Annals of the Royal College of Surgeonis of Englatnd (I976) lol 58
ASPECTS OF TREATMENT*
Short-stay surgery (Shouldice technique) for repair of inguinal hernia Frank Glassow
FRCS
FRCS(C)
Shoildice Hospital, Toronto
Summary Short-stay surgery for inguinal hernia repair uising the Shouldice technique, with local anaesthesia in the great majority of cases, has achievled a recuirrence rate of less than i/% in the repair of both primary and recurrent inuzinal hernia. A personal series of 14 982 consecutive in guinal herniorrhaphies performed during a 2 I-year period with an overall recurrence rate of 0.60%, using the Shouldice technique exclusively, is documented and discussed in some detail. The results sug.gest that the adoption of these methods on a national scale would result in a saving to the economy of many millions of pounds.
Introduction In a recent paper entitled 'The scope and safety of short-stay surgery in the treatment of groin herniae and varicose veins' Doran et al.' emphasize the economic aspects of the treatment of these cases. In Britain in 1972 1 1 7 ooo hernia repairs were performed, representing 12.5%° of the total surgical admissions to general hospitals. In the USA, wvith approximately four times the population, 6oo ooo hernia repairs were performed in Iq64. The average length of stay in the Birmingham area in 1972 for a patient undergoing a hernia repair was 10.2 days. The national figutre for the USA in a recent survey was 5.7 days. The enormous economic and social implications of these figures are obvious. Gaster2 has estimated that the total amount of work loss from hernias in the USA in ig6o was io million days. If either the period of hospital stay or the period of absence from work after
discharge from hospital were shortened or, better still, if both were, then the resulting savings from a personal and a community viewpoint would be considerable, while the savings to the national economy would be immense and measurable in many millions of pounds. Doran et al. suggest that a hospital stay of 48 h might eventually prove perfectly satisfactory. Farquharson3 in Scotland in 1955 performed 485 inguinal repairs successfully on otutpatients. In the USA Gaster2, Lichtenstein4, and Bellis5 discharge their patients 24 h after operation or even earlier. Palumbo' has adduced compelling statistical evidence to suggest that early ambulation and short hospital stay are associated with both a diminished morbidity rate and a lowering of the incidence of complications, including the recurrence rate. He demonstrated convincingly that patients who were ambulatory on the day of operation or on the first postoperative day developed significantly fewer immediate complications and had a lower recurrence rate than those who were ambulatory from the 3rd to the gth postoperative days, while a third group, ambulatory after the ioth postoperative day, had even poorer results in this regard. Short-stay surgery for repair of inguinal hernia, with immediate ambulation, has been practised at the Shouldice Hospital, Toronto, since I945. The great majority of patients remain for 72 h after operation, though the occasional patient is discharged after 48 h. The intention of this article is to demonstrate that, using a standardized technique for the repair, a slhort hospital stay and an early return to normal activity are compatible with
*Fellows and Members interested in submitting papers for consideration with publication in this series should first writc to the Editor.
a
view
to
134
Frank Glassow
a low recurrence rate. The only patients admitted to this hospital are those who have external abdominal hernias or allied conditions such as hydroceles and epididymal cysts. The operation is performed under local anaesthesia in 95°0/ of cases. The patient walks to the operating theatre from the recovery room and then back again after the operation. He is ambtulant throughout his short hospital stay. He is discharged without a dressing on the incision, all Mlichel's clips having been removed. Bilateral hernia repairs are staged 48 h apart. Postoperative complications are minimal, catheterization is eliminated, and the postoperative wound infection rate is now less than I%. The patient frequently drives his own car home and many return to work the following week. For a patient whose work involves strenuous physical activity a period of not more than 4 weeks before return to work may be recommended. A vigorous follow-up plan is essential to assess long-term results. A continuous and strenuous effort is made to follow up all cases annually and a 1-2 I-year follow-up of more than 950 has been obtained7. More than 88% have been followed up for 3 or more years. Many patients report for the first time 5 and more years after the initial repair, so that the continuity and persistence of the follow-up is important. The follow-up data have been assembled from a combined survey consisting of an annual examination at this hospital or an examination by a local physician or from replies to a routine questionnaire. Despite the vagaries introduced by a mobile population, distance, deaths (since approximately io% of the patients were more than 70 years of age at the time of operation), and indifference to enquiries, it is felt that the statistics quoted subsequentlv are reasonably accurate. Naturally in all series the recurrence rate will increase with time. I have shown elsewhere8 that, from my own experience, it is likely that more than 50%° of the recurrences will have appeared at the end of 5 years and more than 75% by the end of IO years. Thus the true or long-term recurrence rate for a series which has only been followed up for a shorter period can be extrapolated. Nevertheless, a 5-year follow-up should be considered minimal and i o-year follow-up preferable.
The argument that those individuials who are lost to the follow-up may be the ones with recurrences is, of course, unanswerable but unlikely. It would seem reasonable, in a welldocumnented series, to apply the same recurrence rates to the untraced as to the traced patients.
