learned best and is familiar with. The comparison between TAPP and the Shouldice repair shows less pain and a higher effectivity after TAPP. The recurrence rate after Lichtenstein repair and after TAPP is similar, but pain and recovery time are significantly less after TAPP. CONCLUSION: Analyzing the own abundant experiences and the reports in the literature, the TAPP technique has the potential to become the standard operative technique for repair of inguinal hernias in future. However, due to the low level of evidence of most of the studies definite conclusions are difficult to draw at this point of time.

Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Outcomes and Predictors of Complications.

BACKGROUND: The robotic approach to an inguinal hernia has not been compared head to head with the open and laparoscopic techniques in randomized controlled trials. Furthermore, long-term outcomes for robotic inguinal hernia repair (RHR) are lacking. In this study, we compared laparoscopic inguinal hernia repair (LHR) and RHR with open inguinal hernia repair (OHR) in veteran patients performed by surgeons most familiar with each approach. METHODS: A retrospective single-institution analysis of 1299 inguinal hernia repairs performed at the VA North Texas Health Care System between 2005 and 2017 was undertaken. Three surgeons performed the operations, each an expert in one approach, and there was no crossover in techniques. A total of 1100 OHRs, 128 LHRs, and 71 RHRs were performed. Univariable analysis was undertaken to determine associations between techniques and outcomes (OHR versus LHR; OHR versus RHR; LHR versus RHR). Setting complications as a dependent variable, multivariable analyses were undertaken to determine an association with complications as well as independent predictors of complications. RESULTS: Patient demographics were similar among groups except for age that was higher in the OHR cohort. The average follow-up was 5.2 ± 3.4 y. In the present report, recurrence was associated with a higher rate in the RHR versus OHR (5.6% versus 1.7%; P < 0.02), but not in the LHR versus OHR (3.9% versus 1.9%; P = 0.09). Inguinodynia was more likely to occur in both the LHR and RHR compared with the OHR (9.4% and 14.1 versus 1.5%; both P's < 0.001). Urinary retention was also more common in the LHR and RHR than in the OHR (5.5% and 5.6% versus 1.8%, both P's < 0.05) as was the rate of overall complications (34.4% and 38.0% versus 11.2%, both P's < 0.001). Multivariable regression analysis showed femoral hernias, ASA, serum albumin, operative room time, a recurrent hernia, and the minimally invasive approaches were independent predictors of overall complications. CONCLUSIONS: Outcomes in the OHR cohort were, in general, superior compared with both the LHR and RHR. However, these strategies should be viewed as complementary. The best approach to an inguinal hernia repair rests on the specific expertise of the surgeon.

Is Shouldice the best NON-MESH inguinal hernia repair technique? A systematic review and network metanalysis of randomized controlled trials comparing Shouldice and Desarda.

BACKGROUND: Current guidelines state that the Shouldice technique has lower recurrence rates than other suture repairs and therefore is strongly recommended in non-mesh inguinal hernia repair. Recently a new tissue repair technique has been proposed by Desarda and studied in trials against Lichtenstein technique. METHODS: The present study was performed according to the PRISMA Statement for Network Meta-analysis and the AMSTAR 2 checklist. The method of network meta-analysis was chosen to evaluate randomized controlled trial published on tissue repair and comparing Lichtenstein respectively with Desarda and Shouldice techniques. The following parameters: operative time, recurrence, complications (general, intraoperative, Surgical Surgical Site Occurrences), VAS score on postoperative day 1, numbness, chronic pain and return to daily activities. RESULTS: Fourteen RCTs, involving 2791 patients, fulfilled the inclusion criteria and were selected for final analysis. The anchored indirect treatment comparison showed that Desarda's technique requires a significantly shorter operative time (MD: -12.9 min; 95% CI: -20.6 to -5.2) and has a quicker recovery (MD: -6.6 days; 95% CI: -11.7 to -1.4). Outcomes concerning intraoperative complications, early postoperative pain, seroma/hematoma, hydrocele and infection rates, recurrence, numbness and chronic pain were similar among the two techniques. CONCLUSIONS: Desarda's hernia repair can be a valuable alternative to Shouldice technique for the treatment of primary inguinal hernia repair if a non-mesh technique is chosen, because of its reproducibility and quicker postoperative recovery. We recommend performing well designed prospective studies comparing both techniques directly.

Inguinal Hernia: Four Open Approaches.

