Dr Jurij Gorjanc is a highly respected specialist in hernia surgery and a leading expert in the field of abdominal wall surgery. With an impressive international career and a host of awards to his name, he has built an outstanding reputation as a surgeon. Following his training in Slovenia, Dr Gorjanc moved to Austria in 2011, where he further honed his expertise in hernia surgery as a specialist.
Not only was he admitted to the prestigious Royal College of Surgeons of England, but he also made a significant contribution to the further development of the discipline. Dr Gorjanc served as President of the Slovenian Hernia Society for 15 years and has also made a name for himself at European level, notably through his appointment as a “Fellow of the European Board of Surgery – Abdominal Wall Surgery” (FEBS AWS). This distinction is awarded only to specialists who make outstanding scientific contributions and can demonstrate a high number of successful abdominal wall operations.
In addition, Dr Gorjanc volunteers in international aid missions and has already operated on patients with hernias in countries such as Tanzania, Madagascar, Ghana, Liberia, Mongolia and India. His expertise encompasses both open and minimally invasive surgical techniques, which he uses to treat a wide range of abdominal wall hernias. He employs modern methods that accelerate healing and minimize complications. Dr Gorjanc is not only an experienced surgeon but also a dedicated researcher who is constantly working on the development of new surgical procedures.
His high level of professional competence and the quality of his work are underlined by the ‘Quality-Assured Hernia Surgery’ seal from the German Hernia Society. Anyone placing themselves in Dr Gorjanc’s care can be sure they are in the best of hands. With his in-depth knowledge, extensive experience and international commitment, Dr Gorjanc sets standards in hernia surgery and offers his patients the best possible treatment. The editorial team at Leading Medicine Guide was able to learn more about Shouldice hernioplasty in a conversation with Dr Gorjanc.
An inguinal hernia occurs when a portion of the intestine or other tissue protrudes through a weak spot in the abdominal wall in the groin area. This condition can cause unpleasant symptoms such as pain and a feeling of pressure, particularly when lifting heavy objects or during physical activity. In most cases, an inguinal hernia should be treated surgically to avoid complications such as the strangulation of bowel loops. There are various ways to treat an inguinal hernia, but one particularly proven method is the Shouldice hernioplasty. This surgical technique, which does not require the use of synthetic meshes, instead utilizes the patient’s own tissue to reconstruct and strengthen the abdominal wall. With a remarkably low recurrence rate and excellent long-term results, the Shouldice method has established itself as one of the preferred procedures for treating inguinal hernias.
Shouldice hernioplasty is considered one of the most proven open surgical methods for treating inguinal hernias and offers several notable advantages compared to other procedures.
“Shouldice hernioplasty is an established open surgical method for treating inguinal hernias, characterized by a high success rate and a low recurrence rate (less than 1–2% in specialist centers). This method uses only the patient’s own tissue and does not require a synthetic mesh, thereby reducing the risk of mesh-related complications such as infections or chronic pain, which can occasionally be associated with synthetic meshes. Over decades, the Shouldice technique has proven its worth, particularly in younger patients under the age of 18, but also in older patients. It also offers specific advantages for patients with mesh allergies, those with concerns about foreign materials, or those with contraindications for minimally invasive procedures, for example due to general health, pre-existing conditions or previous operations. The method is also suitable for infected groins, for example following bowel incarceration and perforation. Furthermore, it is used successfully in countries where plastic meshes are not widely available or by surgeons with specialized experience, as they generally achieve exceptionally good results and further strengthen confidence in this method,” explains Dr Gorjanc at the start of our conversation, adding:
“Despite the advantages of minimally invasive procedures such as TEP or TAPP, such as reduced post-operative pain and faster recovery, Shouldice hernioplasty has retained its firm place in hernia surgery. Minimally invasive procedures are technically demanding, require a longer learning curve and carry specific risks such as injury to intra-abdominal structures. Furthermore, they are not ideal for patients with extensive previous abdominal surgery or those with limited general tolerance for general anesthesia. Although cost is rarely a decisive factor in modern European medicine, the Shouldice method is significantly more cost-effective than laparoscopic procedures while still achieving excellent results. Shouldice hernioplasty remains a relevant method, particularly in specialist centers and for specific patient groups. It complements minimally invasive procedures and has not been completely superseded by them. The choice of the optimal treatment method always depends on the individual needs and circumstances of the patient. Every hernia surgeon should also be proficient in a mesh-free method for treating inguinal hernias, with the Shouldice technique considered the leading approach in this field.