Shouldice repair for primary inguinal hernia The Shouldice repair for inguinal hernia consists of two main parts, the first being the technique used at the internal ring and the second the technique used for the repair of the posterior inguinal wall. A routine procedure is followed at each operation so that secondary hernias are not missed. In 95% of cases local anaesthesia is used. Routinely 200-300 mg of pentobarbitone is given by mouth go min and 50-I 00 mg of meperidine intramuscularly 20 min before the start of the operation. In the elderly these doses are adjusted downwards. Technique A few millilitres of 2% procaine hydrochloride solution is injected 2 or 3 cm medial to the anterior superior iliac spine. Then approximately ioo ml is injected subcutaneously in the line of the inguinal canal. A further 15 ml or so is injected deep to the external oblique aponeurosis, anaesthetizing the ilioinguLinal nerve, and finally approximately I5 ml is injected around the internal ring to eliminate sensory impulses from the peritoneum and along the genital branch of the genitofemoral nerve. A twoway syringe for continous administration of the anaesthetic is used for convenience. Monofilament stainless steel wire, No 34 gauge, is used as the suture material for the repair. The incision, measuring IO-I cm, is made along the line of the inguinal canal. The superficial external pudendal vessels are spared if possible, particularly in bilateral repairs. This minimizes postoperative oedema. The external oblique aponeurosis is divided along the same line, preserving the ilioinguinal nerve wherever possible. The two flaps of external oblique aponeurosis are completely mobilized. During mobilization of the lower an incision is made in the fascia of the thigh to allow inspection of the femoral area from
Short-stay surgery (Shouldice tcchniique) for repair of inguinal hernia below. The cremasteric muscle is divided longitudinally over the spermatic cord into upper and lower flaps. Each of these is then freely mobilized and excised. Excision of the lower or lateral flap, including the cremasteric vessels running deeply within it, is particularly important. It provides an adequate view of the posterior inguinal wall, which otherwise remains obscured. Many direct inguinal hernias, previously invisible or only inadequately visualized, will be revealed by this technique. The subsequent assessment of the strength of the posterior inguinal wall will be markedly aided by this routine cremasteric removal.
I135
Part 2 of the repair The strength of the posterior inguinal wall is assessed first by inspection and then by palpation. Inspection will reveal any direct inguinal hernia or any obvious weakness of the posterior inguinal wall. Palpation will further aid this assessment, whether a direct inguinal hernia is present or not. If the wall is weak a prophylactic repair is indicated. A finger is passed medially through the gap which was previously made at the internal ring in the transversalis plane. It then lies in the preperitoneal space, immediately deep to the transversalis lamina, where it tests the entire length of the posterior inguinal wall. This structure may have to be divided, either partially or completely, depending upon its strength9. Such a division begins laterally, preserving the inferior epigastric vessels, and is directed towards the pubic tubercle (Fig. I). At this time the femoral ring can also be palpated from above and the presence or absence of a femoral hernia determined. An interstitial hernia in the region of the internal ring should also not be overlooked at this stage. In a typical case, in which this division is completed to the pubic bone, two segments or flaps of transversalis result. If a protruding diffuse direct inguinal hernia has stretched or attenuated the overlying aponeuroticofascial
Part i of the repair The internal ring is completely freed from all transversalis attachments. This step is most important. The deep epigastric vessels are avoided. If no indirect inguinal hernia is present a small crescentic reflection of peritoneum will be visible on the cord. It is freed. Routine attention to this important detail will ensure that no indirect inguinal hernia is overlooked. It may also clarify a confusing anatomical picture, for occasionally an indirect inguinal hernia resembles a direct one and vice versa. The indirect sac is now completely freed from the cord to the internal ring. This is Internal just as important as the traditional high ligaobliqueM Rectus been has if the freeing sac. Indeed, the of tion Internal ring accurately performed, then high ligation is Inferior --------------not essential. The sac is now excised. Any epigostric lipoma, commonplace in this region, is excised vessels from the cord, but the cord is not stripped of Spermatic cord--interstitial fat. Inguinal ligament -.......... These techniques at the internal ring are lincisionin /Pubis justified by the following observations: fascia transversalis for indirect inguinal a) The recurrence rate hernia in this hospital is extremely low. Rectus Inguinal I i a ment b) Sliding indirect inguinal hernias, even when very large, are very successfully treated Cross- section solely by freeing and reduction. An other- FIG. I Anterior aspect of posterior wall of wise potentially difficult operation is thus right inguinal canal showing direction of divimade easy. With this technique the recur- sion from internal ring to pubic bone (external rence rate for sliding ingtiinal hernia is very oblique omitted). (Reproduced by permission low. from the Canadian Medical Association journal"2.) c) Testicular atrophy is very rare. ...............
