The Shouldice Method: an expert's consensus

Background Hernia repairs are a commonly performed surgical procedure and the Shouldice Repair of inguinal hernias has been well described before in terms of its outcomes. However, the purpose of this paper was to understand what experts from Shouldice Hospital consider to be the essential steps to the Shouldice Method. Methods Utilizing a Delphi Methodology, surgeons at Shouldice Hospital who are considered content experts, provided their answers on what is essential to the Shouldice Method. The median, interquartile range, and percent agreement from the responses as well as the Delphi's overall Cronbach's Alpha were determined. All Delphi items were ranked on a five-point Likert scale and consensus was reached when Cronbach's Alpha was >= 0.8. The items from the survey that ranked as 5-completely agree or 4-partially agree by >= 80% of participants on the five-point Likert scale were included in the final framework. Results The final consensus for the Shouldice Method included 39 items with 7 overarching steps: preoperative preparation of the patient, anesthetic component, incision and nerve identification, treatment of the cremasteric muscles, hernia identification and treatment, reconstruction of the posterior wall, and post-operative management of patients. Conclusion The results of this consensus provide a step-by-step approach to the Shouldice Method, as well as information that is timely and can be utilized by surgeons incorporating non-mesh hernia repairs into their practice.