Frailty in a low-risk elective setting: a quality improvement study at Shouldice Hospital

This study aims to evaluate the impact of frailty on postoperative outcomes after Shouldice primary inguinal hernia Repair (SPIHR) as a quality control measure in a highly standardized elective setting.

This quality improvement study analyzed data from an ongoing prospective PROM program including patients undergoing primary unilateral or bilateral Shouldice inguinal hernia Repair. Frailty was assessed using the 5-item modified Frailty Index (mFI-5). Postoperative complications were identified via 30-40-day questionnaires and clinically verified when reported. Outcomes were compared between frail and non-frail patients using univariate analyses and multivariable logistic regression adjusted for relevant covariates. Data analysis was performed between December 2025 and January 2026.

A total of 1,300 patients undergoing primary Shouldice inguinal hernia Repair were included (median age 64 years; 94.6% male). Overall, 29.7% of patients were classified as frail (mFI-5 ≥ 1). In univariate analyses, frail patients were older and had a higher body mass index and a greater comorbidity burden compared with non-frail patients. Frail patients also presented with larger hernia sizes for both first and second hernias. Postoperative complications were infrequent and did not differ significantly between frail and non-frail patients. In logistic regression analyses, frailty status was not independently associated with postoperative complications in either unadjusted or adjusted models.

Frailty was present in nearly one-third of patients undergoing Shouldice primary inguinal hernia Repair. Short-term postoperative complication rates were comparable between frail and non-frail patients, suggesting that primary Shouldice Repair is feasible in frail patients within a standardized elective setting.