The recommendation of the HerniaSurge guideline to use a mesh in all adult patients was modified such that a mesh is used in the majority of patients (88%). Although there is strong evidence that mesh repair is superior to non-mesh repair, there are cases in which non-mesh repair may be suggested.
Due to concerns regarding the use of permanent meshes in connection with adverse events, some patients seek surgeons who offer non-mesh repairs. There are some clinical scenarios in which the use of permanent meshes is contraindicated, for example in infected surgical fields.
In low-income countries, suture repair is preferred due to significantly lower costs and lack of availability of meshes.
The value of non-mesh hernia repairs in young male patients with small lateral hernias (L1-2 hernia) is controversially discussed. The evidence for this is very low and does not allow for a recommendation.
Shouldice is the best non-mesh repair, with experts agreeing that there is a learning curve that should not be underestimated.
Standardization of Patient Selection
The Shouldice technique remains the best evaluated and best standardized non-mesh tissue repair. The Shouldice repair shows lower recurrence rates and better outcomes in the repair of primary inguinal hernias than other suture repairs. Recent data with short- to medium-term outcomes have confirmed that the Shouldice tissue repair is an acceptable choice for the repair of primary hernias under certain circumstances. Two high-quality database studies have shown for selected patient groups with specific hernia characteristics (i.e., smaller indirect and direct hernias < 3 cm, female gender after exclusion of any femoral hernias, younger patients under 40 years, and lower average BMI of 24) that the Shouldice technique can be used with appropriate expertise for primary unilateral inguinal hernia repair and achieves 1-year outcomes comparable to those of Lichtenstein, TEP, and TAPP operations (Köckerling et al. 2018 and 2019).
A systematic review from 2021 on the Shouldice technique, published together with a standardized protocol of the surgical technique with clear key points under the supervision of the Shouldice Hospital, identified the following indications for the Shouldice technique, which were mainly proposed based on low evidence:
- primary indirect and small direct inguinal hernias in young men (EHS classification LI, LII, MI) under 40 years
- Primary indirect and direct hernias in women after exclusion of femoral hernias (EHS classification LI, LII, MI, MII)
- recurrent indirect hernias after primary TAPP or TEP (EHS classification LI, LII–R1) (Lorenz et al. 2021).
Recurrence
Recent data show persistently high recurrence rates of over 10 percent for all surgical techniques in more than 300,000 patients in registry data (Mayo Clinic, ACS-NSQIP, Premier Database) (Murphy et al. 2018). Meshes reduce the recurrence risk with moderate evidence quality and higher seroma formation. In absolute numbers, one hernia recurrence was prevented in 46 mesh repairs compared to non-mesh repairs (Claus et al. 2019, Lockhart et al. 2018). In a database registry analysis of female patients, no significant differences in recurrence rate were reported between Shouldice, transabdominal preperitoneal (TAPP), and total extraperitoneal (TEP) hernia repairs (Köckerling et al. 2019).
The long-term follow-up of the randomized controlled trial by Barbaro et al. 2017 reported a 20-year recurrence rate of 9.7 percent for the Shouldice operation.
A large database study from Germany showed in selected cases of inguinal hernias (average age 40 years, 30 percent women, smaller defects < 3 cm, average BMI 24 and no risk factors) no significant differences in recurrence rate for the Shouldice repair compared to TAPP, TEP, and Lichtenstein (Köckerling et al. 2018).
Chronic Pain
Studies on inguinal hernia surgery found no differences in the presence and severity of chronic pain between Shouldice, Lichtenstein, and laparoscopic operations in postoperative follow-up of up to 5 years (Oberg et al. 2018, Clyde et al. 2020).
The database study by Köckerling from 2018 showed after one year lower rest and exertion pain in favor of the Shouldice technique compared to the Lichtenstein technique. When comparing the Shouldice technique with TAPP or TEP, no differences could be found for these outcome parameters (Köckerling et al. 2018). The second study, which analyzed only women, showed after one year no difference in pain between the Shouldice technique, TAPP, and TEP (Köckerling et al. 2019).
Comparison with Tissue-Based Inguinal Hernia Repairs
The Desarda technique involves reinforcement of the posterior wall of the inguinal canal without the use of synthetic meshes by utilizing an autologous tendon plate (part of the aponeurosis of the Musculus obliquus externus abdominis) as a "biological mesh".
Due to its simplicity, the Desarda technique is currently an interesting option for pure tissue repair. It is based on a small number of small randomized controlled trials of mostly acceptable quality. Since there are no sufficient long-term data, it is too early to recommend this technique for daily practice as an alternative to the established Shouldice repair (Ge et al. 2018, Emile et al. 2018).
The analysis of tissue-based inguinal hernia repairs, particularly in comparison to mesh-based techniques, includes many different specific operations with considerable heterogeneity in methodology and technique. Apart from the Shouldice repair, there is no clear standardization of patient selection, surgical technique, and decision-making based on hernia subtypes. Specific non-mesh repairs include the suture-based techniques of Shouldice, Desarda, Marcy, and Moloney. There are no comparative randomized controlled trials between the different non-mesh techniques, particularly the Desarda and Shouldice techniques, and no comparative studies between minimally invasive and pure tissue procedures. As with all techniques, the expertise of the surgeons influences the outcomes in all surgical techniques (Finch et al. 2019, Bracale et al. 2019).
Recommendation
The HerniaSurge guideline recommends an individually tailored approach to inguinal hernia treatment, including the ability to offer patients both an anterior and a posterior approach. Since tissue repair may be indicated in infections and in shared decision-making with the patient, surgeons are recommended to master the Shouldice technique or refer patients to a surgeon experienced in this technique.