Reply To: The Shouldice Method: an expert’s consensus

Hernia Discussion Forums Hernia Discussion The Shouldice Method: an expert’s consensus Reply To: The Shouldice Method: an expert’s consensus


@gohaiga (Watchful), I would like to see more research on the cremaster.

The claim is improved visibility to detect secondary hernias and weak spots, which can be addressed at the same time as the main repair…and that the way the cremaster is resected, with the stump included in one of the suture lines, helps reduce the likelihood of recurrence. There seems to be some allusion to it being relevant to detection of sliding hernias too in the 2nd link below, but it is not clear (wasn’t that Pinto’s problem with their initial Kang repair, btw?)

From the Shouldice site:

“As part of the Shouldice procedure, we do a thorough search for other hernias, or weaknesses, in the area and repair them as well. This aspect of our technique is unique and not commonly practiced elsewhere, as most natural-tissue techniques (including Desarda), or virtually all open mesh techniques, do not go deep enough into the pre-peritoneal space to allow exploration of the whole area. Research has shown that up to 13% of people with hernias have a second weak spot in their muscles, or a “hidden” hernia. Our skilled surgeons have the expertise to find these hidden threats; in fact, it‘s one of the most important benefits of the Shouldice repair, by avoiding the need for a potential second surgery.”

From Dr. Bendavid (

“Resection of the Cremaster
This important step seems to have been entirely forgotten. Few students have seen it performed, and fewer surgeons practice it. This step was clearly described and emphasized by Bassini, repeated by Catterina, and perpetuated by Shouldice. The resection of the cremaster and lateral retraction of the cord bring into view the posterior inguinal wall in a manner that can best be described as a “revelation.” It becomes impossible, then, to overlook a direct or indirect inguinal hernia. The transversus abdominis aponeurosis (i.e., the posterior inguinal wall) is now in full view. Whenever possible, the cremasteric vessels should be doubly ligated separately from the cremasteric muscle.”

“Search for Multiple Hernias
Statistics show that a second, simultaneous, ipsilateral hernia was found, if adequately searched for, in 12.8% of the patients who underwent operation. This search in all instances must rule out an indirect hernia, a direct hernia, a femoral hernia, an interstitial hernia, a prevascular hernia, a Laugier hernia (through the lacunar ligament), a prevesicular hernia (anterior to the bladder), and, lastly, lipomas, which on occasion perforate through the internal oblique and transversus muscles at the deep inguinal ring. The search must be established as a routine.”

Now whether that is enough to justify the accompanying risks associated with cremaster resection is another story and remains perhaps the hottest topic of debate with the traditional Shouldice repair.

It would be expensive and time-consuming to carry out a well-designed study, with a large sample, a sufficiently long follow-up period, and controlling for all potentially relevant variables (notably, surgeon expertise) to compare the traditional protocol with a modified one where the only modification relates to the cremaster not being resected…but one can hope!

New Report


Skip to toolbar