Shouldice standard 2020: review of the current literature and results of an international consensus meeting



For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair has been proven to entail better results in randomized trials. Since the first publication 1953 the Repair has been described in detail in many textbooks, articles and You Tube videos. It appears that the original technique is used almost exclusively in the Shouldice Hospital in Thornhill/ Canada and despite the success of the Shouldice Hospital many surgeons inexplicably modify this original technique in their daily practice. In the last couple of years there appears to be an increasing interest in pure tissue repairs for various reasons, often fear of mesh-related pain. The aim of the study was to review the current evidence and to define an updated standard with key principles of the Shouldice repair.


Because of unpublished evidence regarding many operative details the organizing group decided to create a technical update via a consensus meeting with 13 international designated hernia surgeons from six countries. In preparation of the meeting a review of the current literature regarding Shouldice repair was done by the organizing group. A questionnaire was prepared and sent to all participants before the meeting to get an independent answer on all critical aspects.


All questions regarding a detailed standard of the operation technique could be outlined. As result of the consensus meeting the participants have formulated all key-points of preparation/dissection and repair of the Shouldice technique. For 5 of 6 critical technical surgical steps a strong consensus could be defined in the group. There was no consensus among the group regarding the cremaster resection and the ideal indication for Shouldice repair.


After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.

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© W. Hope Textbook of Hernia)


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Corresponding author

Correspondence to R. Lorenz.

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Conflict of interest

RL, GA, JC, RF, JG, AK, JM, VO, and JC have no conflicts of interest.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki and its later amendments or comparable ethical standards.

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All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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For this type of study, no informed consent is required.

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This paper is dedicated to MD Robert Bendavid (who died on September, 30th, 2019) and MD Dennis R. Klassen (who died on July 29th, 2020).

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Lorenz, R., Arlt, G., Conze, J. et al. Shouldice standard 2020: review of the current literature and results of an international consensus meeting. Hernia (2021).

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  • Shouldice repair
  • Groin hernia
  • Pure tissue repair