Shouldice hernioplasty is an open surgical technique developed specifically for the treatment of inguinal hernias. The method focuses on using the patient’s own tissue to reinforce the abdominal wall, rather than using mesh material. The technique is characterized by its high success rate and low recurrence rate.
“The Shouldice hernioplasty is based on a reinforced layer-by-layer reconstruction of the abdominal wall with the aim of restoring anatomical integrity and minimizing the likelihood of recurrence. Local or regional anesthesia, such as spinal anesthesia, is usually used for this procedure, as it offers advantages such as faster recovery and a lower risk of systemic complications. The procedure begins with an incision over the inguinal canal, followed by step-by-step dissection of the tissue layers to expose the hernial orifice and the hernial sac. The hernial sac, which consists of the peritoneum, is isolated. In indirect hernias, the sac is ligated and removed, while in direct hernias, the hernial sac is reduced into the inguinal canal. Reconstruction of the posterior inguinal wall is performed using a continuous suture in four layers. In the first layer, the fascia transversalis is sutured to the so-called ‘conjoint tendon’, or plicated in the second layer. The internal abdominal muscle is then also fixed to the inguinal ligament in two layers. Finally, the external oblique aponeurosis is closed over the spermatic cord, thereby restoring the inguinal canal. This procedure requires precise surgical skills and is more time-consuming than modern mesh procedures. The Shouldice method is preferred for slender patients and smaller inguinal hernias, as the procedure can be technically more demanding in obese patients or with large hernias. “As only the patient’s own tissue is used, there is no risk of mesh rejection or infection,” explains Dr Gorjanc, outlining the various steps of the operation. The recurrence rate following a Shouldice hernioplasty is generally very low and comparable to other methods, making this technique a preferred choice for many surgeons, particularly for patients seeking a permanent solution without the use of foreign material.
Shouldice hernioplasty differs in several respects from minimally invasive techniques such as laparoscopic hernia repair, particularly in terms of pain and recovery time.
Dr Gorjanc comments: “Immediate post-operative pain is usually slightly more severe with the Shouldice procedure, as it is an open procedure in which the tissue layers are directly dissected and sutured under slight tension. With laparoscopic hernia repair, there is less pain immediately after the operation, as the minimally invasive method requires smaller skin incisions and is tension-free. The return to everyday activities usually takes 1 to 3 weeks with laparoscopic procedures, whereas the Shouldice technique requires around 2 to 4 weeks”.
The Shouldice method for treating inguinal hernias is particularly suitable for certain patient groups and types of hernia where the surgical procedure is straightforward and there are no serious additional health problems.
“The Shouldice technique is particularly suitable for younger patients and those in good general health, as it requires good tissue quality and works exclusively with the body’s own tissue. It is ideal for slim or normal-weight patients, as the anatomy in the surgical area is easily accessible and the tension of the sutures is less stressful. Obese patients or those with high abdominal pressure, for example due to chronic cough or ascites, are, however, considered less suitable candidates. The method is primarily preferred for small to medium-sized direct or indirect inguinal hernias where the hernial orifice is easy to reconstruct. Large or complex hernias with significantly weakened tissue may require a mesh, which is not used in the Shouldice technique. The Shouldice method is also attractive for patients who wish to avoid synthetic materials such as meshes, whether for personal or medical reasons such as allergies or a fear of foreign body reactions. It is particularly suitable for patients at increased risk of infection, as no synthetic materials are used, and for patients with contraindications to general anesthesia, as the operation can be performed under local anesthesia. Bilateral or recurrent hernias following open procedures are better suited to laparoscopic methods such as TEP or TAPP. “The decision to use the Shouldice method should always be made on a case-by-case basis, based on the patient’s profile, the size and complexity of the hernia, and the surgeon’s experience,” explains Dr Gorjanc, clarifying which patients are better off not having the technique used:
“The Shouldice method is less suitable for patients with very large or complex hernias, as the tension created by the suturing technique can increase the risk of recurrence. Obese patients, those with chronic cough, high physical exertion or high intra-abdominal pressure—such as due to COPD or chronic constipation—may also benefit less from this method. Previous operations or scar tissue in the groin region further complicate the technique, as the local anatomy may be altered. In such cases, mesh-based procedures are often preferable. Similarly, bilateral or recurrent hernias are considered better suited to laparoscopic methods such as TEP or TAPP. The decision to use the Shouldice method should always be made on an individual basis, based on the patient’s profile, the size and complexity of the hernia, and the surgeon’s experience.
