The Shouldice Procedure:
Close to Home
If you are interested in an inguinal hernia repair without mesh, our surgeons are trained in the Shouldice procedure. This specialized tissue repair may be an option for selected patients. Your surgeon will assess your hernia and discuss whether it fits your needs and goals.
Learn about the procedure, patient selection, and recovery below.
The Shouldice procedure has been around and well studied since 1945 and is an excellent alternative to the traditional open inguinal hernia repair with mesh. The concept of the Shouldice repair is to restore the abdominal wall and groin region to normal anatomy using only sutures (stitches). This is performed through a groin incision and the repair brings 4 separate layers of tissue together, dispersing the tension over 4 different layers, thereby reducing the chances of recurrence versus a 1 or 2 layered closure.
Why Choose the Shouldice Procedure?
You might want to choose the Shouldice procedure for your hernia repair if you:
Do not want implantable mesh
You have a small or medium inguinal hernia
You are otherwise healthy and want to remain active
You might not be a candidate if your hernia is larger, you have a femoral or obturator hernia, or you have multiple other medical problems. The Shouldice procedure may also not be ideal for recurrent hernias, as you may need additional reinforcement in the form of a synthetic mesh. Discuss your options with one of our Experts.
The Procedure
The Shouldice procedure involves an incision through the groin and then isolation of the outermost oblique muscle, which overlies the inguinal canal, the external oblique. The oblique is cut to enter the canal and then the spermatic cord (in men) or the round ligament (in women) is seen.
The inguinal floor and the hernia are identified. The hernia sac, the lining around the hernia contents, is separated from nearby structures and returned to the abdominal cavity. The repair then begins. The transversalis fascia, a connective tissue layer forming the floor of the inguinal canal, is opened to prepare it for reconstruction.
The two flaps of transversalis fascia are identified. The first suture line brings the lower flap toward the connective tissue beneath the rectus abdominis and the internal oblique–transversus abdominis region, beginning the layered reconstruction of the inguinal floor.
A continuous suture forms the first row. The suture then returns in the opposite direction to form the second row, securing the upper flap to the inguinal ligament region.
The second row is tied to the starting end of the suture to complete the first two layers.
The third and fourth rows use another continuous suture to reinforce the repair with the internal oblique–transversus abdominis tissues and the inguinal ligament/external oblique fascia. The four overlapping suture rows distribute tension across the reconstructed inguinal floor.
The external oblique layer is then closed, followed by the skin. The cross-sectional illustration shows the four-layer repair and the closure layers.
The Recovery
Recovery after a Shouldice repair is individualized. Your surgeon will advise when to return to work, lifting, exercise, and vigorous activity based on the size of your hernia, the repair, your health, and your progress. Follow your specific discharge instructions rather than a fixed timetable.
Shouldice repair avoids implanted mesh, but it still carries risks, including pain and hernia recurrence. Your surgeon will discuss these tradeoffs and how they apply to your case. We focus on careful patient selection, surgical technique, and ongoing review of our outcomes.
Contact your surgical team about a new bulge, persistent or worsening pain, or other concerns. For more general information, see inguinal hernia repair and recovery.