More than 98% of our cases are performed with our natural tissue technique…without the use of mesh.

The Shouldice repair is internationally recognized as one of the safest and most effective techniques for repairing hernias. When performed by a specially trained and well-experienced Shouldice surgeon, this pure, natural tissue repair virtually eliminates complications or repeat hernias (recurrences). For over 70 years, we have maintained a success rate of 99.5% on primary inguinal hernias – an accomplishment that sets us apart from any other medical facility.

How are hernia repaired?

The type of hernia repair performed by your surgeon will depend on the size and location of the hernia, anaesthesia risk, strength of the surrounding tissue and the expertise of the Surgeon.

Hernias can be repaired in one of the following two ways:

1. Using your Natural Tissue without the use of surgical mesh.

These repairs are often called “anatomical” repairs as they use your own tissue to repair the hernia defect.
Natural tissue repairs are always performed using an “open anterior” surgical procedure which entails making an open incision over the hernia site, in contrast to laparoscopic procedures as outlined below.

Groin hernias make up over 80% of all abdominal wall hernias, and over the past 100 years, many natural tissue repairs have been developed with the Bassini, McVay and Shouldice methods being the most recognized. Although all these methods differ in their approach to reconstructing the abdominal wall, they are all similar in that they use the body’s natural tissue instead of mesh, and use permanent sutures to approximate the surrounding tissue around the hernia defect and repair the posterior wall of the inguinal canal.

Natural tissue repairs can be used to successfully repair virtually all direct and in-direct inguinal hernias and many ventral hernias. Mesh is most often required when the surrounding natural tissue is inadequate, or of poor quality, to allow for a strong anatomical repair – this is most often seen when repairing femoral, large incisional and recurrent hernias. Shouldice Hospital uses natural tissue repair whenever possible, or in over 98% of all its hernia cases.

Natural tissue repairs can safely be done using local and conscious IV sedation which avoids the complications of general anaesthesia.

2. Using Synthetic Mesh to either “patch” or “plug” the hernia defect instead of your natural tissue.

Hernia repair using mesh can be done by using either the “open anterior” surgical technique or using a Laparoscopic approach.

a) Open anterior mesh repairs use the same initial approach as natural tissue repairs, however, instead of suturing the fascial tissue and muscle layers together to repair the hernia defect, synthetic mesh is used. There are many types of mesh repair techniques but the most recognized is the Lichtenstein patch technique (75% of all cases), plus numerous others which includes Plugs, Plugs and Patches and other hybrid systems.

In the patch method (Lichtenstien) the hernia defect is overlaid with synthetic mesh which is then secured using either sutures or with a range of other methods including tacks, staples or glues.

In the plug method (Rutkow), a mesh plug is used to fill the hernia defect like a cork stoppering a bottle. The plug is then secured by a variety of methods.

In plug and patch systems, an overlay mesh patch is anchored over the plug. In other hybrid techniques an underlaid patch is added to the overlaid patch and plug to form a once piece plug with top and bottom mesh patches. The underlaid patch is “splayed” and left unsecured while the overlaid patch is anchored.

What is common in all these techniques is the anchoring of the mesh, which puts tension on the surrounding tissues, particularly over time as the mesh shrinks and hardens.

Some of these methods often claim they are not anchored (tension free, at least initially) but this in itself creates issues when the mesh moves or “migrates”. These are more fully outlined in the following section natural tissue vs. mesh in hernia repair.

b) Laparoscopic repairs are always performed under General Anaesthetic and always use mesh, as it is very difficult to do a true anatomical or natural tissue repair laparoscopically.

In this approach, three 1 cm punctures are made in the abdominal wall, one to allow a surgical scope to be inserted, along with two additional narrow tubes (trocars) to allow placement of the surgical instruments. The abdomen is inflated with carbon dioxide to create a positive pressure in the abdominal cavity that allows the bowel to fall away from the operative site, thus identifying the hernia. The hernia is then repaired by stapling, tacking or glueing a mesh patch over the defect from behind (“posterior”).

How does Shouldice repair Hernias?

For over 70 years, Shouldice Hospital has been committed to repairing hernias whenever possible using your own natural tissue, and we do so in over 98% of all cases.

Why introduce a foreign body that ignores physiology, and does not match human tissue and anatomy, where natural-tissue techniques can successfully and safely repair the hernia and restore the body’s natural anatomy?

Few people know that Shouldice Hospital was a pioneer in the early development of mesh in the 1980’s. We are not “anti-mesh”; rather, “we are against the indiscriminate and injudicious use of mesh”.

