Shouldice / No-mesh Inguinal Hernia Repair

You are having a no-mesh inguinal hernia repair, also called the Shouldice repair. 

 

The procedure:

This repair is performed through an incision in the groin and involves suturing the defect in the abdominal wall back together in four layers. It relies on a patient’s own strength of tissues and healing rather than using mesh to support this repair. Because of this, this type of repair requires strong tissue in the groin. 

One important difference in this approach is that the stitching is being performed in an area where three nerves are present. Without careful attention paid to identifying and avoiding inadvertent injury to these nerves, they can become inadvertently injured resulting in chronic pain. Because of this, we are very careful to find these three nerves and either ensure they are out of the area where they could be injured, move them out of the area where they could be injured or if needed, remove a portion of the nerve to prevent it from being caught in a stitch. Removing a segment of nerve results in a small area of numbness of the skin – a far better outcome than the possibility of developing chronic pain. Removing a segment of the nerve does not affect any physical or sexual function. 

 

Anesthesia:

It is usually accomplished without general anesthesia and most of the time with just IV sedation (similar to the anesthesia for a colonoscopy) and local numbing medication. 

 

Why we recommend this repair:

This type of repair is only an option for patients who are very thin and healthy with smaller hernias who prefer to avoid mesh. As is the case at the Shouldice Hospital where this technique originated, we have to be very careful to choose only the best suited patients for this repair. It is not possible to perform this repair in patients who have a Body Mass Index (BMI) greater than 25, in those who have weaker tissues due to body shape, medical history, or previous surgery in the area. The chance of a hernia coming back is lowest when this is performed in younger, athletic, thinner patients. The surgery usually takes about an hour. 

 

Recovery after No-Mesh inguinal hernia surgery:

Recovery is typically longer with no-mesh surgery compared to mesh surgery. Allowing adequate healing is so essential to this being a strong repair that we limit strenuous activity for 3-4 weeks after surgery. Patients should not do anything more aggressive than casual walking during this period of time. It can be a little more painful of a recovery because of the extensive stitching of strength layers, though patients usually avoid the use of opioids in the recovery period. Because of all of this, we also will only perform one side at a time- if you have inguinal hernias on both the right and the left, we will repair one side and allow you to recover from this before repairing the other side. 

 

Risks of surgery:

During your appointment, you discussed the risks of surgery. Every surgery comes with risk, but we do everything we can to minimize the chance that you have a complication related to one of these risks.

  1. Hernia recurrence – 3/100 – Hernias can come back after repair. After no-mesh inguinal hernia repair, the risk of recurrence is likely 3-5%.

  2. Infection risk – 1/200 – If an infection occurs after surgery, this is usually a skin infection and is well treated with antibiotics.

  3. Chronic pain risk – 1/50 This can occur through stitching or placing mesh over the nerves in the area. The rate of this occurring in this country is 5-15%, when mesh is not used, this risk decreases to about 2% in our experience. We minimize this risk by identifying and managing the nerves as described above.

  4. Bleeding – 1/400 – The risk of any significant bleeding after inguinal hernia repair is less than 1/400 and this is kept very low risk when patients adhere to activity restrictions in the first couple weeks after surgery.
  5. Complication requiring additional surgery – about 1/400 patients require a second operation after their first operation to fix bleeding or an intestinal issue. While this is not common, we take a very proactive approach in order to speed up the healing process.

 

Preparing for surgery: 

  • Please continue to be as active as you normally are. It is safe to exercise as long as you do not have pain with your activities. 
  • Make sure you have acetaminophen (tylenol) and ibuprofen (motrin, advil) at home as these medications are typically all that is needed to treat post-operative pain.
  • No bowel prep is needed before surgery. 
  • You will likely need to have a Covid test within 72 hours before surgery. Our medical assistants give you instructions on how best to arrange this at the time of your consultation. 
  • Depending on what facility you are having surgery in, another step is required prior to surgery: 
    • Newton-Wellesley Hospital – Our medical assistants will schedule you a pretesting phone appointment and we will contact you regarding the scheduling of this appointment. 
    • BOSS – You were given a sheet detailing what you need to do to register prior to surgery. 
    • Surgical Center of NH at Derry – You will receive an email or text from the surgery center itself to register as a new patient.  

 

The day of surgery: 

  • Please arrive promptly at the time you are given as a lot has to happen before you are wheeled into the operating room.
  • You will get an IV, meet the team (including the preoperative nurses, the OR nurse, the anesthesiologist or nurse anesthetist), and see your surgeon and physician assistant in preparation for surgery. 
  • After surgery, you will spend about 1-2 hours in the recovery room before you go home. 

 

After surgery: 

  • Take acetaminophen and ibuprofen together every 6 hours for the first 2-5 days for pain control. 
  • Avoid any activity more strenuous than casual walking for two weeks after surgery.
  • Remove bandage (if present) 48 hours after surgery. 
  • Please see these instructions for more details on your post-operative care.

  • A note on resuming exercise after the 4 week recovery period: Once you are two weeks out from surgery, you can start testing different activities. Approach activities slowly until you are sure they don’t cause you sharp pain. Any activity that causes sharp pain at the incision should be avoided. If you feel well and are active throughout one day, it is normal to feel more sore the next day while you continue to recover. You didn’t hurt yourself so long as you don’t push through an activity that’s causing you pain while doing it. Ultimately, the goal after you are fully recovered is to get you back to all of your activities without restriction. For most of our patients who have this type of surgery, they are back to most of their pre-op activities about 1 month after surgery.  

 

We hope this information has helped you prepare for your upcoming hernia surgery. If you have any questions about the above information, please call our office at 617-466-3373 to set up a follow up appointment so that we can ensure all of your questions are adequately answered and you feel comfortable prior to your surgery.