136
Frank Glassow
transversalis layer some of this may be excised from each flap. The upper or medial flap is usually narrower than the lower or lateral one. It is the appreciation of, and the treatment of, this lower flap, usually I or 2 cm in width, which is vital to the understanding of and the conduct of the Shouldice repair of the posterior inguinal wall. This lower flap is usually quite substantial, somnetimes strong, and, even when weak, it can still always be identified. Even in the presence of a large direct inguinal hernia or a recurrent inguinal hernia it can also almost always be defined by careful dissection and ultimately completely freed when it can be demonstrated as being perfectly suitable for the subsequent reconstruction of the normal anatomical planes. Diffuse direct hernias are freed from the transversalis and reduced. If they are elongated they are excised. The posterior inguinal wall is now reconstructed. The essence of this part of a Shouldice repair is the overlap of the divided transversalis layer with subsequent reinforcement of this area. It has been described in detail elsewhere"0-2. Four continuous lines of wire are used, but only two separate lengths. The first length, starting at the pubic bone, is inserted as far as the internal ring (first line) and then, reversing itself here, returns to the pubic bone (second line), where it is tied. The second length starts at the internal ring, travels to the pubic bone (third line), and then returns to the internal ring (fourth line). These continuous sutures are inserted firmly but not tightly, using small bites. I have frequently observed recurrent direct inguinal hernias breaking through the posterior inguinal wall between individually tied non-absorbable sutures. The first suture, starting medially at the pubic bone, attaches the free edge of the lateral flap of transversalis to the edge of the rectus at its insertion, identified as a whitish border. The entire free edge is now brought upwards and medially, under the medial flap which overlaps it, so that a line of attachment extends to the internal ring (Fig. 2 (a)). Laterally the undersurface of transversus and internal oblique are used. The internal ring is made snug, but not tight, by including laterally the lateral stump of the lower flap of the divided cremaster. After the suture line is reversed
I ~ Rectus|
here the second line picks up the free edge of the upper flap of divided transversalis, along with some muscular fibres of internal oblique and transversus, and attaches it to the deep surface of the inguinal ligament as it returns medially (Fig. 2 (b)). The 'pocket' medial to the femoral vein must be eliminated, occasionally using the lacunar ligament to do so. This overlap strengthens the first layer or barrier already provided by the reconstruction of the lower flap of transversalis. Occasionally, when the lower flap is weak or defective, this second line assumes considerable importance. The second line is tied at the pubic bone. The third line, starting at the internal ring, reinforces the second, gradually eliminating all dead space as it travels medially, bringing internal oblique and transversus down to the deep surface of Poupart's ligament. The fourth line, returning from the pubic bone, attaches the same structures in a slightly more superficial plane. It is tied at the internal ring. The spermatic veins should not be engorged and the cord should slide easily into the internal ring. The external oblique aponeurosis is closed over the cord, which is never left in the subInternal
oblique
Internal
ring ---ct---
inferiorepiqastric
vessels
Spermatic cord ....... Inguinal ligament
------
Pubis
iInguinal I qament
Rectus
Cross-section
Anterior aspect of posterior wall of right inguinal canal after completion of first line of repair by attachment of free edge of lateral flap of divided transversalis fascia to rectus (a). Second line of repair is about to begin laterally at the internal ring with attachment of free edge of medial flap (b) to inguinal ligament. (Reproduced by permission from the Canadian Medical Association Journal2.) FIG. 2
Short-stay
surgery
(Shouldice technique) for repair of iniguinal hernia
pl,ane. The subcutaneous plane is closed separately, clinminating all dead space, by picking up the ssurface of the external oblique aponeurosis. Michel's skin clips are used. cutaneous
Results During the period from 1945 to 1973 a total of 84 500 inguinal hernia repairs were performed in this hospital. The Shouldice repair was devised by the late Dr E E Shouldice, who died in I965, but it did not become standardized until about I95I. Even so, in this entire period there were only 65o recurrences (o.8%). Approximately 5o 500 repairs were for primary indirect inguinal hernia with 335 recurrences (0.7%/,) and 25 ooo repairs vere for primary direct inguinal hernia with I 8 recurrences (o.9%°/0). Approximately 4300 repairs were for recurrent indirect inguinal hernia with 32 rerecurrences (o.8%) and 4700 repairs were for recurrent direct inguinal hernia with 65 rerecurrences (I .4%). Five or 6 surgeons performed the vast majority of these operations. An analysis of my own series of 14 982 inguinal hernia repairs was considered the simplest way of minimizing as many variables as possible, since it reflects the experience of a single surgeon using the Shouldice technique for inguinal repair exclusively throughout the entire I 974. A small year period from I 954 to personal group of 123 ipsilateral combined inguinal and femoral hernia repairs was also eliminated for the sake of simplicity. Tables I and II summarize these results. Of the 73 patients with recurrences after primary inguinal herniorrhaphy, 46 underwent a second repair, at which I5 direct inguinal recurrences and 3I femoral 'recurrences' were dealt with. No instance of indirect inguinal recurrence occurred in this group. In the remaining 27 cases, consisting of I 3 clinically inguinal recurrences and 14 clinically femoral recurrences, no further repair has been performed. Out of a total of I874 recurrent inguinal herniorrhaphies which I performed in this hospital during this period on patients who had undergone the initial repair or repairs elsewhere there were i8 rerecurrences (i%) Of these i8 patients, have undergone yet a further (second) operation here for cure of the rerecurrence. At this operation indirect rerecurrence, 7 direct re2
2
recurrences, and 4 femoral rerecurrences were encountered and dealt with. In the remaining group of 6 rerecurrences, consisting of 4 clinically inguinal and 2 clinically femoral rerecurrences, no further repair has been performed. The significance of the types of recurrence after the Shouldice repair of inguinal hernia has been discussed in detail elsewhere8. Indirect inguinal recurrences are extremely rare. An indirect inguinal recurrence should generally be regarded as a failure of the surgical technique employed at the internal ring. The Shouldice technique at the internal ring, described in some detail above, appears to be effective in this regard. Direct inguinal hernia recurrences, though rare, were somewhat more frequent in the early years of the period. For example, I performed 23IO primary direct inguinal hernia repairs from 1954 to I964 with 2 4 recurrences (I%), yet of 2302 primary direct inguinal hernia repairs that I performed be-
primary inguinal
TABLE I Personal series of
herniorrhaphies using Shouldice technique '954-74. No
No
of repairs
recurrences
Indirect
7863
43
Direct
3814
27
o.6 0.7
798
3
0.4
633 I 3 Io8
0
0
73
o.6
Type
of
hernia
of
Recurrence (%)
rate
-
1
12
i
I3 7
Indirect and direct Sliding
Total
TABLE II Personal series of recurrent
inguinal
herniorrhaphies using Shouldice technique 1954-74.