Shouldice hernioplasty is still regarded as one of the most effective and reliable methods for treating inguinal hernias, particularly in terms of long-term outcomes. Studies and clinical data show that the method has particularly low recurrence rates compared to other hernia operations.
Although there are now widely accepted and commonly used laparoscopic methods such as TAPP and TEP, and an excellent open method for inguinal hernia repair such as the Lichtenstein technique, the Shouldice procedure has by no means been forgotten. Recurrence rates with other techniques are comparable, but the surgeon must have expertise in the procedure. Dr Gorjanc explains: “Studies show that the recurrence rate of the Shouldice technique in specialist centers where surgeons regularly use this procedure is below 2%, as is the case, for example, at the Shouldice Clinic in Ontario, Canada. The best results are achieved with small to medium-sized indirect hernias. In less experienced hands, however, the recurrence rate can be higher and often lies in the range of 4–8%, as the method is technically demanding and requires a high degree of precision. By comparison, the Lichtenstein repair, an open procedure using mesh, is considered the gold standard for open inguinal hernia surgery. It achieves a recurrence rate of 1–3% in most centers and is less demanding and universally applicable. The laparoscopic methods TAPP and TEP also have a recurrence rate of 1–3%, which is comparable to the results of the Shouldice technique when performed by experienced surgeons.
The Shouldice hernioplasty is one of the most effective methods for treating inguinal hernias; however, as with any surgical technique, certain risks and complications are possible. It is important to consider these in advance, even though they are generally rare.
“General, non-specific risks such as infections, hematomas and recurrences are similar to those of other methods and are shown in the table below. Specific risks associated with the Shouldice method include postoperative pain, which can occur in 10–15% of patients. Chronic pain affects up to 5% of cases in the long term and, in rare cases, requires further treatment. However, it is important to note that these risks occur significantly less frequently in specialist centers than in other clinics. Testicular complications such as testicular atrophy are rare (<1%), but must be taken into account with the Shouldice technique, as surgeons frequently perform a resection of the cremaster muscle, as described in the original technique. Further details can be found in the table below,” says Dr Gorjanc.
The risk of recurrence could be increased in some cases by inadequate suturing techniques or incomplete restoration of the abdominal wall structure following surgery. Hematomas (bruising) and serous collections (seromas) are further possible complications, as with all other operations. A seroma occurs when fluid accumulates under the skin and often needs to be treated by drainage. These complications are also relatively rare, but are possible if the healing process does not proceed optimally.
Following a Shouldice hernioplasty, careful post-operative care is crucial to promote the healing process, prevent complications and achieve the best possible results.
Most patients can return to their daily routine relatively quickly after the operation, although it is important to follow the recommended aftercare instructions consistently. “In the immediate postoperative phase, which covers the first few days up to two weeks after the operation, patients usually remain in hospital for one to two days so that the healing process can be monitored. Particular attention is paid to signs of infection such as redness, swelling or fever, bruising, bleeding and difficulty urinating. Painkillers, usually non-steroidal anti-inflammatory drugs such as ibuprofen or paracetamol, are administered, and local cooling, for example with ice packs, helps to reduce swelling. Early mobilization is essential; patients should get up and walk around within 24 hours to promote blood circulation and prevent thrombosis. Strenuous physical activity and sudden straining of the abdominal muscles should be avoided. The wound should be cleaned daily in accordance with the doctor’s instructions, for example using antiseptic solutions. At the first follow-up appointment, which usually takes place 7–10 days after the operation, the doctor checks the wound healing. Non-absorbable sutures are removed approximately 7–14 days after the operation. During the medium-term follow-up period, which lasts around two to three weeks, light activities such as walks and everyday tasks are permitted. However, lifting or carrying loads exceeding 5–10 kg, as well as sporting activities that strain the abdominal muscles, such as weight training or jogging, should be avoided. From around four weeks onwards, it is possible to resume sporting activities, depending on recovery and following medical clearance. More intensive activities or heavy lifting should also only be undertaken after consulting your doctor. For high-risk patients, such as those with high abdominal pressure, additional follow-up examinations may be advisable to ensure the healing process is optimally supported,” recommends Dr Gorjanc, and with that we conclude our conversation.
Thank you very much, Dr Gorjanc, for this important information!
