Is Shouldice the best NON-MESH inguinal hernia repair technique? A systematic review and network metanalysis of randomized controlled trials comparing Shouldice and Desarda

Background: Current guidelines state that the Shouldice technique has lower recurrence rates than other suture repairs and therefore is strongly recommended in non-mesh inguinal hernia repair. Recently a new tissue repair technique has been proposed by Desarda and studied in trials against Lichtenstein technique. Methods: The present study was performed according to the PRISMA Statement for Network Meta-analysis and the AMSTAR 2 checklist. The method of network meta-analysis was chosen to evaluate randomized controlled trial published on tissue repair and comparing Lichtenstein respectively with Desarda and Shouldice techniques. The following parameters: operative time, recurrence, complications (general, intraoperative, Surgical Surgical Site Occurrences), VAS score on postoperative day 1, numbness, chronic pain and return to daily activities. Results: Fourteen RCTs, involving 2791 patients, fulfilled the inclusion criteria and were selected for final analysis. The anchored indirect treatment comparison showed that Desarda's technique requires a significantly shorter operative time (MD: -12.9 min; 95% CI: -20.6 to -5.2) and has a quicker recovery (MD: -6.6 days; 95% CI: -11.7 to -1.4). Outcomes concerning intraoperative complications, early postoperative pain, seroma/hematoma, hydrocele and infection rates, recurrence, numbness and chronic pain were similar among the two techniques. Conclusions: Desarda's hernia repair can be a valuable alternative to Shouldice technique for the treatment of primary inguinal hernia repair if a non-mesh technique is chosen, because of its reproducibility and quicker postoperative recovery. We recommend performing well designed prospective studies comparing both techniques directly.