Type
of
hernia Indirect Direct
No
No
of repairs
recurrences
of
Sliding Total
(%)
rate
627
4
o.6
927
10
1.1
249
4
i.6
71
0
0
1874
18
I.0
Inclirect and direct
Recurrence
138
Fr(ank Glassow
tween I964 and I974, only 6 (0.3%) are known to have recurred so far. Even allowing for the shorter follow-up in this latter group, it is probable that the final recurrence rate will not be as large as in the former, as determined by the extrapolation method previously mentioned. It appears, therefore, that the recurrence rate for primary direct inguinal hernia, about I % in the earlier years is now slowly decreasing. The femoral 'recurrences' are perhaps the most interesting group. Elsewhere I have discussed in detail the significance of femoral hernia following inguinal herniorrhaphy"3. Out of a total of 9 i personal recurrences in this entire series there were 40 inguinal recurrences and 5 I femoral 'recurrences'. These femoral 'recurrences', constituting more than one-half of all my own recurrences, nevertheless represent only 0.3% of the entire series. They may represent some missed femoral hernias, despite the routine examination of the femoral region from both above and below the inguinal ligament. They may represent an occasional technical error in dealing with the lower transversalis flap in its central area, where it lies nearest to the femoral vein. They may be due to the use of too much tension in the repair, despite all precautions to the contrary. In this respect it should be noted that the recurrence rate in bilateral repairs is slightly, but significantly, higher than in unilateral repairs. It is also noteworthy that the number of femoral recurrences in my personal series is diminishing. In the period from I954 to I960, during which I performed 5236 inguinal hernia repairs, there were 47 recurrences altogether, io of which were inguinal and 37 femoral. Yet in the period from I960 to 1974, during which I performed 9746 inguinal repairs, there were 44 recurrences, 30 of which were inguinal and I4 femoral. Perhaps, with increasing experience, the proportion of femoral 'recurrences' following inguinal herniorrhaphy in a large series decreases with time. The Shouldice technique is equally applicable to the repair of recurrent inguinal hernia. The first part of the operation for the repair of a recurrent inguinal hernia consists in almost every case of dis;nantling the original repair and then the reestablishment of the normal anatomy and normal anatomical
planes. This can almost always be accom-plished with patience. In recurrent inguinal hermia repair, as in primary repair, relaxingincisions"4`" are not used, the use of Cooper's ligament7-20 is not required, grafts2", meshes22-24, and special materials25'26 are considered unnecessary, and transection of thespermatic cord27 is limnited to a very few very difficult multiple recurrent herniorrhaphies. Orchidectomy is very rarely performed and the testis is preserved whenever possible, irrespect-' ive of age. In my series of 1874 recurrent inguinal hernia repairs I449 of the hernias had recurred once, 360 twice, 57 three times, 6, four times, and 2 five times before admission to this hospital. The overall re-. recurrence rate of i.o0% for this entire group, a rate only slightly higher than the o.6%/ recorded in the primary group of hernias, was achieved without any basic change in the principles of the Shouldice technique used throughout, suggesting that it is also well suited to the treatment of recurrent inguinal hernia. In view of this experience I can find no more fitting conclusion than to quote Wakeley28, who, in his Hunterian Lecture in January 1940, said: 'A surgeon can do more for the community by operating on hernia cases and seeing that his recurrence rate is low than he can by operating on cases of malignant disease'.
References I
2 3 4 5 6
7 8
Doran, F S A, White, M, and Drury, M (1972) British Journal of Surgery, 59, 333. Gaster, J (I970) in Hernia-One Day Repair, p. Io6. Darien, Connecticut, Hafner. Farquharson, E L (I955) Lancet, 2, 517. Lichtenstein, I L (1970) in Hernia Repair without Disability, p i86. St Louis, Mosby. Bellis, C J (I975) International Surgery, 6o, 37. Palumbo, L T, and Sharpe, W S (1971) Surgical Clinics of North America, 5I, I293. Iles, J D H (I965) Lancet, I, 751. Glassow, F (1970) British Medical Journal, I, 215.
(I973) British Journal of Surgery, 6o, I0 Glassow, F (I964) Canadian Journal of Surgery,
9 Glassow, F 342.
ii
7, 248. Glassow, F (i965) American Journal of Surgery, I 09, 460.
I2 Glassow, F (I973) Canadian Medical Association Journal, io8, 308. I 3 Glassow, F (1970) Canadian Journal of Surgery, I3, 27.
Short-stay surgery (Shouldice technique) for repair of inguinal hernia 14 Tanner, N (1942) British Journal of Surgery, 29, 285.
15 Ponika, J L (I968) American Journal of Surgery, II5, 552.
i6 McVay, C B (I962) Quarterly Bulletin of Northwestern University Medical School, 36, 245. 17 Harkins, H N (I964) in Hernia, ed. Nyhus, L M, and Harkins, H N, p. 179. Philadelphia, Lippincott. i8 Rains, A J H (I95 i) British Journal of Surgery, 39, 21 I. 19 McVay, C B (I965) Surgery, 57, 6I5. 20 Maingot, R (973) British Journal of Clinical Practice, 27, 237.
I39
2I Smith, R S (1971) Surgical Clinics of North America, 51, I387. 22 Usher, F C (I964) in Hernia, ed. Nyhus, L M, and Harkins, H N, p. 752. Philadelphia, Lippincott. 23 Koontz, A R (I964) in Hernia, ed. Nyhus, L M, and Harkins, H N, p. 734. Philadelphia, Lippincott. 24 Zimmerman, L M (I968) Surgical Clinics of North America, 48, I43. 25 Doran, F S A, Gibbins, R E, and Whitehead, R (i96i) British Journal of Surgery, 41, 354. 26 Moloney, G E (1958) Lancet, 2, 273, 27 Heifetz, C J (I97I) Archives of Surgery, I02, 36. 28 Wakeley, C P G (1940) Lancet, i, 822.
