Intial Experience with the Shouldice Procedure for Inguinal Hernia Prior to Renal Transplantation

Abstract

A 56-year-old male patient visited urology department of the hemodialysis clinic because of discomfort and bulging in the left inguinal region for several months. He was referred to our hospital with a diagnosis of left inguinal hernia. In consideration of future kidney transplantation, the urologist requested a surgical procedure that does not use a mesh. While the Shouldice procedure has a reported recurrence rate of 1.15% and is a tissue-to-tissue herniorrhaphy procedure recommended by international guidelines, it is rarely performed in Japan. In fact, a search of the Japan Medical Abstracts Society for the keyword ‘Shouldice procedure' (excluding conference proceedings) yielded only six results. Following are the steps different in the Shouldice method compared to other conventional methods : (1) the cremaster muscle is dissected in the inguinal canal, and the lateral segment is wrapped around the spermatic cord to “externalize the internal inguinal ring,” (2) the posterior inguinal canal wall is incised and the preperitoneal space is fully dissected, and (3) the rectus abdominus muscle and internal abdominal oblique muscle are used for repair with four layers of sutures. In this report, we describe a rare case in which the Shouldice method, which is very rare in Japan, was used as a tissue suture method without a mesh.