Open inguinal hernia approaches are varied. The best studied approaches are reviewed herein. The common factor among them is the imperative anatomy knowledge of the surgeon. This knowledge is key to improved outcomes. A tailored approach is best to determine which open technique, if any, is most appropriate for the patient. Although the anterior mesh approach is the most commonly applied, there is support in using the posterior approach or a tissue repair for subsets of patients, such as women.

International guidelines for groin hernia management.

INTRODUCTION: Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. METHODS: An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. CONCLUSIONS: The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Retorno ao trabalho após herniorrafia inguinal convencional com prótese e sem prótese,por videolaparoscopia / Return to work activities after conventional inguinal hernia repair with prosthesis or not, and by laparoscopy

Este estudo tem como objetivos avaliar e comparar o tempo de afastamento das atividades laborais necessário para a recuperação de pacientes submetidos à hernioplastia inguinal por via convencional ? com prótese ou não, por via laparoscópica. Foi realizada revisão da literatura e análise de resultados de diversos artigos que tratam do tema. As médias ponderadas referentes a herniorrafias por inguinotomia foram comparadas com as de herniorrafias laparoscópicas. Observou-se redução de 39% no tempo para que os pacientes submetidos a cirurgia laparoscópica retornassem às atividades laborais quando comparados àqueles operados com a técnica convencional.

The objective of this study is to evaluate and compare the time away from work for the recovery of patients who have undergone inguinal hernioplasty by conventional technique ? with or without use of synthetic prosthesis, to that needed by those who have been submitted tolaparoscopic herniorrhaphy. A literature review and analysis of the results from several articles on the subject were conducted. Weighted averages related to open hernia repair were compared with data from laparoscopic hernia repair. Patients who had undergone laparoscopic surgery needed 39% less time to return to work, as compared with those submitted to theconventional technique.

The Shouldice technique for the treatment of inguinal hernia.

The Shouldice repair has been refined over several decades and is the gold standard for the prosthesisfree treatment of inguinal hernias. A recurrence rate around 1% has been consistently demonstrated over the years. The objective of this paper is to outline and highlight the key principles, including the dedicated pre-operative preparation, the use of local anesthesia, a complete inguinal dissection and the eponymous four-layered reconstruction. A knowledge and understanding of inguinal hernia anatomy and the patho-physiology of recurrence are vital to achieving a long-term success and patient satisfaction for a pure tissue repair.

A COMPARATIVE STUDY OF REPAIR OF INGUINAL HERNIAS BY SHOULDICE TECHNIQUE VIS-A-VIS BASSINIS TECHNIQUE.

A comparative study of repair of inguinal hernias by Shouldice technique (ST) vis-a-vis Bassinis technique (BT) was conducted on 100 patients who presented with inguinal hernia in the OPD services of our hospital. The patients were worked up and alternatively distributed to undergo repair by ST (n=50) or BT (n=50). Repair by ST required longer operating time (Avg 95 min vs 80 min), but involved lesser hospitalization (4.0 days vs 4.5 days), lesser complication rate (2 vs 4), lesser recurrence rate (0 vs 2) and higher rate of satisfaction. The study confirms the advantages of Shouldice repair in the treatment of inguinal hernia.

Outcome after Mesh or Shouldice Herniorrhaphy

BACKGROUND: Inguinal herniorrhaphy remains one of the most common general surgical operations. Mesh repair is advocated by several specialized hernia centers. The purpose of this study was to compare results of mesh and Shouldice repair for inguinal herniae. METHODS: A clinical review was made of 73 cases of inguinal herniae treated during the 3 years from January 1993 to December 1996 at the Department of Surgery, Dae Rim Saint Mary's Hospital, and at the Department of Surgery, Eum Sung Saint Mary's Hospital. We treated 38 patients with mesh repair and 35 patients with a Shouldice procedure. Among 73 cases, 72 cases were males and only one case was a female. All except 8 cases had indirect types of hernias. RESULTS: Mesh repair required less time (80 minutes) and was an easier operative technique than the Shouldice procedure (95 minutes), but postoperative pain was similar between the two procedures. Postoperative pain was relieved after one week in 60% of the patients and after four weeks in 88% of the patients. The complications following the operations were similar between the two procedures: voiding difficulties developed in two cases, wound infection in one case, and a hematoma in two cases. There were no recurrences during the 6 month to 3 year follow up. CONCLUSIONS: Inguinal herniorrhaphy using a mesh repair technique provides is simple, rapid, less painful, and effective.