ASPECTS OF TREATMENT*
Short-stay surgery (Shouldice technique) for repair of inguinal hernia Frank Glassow
FRCS
FRCS(C)
Shoildice Hospital, Toronto
Summary Short-stay surgery for inguinal hernia repair uising the Shouldice technique, with local anaesthesia in the great majority of cases, has achievled a recuirrence rate of less than i/% in the repair of both primary and recurrent inuzinal hernia. A personal series of 14 982 consecutive in guinal herniorrhaphies performed during a 2 I-year period with an overall recurrence rate of 0.60%, using the Shouldice technique exclusively, is documented and discussed in some detail. The results sug.gest that the adoption of these methods on a national scale would result in a saving to the economy of many millions of pounds.
Introduction In a recent paper entitled 'The scope and safety of short-stay surgery in the treatment of groin herniae and varicose veins' Doran et al.' emphasize the economic aspects of the treatment of these cases. In Britain in 1972 1 1 7 ooo hernia repairs were performed, representing 12.5%° of the total surgical admissions to general hospitals. In the USA, wvith approximately four times the population, 6oo ooo hernia repairs were performed in Iq64. The average length of stay in the Birmingham area in 1972 for a patient undergoing a hernia repair was 10.2 days. The national figutre for the USA in a recent survey was 5.7 days. The enormous economic and social implications of these figures are obvious. Gaster2 has estimated that the total amount of work loss from hernias in the USA in ig6o was io million days. If either the period of hospital stay or the period of absence from work after
discharge from hospital were shortened or, better still, if both were, then the resulting savings from a personal and a community viewpoint would be considerable, while the savings to the national economy would be immense and measurable in many millions of pounds. Doran et al. suggest that a hospital stay of 48 h might eventually prove perfectly satisfactory. Farquharson3 in Scotland in 1955 performed 485 inguinal repairs successfully on otutpatients. In the USA Gaster2, Lichtenstein4, and Bellis5 discharge their patients 24 h after operation or even earlier. Palumbo' has adduced compelling statistical evidence to suggest that early ambulation and short hospital stay are associated with both a diminished morbidity rate and a lowering of the incidence of complications, including the recurrence rate. He demonstrated convincingly that patients who were ambulatory on the day of operation or on the first postoperative day developed significantly fewer immediate complications and had a lower recurrence rate than those who were ambulatory from the 3rd to the gth postoperative days, while a third group, ambulatory after the ioth postoperative day, had even poorer results in this regard. Short-stay surgery for repair of inguinal hernia, with immediate ambulation, has been practised at the Shouldice Hospital, Toronto, since I945. The great majority of patients remain for 72 h after operation, though the occasional patient is discharged after 48 h. The intention of this article is to demonstrate that, using a standardized technique for the repair, a slhort hospital stay and an early return to normal activity are compatible with
*Fellows and Members interested in submitting papers for consideration with publication in this series should first writc to the Editor.
a
view
to
134
Frank Glassow
a low recurrence rate. The only patients admitted to this hospital are those who have external abdominal hernias or allied conditions such as hydroceles and epididymal cysts. The operation is performed under local anaesthesia in 95°0/ of cases. The patient walks to the operating theatre from the recovery room and then back again after the operation. He is ambtulant throughout his short hospital stay. He is discharged without a dressing on the incision, all Mlichel's clips having been removed. Bilateral hernia repairs are staged 48 h apart. Postoperative complications are minimal, catheterization is eliminated, and the postoperative wound infection rate is now less than I%. The patient frequently drives his own car home and many return to work the following week. For a patient whose work involves strenuous physical activity a period of not more than 4 weeks before return to work may be recommended. A vigorous follow-up plan is essential to assess long-term results. A continuous and strenuous effort is made to follow up all cases annually and a 1-2 I-year follow-up of more than 950 has been obtained7. More than 88% have been followed up for 3 or more years. Many patients report for the first time 5 and more years after the initial repair, so that the continuity and persistence of the follow-up is important. The follow-up data have been assembled from a combined survey consisting of an annual examination at this hospital or an examination by a local physician or from replies to a routine questionnaire. Despite the vagaries introduced by a mobile population, distance, deaths (since approximately io% of the patients were more than 70 years of age at the time of operation), and indifference to enquiries, it is felt that the statistics quoted subsequentlv are reasonably accurate. Naturally in all series the recurrence rate will increase with time. I have shown elsewhere8 that, from my own experience, it is likely that more than 50%° of the recurrences will have appeared at the end of 5 years and more than 75% by the end of IO years. Thus the true or long-term recurrence rate for a series which has only been followed up for a shorter period can be extrapolated. Nevertheless, a 5-year follow-up should be considered minimal and i o-year follow-up preferable.
The argument that those individuials who are lost to the follow-up may be the ones with recurrences is, of course, unanswerable but unlikely. It would seem reasonable, in a welldocumnented series, to apply the same recurrence rates to the untraced as to the traced patients.
