A comparison of a new two-layer anatomic repair to the traditional shouldice herniorrhaphy

Since 1976, the Shouldice repair has been the herniorrhaphy of choice at the Veterans Administration Medical Center, Augusta, Georgia. The authors previously reported their experience with this technique, and their recurrence rate of 1.8 per cent was consistent with the experience of the Shouldice clinic. It is often difficult to obtain adequate tissue for a four-layer repair in patients with recurrent hernias or in those patients with large direct or indirect inguinal hernias. In these instances, a two-layer running closure similar to the Shouldice was performed, but the shelving edge of the inguinal ligament was sewn to the conjoined area in one layer and then the fascia of the internal oblique to the inguinal ligament in the second layer. To obtain an estimate of the recurrence rate with this modification, the authors reviewed their herniorrhaphy experience from 1984 to 1988. During this period, 420 herniorrhaphies were performed. Two hundred twenty-six patients were available for follow-up. Of this group, 154 patients had a traditional four-layer Shouldice repair; there were two recurrences in this group (1.2%). Seventy-two patients underwent the described two-layer repair; there were no documented recurrences in this group. Based on this experience, the authors believe that the described running two-layer herniorrhaphy is a valuable alternative when the tissue is inadequate to allow a traditional Shouldice repair. This procedure has now become the authors' method of choice for the majority of repairs.