Notes on Shouldice Repair for Inguinal Hernia

Shouldice technique is one of the famous technique for inguinal hernia repair. Below are few notes regarding this technique.

• Supine position with head tilted at 15 degrees, scrupulous surgical technique throughout.
• Incision is at 1cm above and parallel to inguinal ligament from deep ring to pubic tubercle and then caudally runs over pubic tubercle as shown in figure:

• Divide skin and fat upto external oblique aponeurosis and achieve careful haemostasis (superficial pudendal and superficial Epigastric). 
• Insert self retaining retractor and open deep fascia of thigh below inguinal ligament to make sure that there is no femoral hernia.
• Now external oblique aponeurosis is opened in long axis including dividing the superficial ring and its upper medial edge held in haemostats and lifted off the cremasteric fascia/muscle till its attachment with lateral rectus sheath. 
• Similarly the lower lateral flap is lifted off the cord till the upturned deep edge of inguinal ligament. 
• Now cremasteric fascia/muscle is incised in its long axis and cord structures (pampiniform plexus, vas deferens, testicular vessels etc.) are separated from it upto its proximal attachment to conjoint tendon and distal attachment to pubic tubercle followed by clamping, ligating and cutting both ends. 
• Now excise lipoma if present, but do not strip all the fat and areolar tissue otherwise it may result in testicular edema and even a hydrocele. Cord is lateral to inferior Epigastric vessels.
• If the sac is on anterosuperior aspect of cord it is indirect, if medial to vessels it is direct, it can be both as well in case of direct and indirect hernia. 
• If indirect hernia sac is empty it is lifted and freed by gauze dissection and then traced back to its junction with parietal peritoneum and transfixed and excised.
• If sac is not empty (small bowel or omentum); open it and resect if ischaemic contents (either use paramedical incision which is preferable or extend incision medially from deep ring after ligating the inferior Epigastric vessels. 
• If non-ischaemic than adhesionlysis and reduced and ligated with a transfixion and excised. 
• If sliding type (having cecum and appendix on right side or sigmoid colon on left side or urinary bladder medially on both sides) then do not separate sigmoid, cecum or balder from sac and do not perform appendectomy or remove appendices epiploiacae. 
• Manage by clearing the sac as much as possible and then close it with inside out purse string sutures. And push back behind the transversalis fascia.
• For a broad base direct hernia, the sac is not opened, it is only pushed back. But for a narrow necked direct hernia; open it clear it and excise it after ligating it.
• For both direct and indirect inguinal hernia, bring the sac lateral to inferior Epigastric vessels and manage as indirect inguinal hernia.
• Now identify the transversalis fascia; it will be condensation around the deep ring, separate the deep ring from this condensation and lift the medial flap with a haemostat from the extraperitoneal fat and divide the transversalis fascia upto pubic tubercle.
• Now the lower flap is lifted till the deep part of inguinal ligament, take care to ligate the penetrating cremasteric vessels while this.
• Repair the transversalis fascia via a double breasting technique: start from lower lateral flap at a place where it is condensed into aponeurosis and periosteum of pubic tubercle and it is sutured to undersurface of upper medial flap, 2-4 mm apart and with different depth to create a broken saw tooth
  appearance, till it snugly fits the whole space upto the cord. 
• Now suture the upper flap to transversalis fascia upto its attachment to inguinal ligament in the floor of the canal. Continue back to pubic tubercle. 
• Reinforce the conjoint tendon by stitching it to inguinal ligament. Start from lateral side of either structure and take stitches from inguinal ligament and under-surface of conjoint tendon and when pubic tubercle is reached reverse and stitch the conjoint tendon with external oblique aponeurosis about 0.5 cm above the inguinal ligament. Do not tie these too tightly. 
• Place cord back in the canal and stitch the external oblique aponeurosis in double breasted manner starting from medial to lateral side and then back.
• Close subcutaneous tissue and apply adhesive tape or non-penetrating clips to close the skin. Walk when conscious or from table if local anaesthesia is used. 
• Non-narcotic analgesics are used and remove the dressing on fifth day and take bath at same time. Return to work on 7th day and heavy work after 8 weeks. 
• Do any work which does not cause pain.

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