Shouldice repair for primary inguinal hernia The Shouldice repair for inguinal hernia consists of two main parts, the first being the technique used at the internal ring and the second the technique used for the repair of the posterior inguinal wall. A routine procedure is followed at each operation so that secondary hernias are not missed. In 95% of cases local anaesthesia is used. Routinely 200-300 mg of pentobarbitone is given by mouth go min and 50-I 00 mg of meperidine intramuscularly 20 min before the start of the operation. In the elderly these doses are adjusted downwards. Technique A few millilitres of 2% procaine hydrochloride solution is injected 2 or 3 cm medial to the anterior superior iliac spine. Then approximately ioo ml is injected subcutaneously in the line of the inguinal canal. A further 15 ml or so is injected deep to the external oblique aponeurosis, anaesthetizing the ilioinguLinal nerve, and finally approximately I5 ml is injected around the internal ring to eliminate sensory impulses from the peritoneum and along the genital branch of the genitofemoral nerve. A twoway syringe for continous administration of the anaesthetic is used for convenience. Monofilament stainless steel wire, No 34 gauge, is used as the suture material for the repair. The incision, measuring IO-I cm, is made along the line of the inguinal canal. The superficial external pudendal vessels are spared if possible, particularly in bilateral repairs. This minimizes postoperative oedema. The external oblique aponeurosis is divided along the same line, preserving the ilioinguinal nerve wherever possible. The two flaps of external oblique aponeurosis are completely mobilized. During mobilization of the lower an incision is made in the fascia of the thigh to allow inspection of the femoral area from
Short-stay surgery (Shouldice tcchniique) for repair of inguinal hernia below. The cremasteric muscle is divided longitudinally over the spermatic cord into upper and lower flaps. Each of these is then freely mobilized and excised. Excision of the lower or lateral flap, including the cremasteric vessels running deeply within it, is particularly important. It provides an adequate view of the posterior inguinal wall, which otherwise remains obscured. Many direct inguinal hernias, previously invisible or only inadequately visualized, will be revealed by this technique. The subsequent assessment of the strength of the posterior inguinal wall will be markedly aided by this routine cremasteric removal.
I135
Part 2 of the repair The strength of the posterior inguinal wall is assessed first by inspection and then by palpation. Inspection will reveal any direct inguinal hernia or any obvious weakness of the posterior inguinal wall. Palpation will further aid this assessment, whether a direct inguinal hernia is present or not. If the wall is weak a prophylactic repair is indicated. A finger is passed medially through the gap which was previously made at the internal ring in the transversalis plane. It then lies in the preperitoneal space, immediately deep to the transversalis lamina, where it tests the entire length of the posterior inguinal wall. This structure may have to be divided, either partially or completely, depending upon its strength9. Such a division begins laterally, preserving the inferior epigastric vessels, and is directed towards the pubic tubercle (Fig. I). At this time the femoral ring can also be palpated from above and the presence or absence of a femoral hernia determined. An interstitial hernia in the region of the internal ring should also not be overlooked at this stage. In a typical case, in which this division is completed to the pubic bone, two segments or flaps of transversalis result. If a protruding diffuse direct inguinal hernia has stretched or attenuated the overlying aponeuroticofascial
Part i of the repair The internal ring is completely freed from all transversalis attachments. This step is most important. The deep epigastric vessels are avoided. If no indirect inguinal hernia is present a small crescentic reflection of peritoneum will be visible on the cord. It is freed. Routine attention to this important detail will ensure that no indirect inguinal hernia is overlooked. It may also clarify a confusing anatomical picture, for occasionally an indirect inguinal hernia resembles a direct one and vice versa. The indirect sac is now completely freed from the cord to the internal ring. This is Internal just as important as the traditional high ligaobliqueM Rectus been has if the freeing sac. Indeed, the of tion Internal ring accurately performed, then high ligation is Inferior --------------not essential. The sac is now excised. Any epigostric lipoma, commonplace in this region, is excised vessels from the cord, but the cord is not stripped of Spermatic cord--interstitial fat. Inguinal ligament -.......... These techniques at the internal ring are lincisionin /Pubis justified by the following observations: fascia transversalis for indirect inguinal a) The recurrence rate hernia in this hospital is extremely low. Rectus Inguinal I i a ment b) Sliding indirect inguinal hernias, even when very large, are very successfully treated Cross- section solely by freeing and reduction. An other- FIG. I Anterior aspect of posterior wall of wise potentially difficult operation is thus right inguinal canal showing direction of divimade easy. With this technique the recur- sion from internal ring to pubic bone (external rence rate for sliding ingtiinal hernia is very oblique omitted). (Reproduced by permission low. from the Canadian Medical Association journal"2.) c) Testicular atrophy is very rare. ...............
