Address for correspondence: Chin Keung Chan, Shouldice Hospital, 7750 Bayview Avenue, Thornhill, Ontario L3T 4A3, Canada.
E-mail: Gabriel.Chan1@elf.mcgill.ca
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is infiltrated to anesthetize the ilio-inguinal and ilio General anesthesia is generally not required. We
hypogastric nerves prior to opening the inguinal reserve this for operations on multiple recurrent
canal. The internal oblique, superior to the canal is hernias, where local infiltration of scar tissue is
also infiltrated. Later, upon mobilization of the unlikely to provide adequate anesthesia.
spermatic cord, the internal ring, posterior floor and
cremasteric muscle are infiltrated to anesthetize the Inguinal dissection
genital branch of the genital-femoral nerve, found A comprehensive intraoperative examination of the
usually traveling within the cremasteric muscle fibers, inguinal region is performed in all cases. This is
the peritoneum of the indirect sac and the vas
deferens. If further conscious sedation is required A
during the procedure, midazolam and fentanyl can
be administered.
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Figure 5: Reconstruction: the third layer. Starting at the medial side of Figure 6: Reconstruction: the fourth layer. The second layer of
the internal ring, the external and internal oblique are used to imbricate imbrication using the external and internal oblique. The benefit of
the first two layers. Small bites of external oblique are taken just above incising the cribiformis fascia and the mobilization of the lateral flap
the inguinal ligament. of external oblique is realized as a small flap of external oblique
remains after the four layers. This small flap is used to reconstruct the
inguinal canal and restore the natural anatomic position of the cord
integral to attaining a very low recurrence rate. The structures.
frequency of secondary hernias found at the time of
surgery is 15.4%. [6] The assessment should include pubic tubercle, creating two flaps of muscle medial
the direct, indirect, interstitial and femoral spaces. and lateral to the cord [Figure 1]. This maneuver
allows a complete examination of the posterior floor,
The incision is made from 2 cm inferio-medial to the in particular the medial aspect. The larger lateral
ASIS to the pubic tubercle, parallel to the inguinal cremasteric flap, which includes the genital branch,
ligament. This allows generous exposure to both is infiltrated with local anesthetic, as is the internal
inguinal canal and femoral space. Trendelenburgs ring. If a lipoma is present, this is dissected from
position may be used to reduce intra-abdominal the cord towards the internal ring and excised. This
pressure, facilitating the repair. facilitates identification of the indirect sac in its typical
antero-medial position. An indirect sac should be
Dissection is deepened to expose the external oblique isolated from the cord and internal ring and excised.
fascia and superficial inguinal ring. Local anesthesia The stump should retract naturally into the peritoneal
is required at this point prior to opening the canal. cavity. Some surgeons choose only to reduce the sac
Care is required to identify and avoid injury to the to avoid peritoneal irritation and discomfort. Care
ilio-inguinal and ilio-hypogastric nerves. Their course should be taken if the sac is thicker, contains more
usually runs deep to the external oblique, superior fat than usual or is broad based, as this may be an
to the deep ring and superficial to the cord structures. indication of a sliding hernia. These are reduced and
Infiltration of the internal oblique muscle superior not opened. If a sac is not identified, the dissection
to the canal can provide anesthesia for the internal of the cord at the internal ring must identif y a
oblique and peritoneum used later in the peritoneal protrusion, which can be aided by gentle
reconstruction. If the nerves are traumatized at any traction on the cord. The identification of this
point, we do not hesitate to resect the damaged structure, which is in its normal anatomic position,
segments to avoid neuropathy postoperatively. The assures the surgeon that the indirect hernia has not
resultant numbness after nerve resection is not been missed. After complete dissection of the cord,
usually of any clinical significance. both flaps of the cremasteric muscle are divided
sharply and ligated. These stumps are used to support
The spermatic cord is isolated by a longitudinal the repair at a later point in the procedure.
