Shouldice technique versus other open techniques for inguinal


Inguinal hernia, a condition where abdominal contents protrude through the inguinal canal, is a common problem that requires surgical intervention. There are various open surgical techniques available for inguinal hernia repair, with the Shouldice technique being one of the most debated options. This article aims to compare the Shouldice technique with other open techniques for inguinal hernia repair, focusing on the expertise, authority, credibility, and experience associated with each approach.

Data Collection and Analysis


To ensure the inclusion of relevant studies, all abstracts obtained through our search strategies underwent a thorough assessment by two independent researchers. Studies that did not meet the inclusion criteria were excluded. Full publications of potentially relevant abstracts were obtained and formally assessed for inclusion. Review authors were not blinded to the authors’ names, institutions, journal of publication, or results.

Data Extraction

A data extraction form was created to record important details of the included studies, such as study design, participants, interventions, outcomes, and follow-up. Two authors independently extracted the data, including patient characteristics, surgical techniques, and follow-up information. Discrepancies between reviewers were resolved through discussion with a third author. If any information was missing or required updating, the study authors were contacted for clarification.

Assessment of Methodological Quality

All studies that met the selection criteria were assessed for methodological quality using the scale developed by Jadad et al. This assessment aimed to evaluate the internal validity of individual trials, considering potential sources of bias. The quality of each study was determined based on factors such as detection bias, selection bias, and attrition bias.

Analysis of Data from Individual Trials

Dichotomous Outcomes

Dichotomous outcomes, such as the presence or absence of chronic pain, were reported as proportions and directly compared between treatments. Odds ratios, absolute risk reductions, and numbers needed to treat (NNT) were calculated using these proportions and presented with 95% confidence intervals. For adverse events, the NNT represented the number needed to harm (NNH).

Ordinal Outcomes

When outcome data were presented on an ordinal scale (e.g., none, mild, moderate, severe), a threshold was selected to define clinically significant improvement. These data were then converted into dichotomous form. If splitting the data into dichotomous outcomes was not possible, numeric scores were assigned to each category, and the results were analyzed as continuous data.

Continuous Outcomes

For continuous data, such as the duration of intervention, weighted mean differences (WMD) were reported. If different scales were used to measure the same outcome, standardized mean differences (SMD) were used instead. When variance data were not provided, they were estimated based on primary data or test statistics.

Combining Results Across Studies

A summary analysis of primary outcomes was conducted to provide an overall quantitative estimate of the relative effectiveness of the Shouldice technique compared to other surgical techniques, regardless of whether mesh was used or not. Trials that were deemed clinically heterogeneous were not included in the data synthesis. Data from different time points were pooled to assess the onset and persistence of treatment effects. The final decision regarding which time points to include in the analysis was made by consensus.


Heterogeneity of effect sizes was assessed using statistical tests. An I-squared value greater than 50% indicated substantial heterogeneity. If homogeneity was observed, a fixed-effect model was used for the analysis. In cases of significant heterogeneity, a clinical review of the data was performed to identify the source of heterogeneity. Depending on the findings, the analysis was either redone using homogeneous subgroups or presented as a narrative review of the literature. If necessary, a random-effects model was used for the analysis.

Sensitivity and Subgroup Analyses

Sensitivity analyses were planned to explore the influence of study quality on the effect size. Additionally, analyses excluding very long or large studies were conducted to assess their impact on the results. Subgroup analyses were performed based on the setting (specialized/non-specialized surgery center) and trial country (Canada/other countries) to explore potential differences in effect size.

Grading of Evidence and Clinical Implications

The quality of evidence and clinical implications were graded based on a single-component approach, prioritizing factors such as detection bias, selection bias, and attrition bias. Discordance between data sources was resolved based on this grading system, with higher-grade studies given greater weight.

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The comparison of the Shouldice technique with other open techniques for inguinal hernia repair requires a thorough examination of the available evidence. By considering factors such as expertise, authority, credibility, and experience, we aim to provide a comprehensive analysis of these surgical approaches. Stay tuned for the results, as we delve into the data and shed light on the optimal choice for inguinal hernia repair.

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