136
Frank Glassow
transversalis layer some of this may be excised from each flap. The upper or medial flap is usually narrower than the lower or lateral one. It is the appreciation of, and the treatment of, this lower flap, usually I or 2 cm in width, which is vital to the understanding of and the conduct of the Shouldice repair of the posterior inguinal wall. This lower flap is usually quite substantial, somnetimes strong, and, even when weak, it can still always be identified. Even in the presence of a large direct inguinal hernia or a recurrent inguinal hernia it can also almost always be defined by careful dissection and ultimately completely freed when it can be demonstrated as being perfectly suitable for the subsequent reconstruction of the normal anatomical planes. Diffuse direct hernias are freed from the transversalis and reduced. If they are elongated they are excised. The posterior inguinal wall is now reconstructed. The essence of this part of a Shouldice repair is the overlap of the divided transversalis layer with subsequent reinforcement of this area. It has been described in detail elsewhere"0-2. Four continuous lines of wire are used, but only two separate lengths. The first length, starting at the pubic bone, is inserted as far as the internal ring (first line) and then, reversing itself here, returns to the pubic bone (second line), where it is tied. The second length starts at the internal ring, travels to the pubic bone (third line), and then returns to the internal ring (fourth line). These continuous sutures are inserted firmly but not tightly, using small bites. I have frequently observed recurrent direct inguinal hernias breaking through the posterior inguinal wall between individually tied non-absorbable sutures. The first suture, starting medially at the pubic bone, attaches the free edge of the lateral flap of transversalis to the edge of the rectus at its insertion, identified as a whitish border. The entire free edge is now brought upwards and medially, under the medial flap which overlaps it, so that a line of attachment extends to the internal ring (Fig. 2 (a)). Laterally the undersurface of transversus and internal oblique are used. The internal ring is made snug, but not tight, by including laterally the lateral stump of the lower flap of the divided cremaster. After the suture line is reversed
I ~ Rectus|
here the second line picks up the free edge of the upper flap of divided transversalis, along with some muscular fibres of internal oblique and transversus, and attaches it to the deep surface of the inguinal ligament as it returns medially (Fig. 2 (b)). The 'pocket' medial to the femoral vein must be eliminated, occasionally using the lacunar ligament to do so. This overlap strengthens the first layer or barrier already provided by the reconstruction of the lower flap of transversalis. Occasionally, when the lower flap is weak or defective, this second line assumes considerable importance. The second line is tied at the pubic bone. The third line, starting at the internal ring, reinforces the second, gradually eliminating all dead space as it travels medially, bringing internal oblique and transversus down to the deep surface of Poupart's ligament. The fourth line, returning from the pubic bone, attaches the same structures in a slightly more superficial plane. It is tied at the internal ring. The spermatic veins should not be engorged and the cord should slide easily into the internal ring. The external oblique aponeurosis is closed over the cord, which is never left in the subInternal
oblique
Internal
ring ---ct---
inferiorepiqastric
vessels
Spermatic cord ....... Inguinal ligament
------
Pubis
iInguinal I qament
Rectus
Cross-section
Anterior aspect of posterior wall of right inguinal canal after completion of first line of repair by attachment of free edge of lateral flap of divided transversalis fascia to rectus (a). Second line of repair is about to begin laterally at the internal ring with attachment of free edge of medial flap (b) to inguinal ligament. (Reproduced by permission from the Canadian Medical Association Journal2.) FIG. 2
Short-stay
surgery
(Shouldice technique) for repair of iniguinal hernia
pl,ane. The subcutaneous plane is closed separately, clinminating all dead space, by picking up the ssurface of the external oblique aponeurosis. Michel's skin clips are used. cutaneous
Results During the period from 1945 to 1973 a total of 84 500 inguinal hernia repairs were performed in this hospital. The Shouldice repair was devised by the late Dr E E Shouldice, who died in I965, but it did not become standardized until about I95I. Even so, in this entire period there were only 65o recurrences (o.8%). Approximately 5o 500 repairs were for primary indirect inguinal hernia with 335 recurrences (0.7%/,) and 25 ooo repairs vere for primary direct inguinal hernia with I 8 recurrences (o.9%°/0). Approximately 4300 repairs were for recurrent indirect inguinal hernia with 32 rerecurrences (o.8%) and 4700 repairs were for recurrent direct inguinal hernia with 65 rerecurrences (I .4%). Five or 6 surgeons performed the vast majority of these operations. An analysis of my own series of 14 982 inguinal hernia repairs was considered the simplest way of minimizing as many variables as possible, since it reflects the experience of a single surgeon using the Shouldice technique for inguinal repair exclusively throughout the entire I 974. A small year period from I 954 to personal group of 123 ipsilateral combined inguinal and femoral hernia repairs was also eliminated for the sake of simplicity. Tables I and II summarize these results. Of the 73 patients with recurrences after primary inguinal herniorrhaphy, 46 underwent a second repair, at which I5 direct inguinal recurrences and 3I femoral 'recurrences' were dealt with. No instance of indirect inguinal recurrence occurred in this group. In the remaining 27 cases, consisting of I 3 clinically inguinal recurrences and 14 clinically femoral recurrences, no further repair has been performed. Out of a total of I874 recurrent inguinal herniorrhaphies which I performed in this hospital during this period on patients who had undergone the initial repair or repairs elsewhere there were i8 rerecurrences (i%) Of these i8 patients, have undergone yet a further (second) operation here for cure of the rerecurrence. At this operation indirect rerecurrence, 7 direct re2
2
recurrences, and 4 femoral rerecurrences were encountered and dealt with. In the remaining group of 6 rerecurrences, consisting of 4 clinically inguinal and 2 clinically femoral rerecurrences, no further repair has been performed. The significance of the types of recurrence after the Shouldice repair of inguinal hernia has been discussed in detail elsewhere8. Indirect inguinal recurrences are extremely rare. An indirect inguinal recurrence should generally be regarded as a failure of the surgical technique employed at the internal ring. The Shouldice technique at the internal ring, described in some detail above, appears to be effective in this regard. Direct inguinal hernia recurrences, though rare, were somewhat more frequent in the early years of the period. For example, I performed 23IO primary direct inguinal hernia repairs from 1954 to I964 with 2 4 recurrences (I%), yet of 2302 primary direct inguinal hernia repairs that I performed be-
primary inguinal
TABLE I Personal series of
herniorrhaphies using Shouldice technique '954-74. No
No
of repairs
recurrences
Indirect
7863
43
Direct
3814
27
o.6 0.7
798
3
0.4
633 I 3 Io8
0
0
73
o.6
Type
of
hernia
of
Recurrence (%)
rate
-
1
12
i
I3 7
Indirect and direct Sliding
Total
TABLE II Personal series of recurrent
inguinal
herniorrhaphies using Shouldice technique 1954-74.
