Chronic pain after Shouldice versus Lichtenstein inguinal hernia repair: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: p < 0.00001

• Effect Size: 34% relative risk reduction with Shouldice technique

• Primary Outcome: Chronic postoperative pain prevalence

• Nnt Or Sensitivity: Shouldice associated with significantly lower chronic pain but 2.54-fold higher recurrence risk

• Confidence Interval: RR 0.66 (95% CI 0.56-0.78)

Clinical Application

Both techniques are established procedures available in Australian hospitals with appropriate surgical expertise Relevant to Australian general surgeons; both techniques covered under Medicare with similar item numbers; choice may influence patient outcomes and healthcare costs Adult patients requiring open inguinal hernia repair, particularly those at higher risk for chronic pain development

Abstract

PURPOSE: The Lichtenstein (mesh) and Shouldice (non-mesh) techniques are the main options for open inguinal hernia repair. This systematic review and meta-analysis compared the prevalence of chronic postoperative pain between them. METHODS: A systematic search was conducted in Medline, Embase and Cochrane databases for studies comparing the prevalence of chronic pain after Shouldice and Lichtenstein techniques in adult patients undergoing inguinal hernia repair. Meta-analysis was performed using RevMan and the effect model was determined based on heterogeneity, assessed by the I² statistic. Subgroup analyses were conducted by mean follow-up duration and study design. RESULTS: Ten studies with 4,122 patients (59.8% Lichtenstein) were included. Shouldice repair was associated with a 34% relative risk reduction in chronic postoperative pain compared to Lichtenstein (RR 0.66; 95%CI 0.56-0.78; p < 0.00001; I² = 5%). Conversely, the Shouldice technique demonstrated a higher risk of long-term hernia recurrence (RR 2.54; 95%CI 1.15-5.63; p = 0.02). There were no statistically significant differences between the two techniques regarding early postoperative complications (RR 1.01; 95%CI 0.85-1.19; p = 0.95) or mean operative time (MD 5.96 min; 95%CI -0.79 to 12.71; p = 0.08). CONCLUSION: Although the Lichtenstein repair is more widely practiced, the Shouldice technique yields significantly lower rates of chronic postoperative pain, albeit with a higher risk of long-term recurrence. This trade-off highlights Shouldice as a potential alternative in selected patients.

References

1. 1.Silva Carvalho, L., Bastos, L., Muricy, E. F., Habib, M. M., Barros, L. S., & de Lima, M. L. A. (2023). Chronic pain after Shouldice versus Lichtenstein inguinal hernia repair: a systematic review and meta-analysis. Hernia, 1-12. https://doi.org/10.1007/s10029-023-02874-0