Mesh Free Shouldice Repair FAQsShomaf Nakhjo, DO Advanced Minimally Invasive Surgery

Any inguinal hernia repair, whether robotic, laparoscopic, or the Shouldice Repair can have a high recurrence rate. It all relies on surgeon experience and volume. Simply put, the more a certain procedure is performed the better the outcome. High volume centers like ours have very low recurrence rates (less than 1 percent). That said, both lap/robotic repairs can have the same low recurrence rates if performed at high volume centers. However, the difference is in safety. Unfortunately, disastrous complications can and do happen in laparoscopic/robotic inguinal hernia repairs, even in the best of hands. Major complications are extremely rare in the Shouldice Inguinal Hernia repair.

After several thousand laparoscopic/robotic inguinal repair we have come to realize the mesh free Shouldice inguinal hernia procedure is a superior repair and we have completely switched to it for our inguinal hernia repairs. Lap/robotic isn’t necessarily a bad repair but it is not the best option in our opinion. (see comparison table on main page of our website).

We have been performing the Shouldice Repair for the past 5 years (about 400-500 a year) and we are achieving excellent results. We have no intention of switching back to the lap/robotic approach.

All hernias should be fixed as soon as possible. Not because we fix them for a living but because we see the consequences of delayed repairs. We always say waiting a few weeks to several months is generally ok. However, do not wait years. Reason being that anecdotally we see at least 1 patient a week telling us that they wished they had taken care of it earlier. Many well intended primary care physicians will tell their patients “If it doesn’t bother you leave it alone”. The hernia is now many times bigger, and the patient has less chance of being a candidate for the Shouldice repair and in need of a bigger repair and longer recovery time. Not to mention the risk of incarceration which would necessitate emergency surgery.

If your hernia is symptomatic or appears to be worsening, we recommend purchasing an “Inguinal Hernia Support Belt” to help support and stabilize your hernia. It should be worn anytime while upright and ambulating. Amazon.com or any surgical supply store near you will have one. We always say stay active but listen to your body. If you experience any kind of discomfort, then back down a bit.

Two major differences.

1. We do not use steel sutures for the first 2 layers of our repair. Instead, we use Prolene Suture. It is made of polypropylene, which is easier to use, has a high tensile strength, resistant to infection, elastic and well tolerated in the body.
   In our experience, we have never seen any patient experience issues in the short or long term. However, if a patient is not comfortable with any permanent material in their body, we can perform the procedure entirely with absorbable suture.
2. We do not completely sever the cremasteric muscle. Severing the entire muscle leads to increased risk of the testicle laying too high or too low compared to the other. You may also lose ability to temperature regulate the testicle on that side.
   We instead only sever approximately 20% of the cremasteric muscle. This way no function is lost, and the testicle will lay in a normal position.

A lap/robotic repair will use three 8mm incisions which total about 1-1.5 inches in length. The Shouldice repair is usually performed with a 1.5-2-inch incision, so the difference is negligible.

It is true that both inguinal hernia sides can be repaired at the same time with the same incisions and will probably be less painful in the first day or two after surgery.

The Shouldice Repair would require 2 separate 1.5-2-inch incisions on each side and post operative pain may be slightly higher. However, it is negligible and in the long run inconsequential. Back to work and daily activity are essentially the same.

The important thing to remember is that bilateral lap/robotic inguinal hernia repair requires 2 pieces of mesh, one for each side. Each mesh is 5 x 7 inches. So, a total of 10x14 inches of your pelvis is covered in mesh. It is difficult to say exactly what percent of a pelvis that would cover, but I would estimate it to be at the very least 30%.

Bottom line is, if I personally had 2 inguinal hernias, I would opt to have slightly more pain after surgery with two 1.5-2-inch incisions on each side then have to worry about two large pieces of mesh covering a large percentage of my pelvis the rest of my life with its potential complications.