Shouldice versus Lichtenstein inguinal hernia repair: A meta-analysis of randomized controlled trials

Background: The Lichtenstein technique is the standard treatment for adult open inguinal hernia repair. Among the non-mesh repair techniques, Shouldice has shown the best results and is comparable to mesh repairs in selected cases. Due to the risk of chronic groin pain associated with the Lichtenstein technique, Shouldice has increased in popularity, and some surgeons have adopted it as a viable first-line option. Methods: MEDLINE, Cochrane, Central Register of Clinical Trials, and EMBASE for randomized controlled trials (RCT) published until February 2024. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed using the Cochran Q test and I-2 statistics with p -values < 0.10 and I-2 > 25% considered significant. Statistical analysis was performed using R Software, version 4.1.2. Results: Fourteen RCTs comprising 2784 patients were included, of whom 1379 (47.5%) were submitted to the Shouldice hernia repair and 1513 (52.5%) to the Lichtenstein technique. Shouldice was associated with a significant increase in the recurrence rate (4.2% vs. 0.9%; RR 3.68; 95% CI 2.05-6.60; p < 0.001; I-2 = 0%) compared with Lichtenstein. The number needed to treat (NNT) to prevent one Shouldice recurrence was 30.3. There were no significant differences between groups in chronic pain, urinary retention, bladder injury, testicular atrophy, wound infection, hematoma-seroma, or hypesthesia. Conclusion: The Lichtenstein technique was associated with reduced recurrence rates compared with Shouldice in patients undergoing inguinal hernia repair. However, the overall recurrence rate with the Shouldice technique was still low (4.2%), suggesting that it may be a viable option in selected patients.