Patient Education

Toronto, ON Hernia Treatments & Surgery

Benefits of the Shouldice techqnique over
the minimal access surgery

Shouldice Repair Technique

NTHR adheres to the Shouldice technique of repair. The incision itself depends on your size, but is generally only 3-4 inches in length. It is quite comfortable for patients after surgery. We prefer this 'open' technique of surgery as it allows your surgeon the best view of all your tissues at the surgery site. We are able to see nerves and vessels up close to manage them properly. In the repair of groin hernias we design a tailored (to you), hand sewn, continuous, meshwork of flexible, permanent, modern, suture and is placed, in layers, into the floor of the inguinal canal. The muscles are gently placed without undue tension (pulling) into a flexible, vital, alive and reinforced framework next to each other using the inguinal ligament at it's base.

Minimal Access Surgery and surgeries using artificial mesh

Minimal access surgery relies on newer laparoscopic or small (minimal access surgery) incision techniques. The thinking is that such minimal access incisions allows fixing of the hernia with minimal discomfort. We feel this compromises the view and the assessment your surgeon has of your tissues.

It compromises your surgery in some very important ways:
Reoccurence rates: Minimal access operations do not allow for a complete examination of all the structures of that area. With our slightly larger incision, we often (about 10%) discover nearby weaknesses that should and can be repaired as well, during surgery. We feel this is the reason why others have high recurrence rates. They are not recurrences per se and are avoidable. Other operations, with minimal access, simply don't discover these other nearby weaknesses at the first opportunity, because they don't see it adequately. This particularly applies to groin hernias.

Using these tiny incisions one cannot place the mesh in its proper location: We have known for some time that adequate hernia surgery with mesh demands that, as often as possible, one should place the mesh not on top of the muscle (surgically, we call this the On-lay, or Lichtenstein technique) but below the muscle (Sub-lay) and secured properly to ligaments in the area. This allows the pressure from inside the abdomen (or tire using our analogy) to work in your favour and not against you thus lifting the patch off prematurely, causing early recurrence of the hernia.

Increasing risk: Making a tiny incision and stuffing a piece of plastic mesh into or around the area of weakness down this tiny hole is risky. Adequate visualization of all the anatomical structures in that area is key to preventing inadvertent injury to nerves and blood vessels. We prefer to have adequate visualization of tissues and not compromise your repair in any way.

Shrinkage of artificial mesh:


What's the big deal with using mesh any way? Aren't synthetic material implanted into the body all the time without much problem. Yes this is true, like knee and other joint replacements, fixing aneurysms etc. However, these are areas that:

1. Are not constantly being pulled and stretched all the time.
2. Are not directly in contact with nerves, that if injured can cause chronic pain.
3. The synthetic materials used for knee replacement and so on, do not undergo significant shrinkage over time. However, mesh used in traditional hernia repair, shrinks by 16-30% in size. This can take many years; which is why many hernias show up so many years after the initial surgery. Mesh surgeons generally quote recurrence rate number only over a few years. Our muscle transposition technique (Shouldice) doesn't shrink because it does not use a plastic sheet. We only use your own alive and flexible muscles. Your own muscles are just held in a slightly different position, enough to block your hernia for the rest of your life. No shrinkage, no recurrence.

The Shouldice repair technique has follow up recurrence rates (<0.5%) over decades.