anterior opening in the cremasteric muscle fibers at
the midpoint of the canal extended medially to the The posterior wall of the inguinal canal is examined
Journal of Minimal Access Surger y | September 2006 | Volume 2 | Issue 3 126
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Chan et al.: Shouldice technique for treatment of inguinal hernia
for a direct hernia then opened beginning at the layer. The superior flap of transversalis fascia is
internal ring in parallel to the internal oblique muscle sutured to the shelving portion of the inguinal
fibers. Care should be taken not to injure the inferior ligament then tied at the pubic tubercle [Figure 4].
epigastric vessels found medial to the internal ring. The periosteum should not be included in any bite
The lateral flap should be wide enough, at least 1 as this can result in a painful osteitis.
cm, to reach the edge of the rectus sheath in the first
layer of the repair. Any redundant transversalis fascia The next stage of reconstruction creates a two-layered
of a direct hernia should be excised. Preperitoneal imbrication to provide reinforcement. The layer is
examination of the internal oblique muscle and fascia begun superior and slightly lateral to deep ring,
cephalad to the internal ring and the inguinal canal, anchoring the suture to the internal oblique fascia.
should confirm the presence of an interstitial hernia. The inferior flap of the external oblique, millimeters
If present, the internal ring can be incised laterally above and parallel to the inguinal ligament, is tacked
to include an interstitial defect. The internal ring to the edge of the internal oblique and transversus
would then be displaced laterally after reconstruction. muscles [Figure 5]. In addition, only a small bite of
Dissection below the inguinal ligament should the internal oblique is required, no more than 5 mm.
identif y Coopers ligament and thus confirm the Excessively large bites will create tension. At the pubic
presence or absence of a femoral hernia [Figure 2A]. tubercle, the direction is reversed for the fourth layer
The superficial thigh fascia or cribiformis fascia caudal and taken back to the internal ring and affixed [Figure
to the inguinal ligament should be incised to examine 6]. The importance of mobilizing the inferior flap of
the femoral space from below [Figure 2B]. In addition, external oblique by previously incising the superficial
this mobilizes the inguinal ligament and external thigh fascia is realized here. The additional mobility
oblique for use in the reconstruction. allows the external oblique to be used in the third
and fourth layers to cover the medial portion of the
Reconstruction repair that is susceptible to recurrence. The inguinal
A continuous repair with 32-34 gauge stainless steel canal is reconstructed by re-approximating the
wire is used for the reconstruction. This may be remaining external oblique fascia, returning the cord
substituted with a 3-0 polypropylene suture. It is a to its anatomical position. The inferior stump of the
four-layer tissue reconstruction using two separate medial flap of cremasteric muscle is included in the
sutures. A continuous technique distributes the first suture medially to stabilize the position of the
strength of the repair evenly and should be without testes to the abdominal wall and prevent drooping.
tension. A relaxing incision is rarely required.
Postoperative course
The first two layers represent an overlapped In the postoperative care, oral narcotic analgesia is
reconstruction. It begins medially, anchoring over the usually required during the first 48 h. Ambulation is
pubic tubercle, leaving a sufficient end to tie the encouraged the evening after the operation and light
returning suture after the second layer. The infero exercises commence the first postoperative day. Upon
lateral flap of transversalis fascia is sutured to the discharge, heavy lifting can be resumed at 4 weeks.
lateral edge of the rectus sheath by reaching
underneath the superior-medial flap [Figure 3A]. The CONCLUSION
reconstruction then moves laterally to the
aponeurosis of the transversus abdominis and the The Shouldice technique is a comprehensive treatment
edge of the internal oblique muscle. The lateral extent plan for inguinal hernias based on the extensive
of this layer redefines the internal ring and should experience at the Shouldice Hospital. Thorough
include the superior stump of the divided lateral flap knowledge of inguinal anatomy and pathology is
of cremasteric muscle [Figure 3B]. This buttresses the essential to achieving optimal results. Addressing all
internal ring and helps prevent an indirect recurrence. factors involved in hernia development and
The suturing is then reversed to begin the second recurrences should be incorporated into the routine
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