Type
of
hernia Indirect Direct
No
No
of repairs
recurrences
of
Sliding Total
(%)
rate
627
4
o.6
927
10
1.1
249
4
i.6
71
0
0
1874
18
I.0
Inclirect and direct
Recurrence
138
Fr(ank Glassow
tween I964 and I974, only 6 (0.3%) are known to have recurred so far. Even allowing for the shorter follow-up in this latter group, it is probable that the final recurrence rate will not be as large as in the former, as determined by the extrapolation method previously mentioned. It appears, therefore, that the recurrence rate for primary direct inguinal hernia, about I % in the earlier years is now slowly decreasing. The femoral 'recurrences' are perhaps the most interesting group. Elsewhere I have discussed in detail the significance of femoral hernia following inguinal herniorrhaphy"3. Out of a total of 9 i personal recurrences in this entire series there were 40 inguinal recurrences and 5 I femoral 'recurrences'. These femoral 'recurrences', constituting more than one-half of all my own recurrences, nevertheless represent only 0.3% of the entire series. They may represent some missed femoral hernias, despite the routine examination of the femoral region from both above and below the inguinal ligament. They may represent an occasional technical error in dealing with the lower transversalis flap in its central area, where it lies nearest to the femoral vein. They may be due to the use of too much tension in the repair, despite all precautions to the contrary. In this respect it should be noted that the recurrence rate in bilateral repairs is slightly, but significantly, higher than in unilateral repairs. It is also noteworthy that the number of femoral recurrences in my personal series is diminishing. In the period from I954 to I960, during which I performed 5236 inguinal hernia repairs, there were 47 recurrences altogether, io of which were inguinal and 37 femoral. Yet in the period from I960 to 1974, during which I performed 9746 inguinal repairs, there were 44 recurrences, 30 of which were inguinal and I4 femoral. Perhaps, with increasing experience, the proportion of femoral 'recurrences' following inguinal herniorrhaphy in a large series decreases with time. The Shouldice technique is equally applicable to the repair of recurrent inguinal hernia. The first part of the operation for the repair of a recurrent inguinal hernia consists in almost every case of dis;nantling the original repair and then the reestablishment of the normal anatomy and normal anatomical
planes. This can almost always be accom-plished with patience. In recurrent inguinal hermia repair, as in primary repair, relaxingincisions"4`" are not used, the use of Cooper's ligament7-20 is not required, grafts2", meshes22-24, and special materials25'26 are considered unnecessary, and transection of thespermatic cord27 is limnited to a very few very difficult multiple recurrent herniorrhaphies. Orchidectomy is very rarely performed and the testis is preserved whenever possible, irrespect-' ive of age. In my series of 1874 recurrent inguinal hernia repairs I449 of the hernias had recurred once, 360 twice, 57 three times, 6, four times, and 2 five times before admission to this hospital. The overall re-. recurrence rate of i.o0% for this entire group, a rate only slightly higher than the o.6%/ recorded in the primary group of hernias, was achieved without any basic change in the principles of the Shouldice technique used throughout, suggesting that it is also well suited to the treatment of recurrent inguinal hernia. In view of this experience I can find no more fitting conclusion than to quote Wakeley28, who, in his Hunterian Lecture in January 1940, said: 'A surgeon can do more for the community by operating on hernia cases and seeing that his recurrence rate is low than he can by operating on cases of malignant disease'.
References I
2 3 4 5 6
7 8
Doran, F S A, White, M, and Drury, M (1972) British Journal of Surgery, 59, 333. Gaster, J (I970) in Hernia-One Day Repair, p. Io6. Darien, Connecticut, Hafner. Farquharson, E L (I955) Lancet, 2, 517. Lichtenstein, I L (1970) in Hernia Repair without Disability, p i86. St Louis, Mosby. Bellis, C J (I975) International Surgery, 6o, 37. Palumbo, L T, and Sharpe, W S (1971) Surgical Clinics of North America, 5I, I293. Iles, J D H (I965) Lancet, I, 751. Glassow, F (1970) British Medical Journal, I, 215.
(I973) British Journal of Surgery, 6o, I0 Glassow, F (I964) Canadian Journal of Surgery,
9 Glassow, F 342.
ii
7, 248. Glassow, F (i965) American Journal of Surgery, I 09, 460.
I2 Glassow, F (I973) Canadian Medical Association Journal, io8, 308. I 3 Glassow, F (1970) Canadian Journal of Surgery, I3, 27.
Short-stay surgery (Shouldice technique) for repair of inguinal hernia 14 Tanner, N (1942) British Journal of Surgery, 29, 285.
15 Ponika, J L (I968) American Journal of Surgery, II5, 552.
i6 McVay, C B (I962) Quarterly Bulletin of Northwestern University Medical School, 36, 245. 17 Harkins, H N (I964) in Hernia, ed. Nyhus, L M, and Harkins, H N, p. 179. Philadelphia, Lippincott. i8 Rains, A J H (I95 i) British Journal of Surgery, 39, 21 I. 19 McVay, C B (I965) Surgery, 57, 6I5. 20 Maingot, R (973) British Journal of Clinical Practice, 27, 237.
I39
2I Smith, R S (1971) Surgical Clinics of North America, 51, I387. 22 Usher, F C (I964) in Hernia, ed. Nyhus, L M, and Harkins, H N, p. 752. Philadelphia, Lippincott. 23 Koontz, A R (I964) in Hernia, ed. Nyhus, L M, and Harkins, H N, p. 734. Philadelphia, Lippincott. 24 Zimmerman, L M (I968) Surgical Clinics of North America, 48, I43. 25 Doran, F S A, Gibbins, R E, and Whitehead, R (i96i) British Journal of Surgery, 41, 354. 26 Moloney, G E (1958) Lancet, 2, 273, 27 Heifetz, C J (I97I) Archives of Surgery, I02, 36. 28 Wakeley, C P G (1940) Lancet, i, 822.
