The Shouldice Repair
The Shouldice repair is a pure tissue repair designed to correct direct and indirect inguinal hernias. The advantages of the repair are (1) the thorough dissection and demonstration of the inguinal anatomy, (2) surgery under local anesthesia, and (3) earl
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The Shouldice Repair Robert Bendavid
Introduction The Shouldice repair is a pure tissue repair designed to correct direct and indirect inguinal hernias. The advantages of the repair are (1) the thorough dissection and demonstration of the inguinal anatomy, (2) surgery under local anesthesia, and (3) earlyambulation.
History The Shouldice repair has also been called the Canadian repair and the Bassini-Shouldice repair. 1•2 Ironically, Bassini ushered in the modem era of herniorrhaphies at the end of the nineteenth century,3 while the Shouldice operation remains a popular pure tissue repair at the end of the twentieth, 116 years later! There have been over 79 attempts at various pure tissue repairs in that interval. 4 The fact that the Shouldice operation prevails is an indication of the excellence of Bassini's original contribution. The two operations vary but little, and the essential difference is in the reconstruction of the posterior inguinal wall, which in the Bassini repair is carried out with interrupted sutures while the Shouldice uses continuous sutures back and forth (four lines), creating an overlap, as is described later. The importance of the Shouldice contribution lies even more importantly in the emphasis and later wide acceptance of local anesthesia for what should not be considered minor surgery. Although cocaine local anesthesia had been introduced in hernia repairs by Halsted and by Cushing,5 it was E.E. Shouldice who established it convincingly and on a massive scale (in more than 6000 cases a year). Another asset of the Shouldice contribution is earlyambulation. Realizing that children who underwent herniorrhaphies could not be easily kept in bed, E.E. Shouldice encouraged the same attitude for adults. Going a step further, these patients are put through mild, nonstrenuous exercises: stretch, flexion, extension. Not least in importance to the success of the Shouldice institution is the dedication of a team of surgeons to whom hernia repairs have become second nature. In fact, the surgeon at that institution does in 2 years 1400 to 1600 operations, as many hernia cases as the average general surgeon does in a lifetime! Although the Shouldice Hospital was established in 1945, the fi370
R. Bendavid et al. (eds.), Abdominal Wall Hernias © Springer Science+Business Media New York 2001
nal aspect of the repair was established in 1952, thanks to the concerted efforts of E.E. Shouldice, N. Obney, and E.A. Ryan, all surgeons on staff at that time.
General Principles To date, more than 250,000 operations have been carried out on every conceivable hernia of tlIe abdominal wall. That experience has been carefully recorded to be shared.
Weight Control It has always been the custom to encourage patients at tlIe
Shouldice Hospital to lose weight before surgery. The advantages are obvious in tlIat tlIere is a lesser requirement of medication, sedation, and local anestlIesia. Dissection is easier and less extensive. There is a lesser incidence of wound infections (less than 1% every year). Most of all, ea
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