Why do we avoid the use of mesh whenever possible? The answer is simple. “No mesh technique has surpassed the results achieved by the experienced surgeons of Shouldice Hospital when natural tissue repairs are used to repair the hernia defect”.

Our recurrence rate for primary inguinal hernias of around 1% is more than comparable to the best results of any mesh surgeon in the world, yet we do so with a complication rate of <0.005 (less than one half of one percent). When we compare this with the growing evidence of mesh related complications ranging between 10 and 20% it is hard to justify the use of mesh when there are safer, and more reliable, natural tissue alternatives.

The obvious question is why do we use mesh at all? The answer is again simple. To achieve the best surgical outcome, not all hernias can be repaired using the body’s natural tissue. There are times when the tissues surrounding the hernia defect are so poor, damaged or missing, that mesh must be used to reinforce the repair. Mesh, at times, may be required when repairing recurrent hernias, incisional hernias, most femoral hernias and large umbilical hernias. Mesh is rarely required in any primary direct inguinal hernia, and virtually never needed for primary indirect inguinal hernia repair.

Almost all of the hernia repairs at Shouldice are done using local and IV conscious sedation which enables patients to sleep during the operation and adds to the safety of our technique. This approach improves recovery, and ensures that our patients are comfortable during surgery. Additional medication may be used when necessary or, in some rare cases, a general anaesthetic may be required.

Most importantly, while working at Shouldice, every surgeon on the Shouldice team focuses their professional time and training on becoming an expert on the successful lifelong repair of external abdominal wall hernias. On average, each Shouldice surgeon performs over 700 hernia operations a year, giving them the experience, and skills, to expertly manage even the most complex hernia repair. When it comes to successful hernia repairs, there is simply no substitute for repetition and experience.

In a [Can J Surg, Vol.59, No.1, February 2016] landmark study, originating independently of Shouldice, from the University of Toronto 1 (NTR – link to Article) 235,192 hernia patients were followed-up over a 14 year period (1993-2007) with a total follow-up period of 16 years and 3 months. All patients had primary groin repairs, and were divided into 5 populations based on the volume of hernias performed at the respective hospital. Shouldice patients represented one entire group for direct comparison. The published results revealed that the recurrence rate of all general hospitals in the Province of Ontario ranged from 5.21% among lowest volume hospitals to 4.79% for patients at the highest volume hospitals. By contrast patients who had surgery at Shouldice Hospital had standardized recurrence risk of 1.15%. Within these populations mesh was used in 85.7% of patients in non-Shouldice hospitals and in only 1.46% at the Shouldice Hospital.

The Operation

The muscles and connective tissue of the abdominal wall are arranged in three separate layers. Before repairing any weakness, we gently place fatty tissue, and any part of the intestine (bowel) that may have bulged through the abdominal wall, back inside the abdomen. Then we repair each muscle layer individually, using a technique that puts virtually no immediate, nor long-term, tension on the natural tissue. By carefully overlapping and securing each layer, just like you do when you button a coat, we strengthen and reinforce this section of the abdominal wall using only your natural tissue.

As part of the Shouldice procedure, we do a thorough search for other hernias, or weaknesses, in the area and repair them as well. This aspect of our technique is unique and not commonly practiced elsewhere, as most natural-tissue techniques (including Desarda), or virtually all open mesh techniques, do not go deep enough into the pre-peritoneal space to allow exploration of the whole area. Research has shown that up to 13% of people with hernias have a second weak spot in their muscles, or a “hidden” hernia. Our skilled surgeons have the expertise to find these hidden threats; in fact, it‘s one of the most important benefits of the Shouldice repair, by avoiding the need for a potential second surgery.

At Shouldice, we firmly believe that it is in the best interests of our patients to cure hernias permanently by finding and repairing all secondary hernias the first time.

The Recovery

Patient recovery begins the moment the operation is over. Patients not requiring general anaesthesia are able to walk out of the operating room, assisted by the surgical team to a wheelchair, and comfortably returned to their room. Within hours patients will be up and about, and by the next morning, doing gentle exercises along with all the other patients. Throughout their stay patients are supported by a buddy system, their roommate and new friends, who are sharing the same experience. This allows for discussion and comparison of their recovery, thus alleviating anxiety and stress that would be taken home to their family.

During the recovery, patients receive a holistic program of patient care that encourages a safe, healthy and rapid return to normal activities. Most of our patients are back to their regular routines in less than a week, and some even go back to work as soon as they are discharged from the hospital.

Our repair techniques have been widely acclaimed, but it is the total Shouldice experience that underlies our success and attracts patients from around the world to our hospital.