Inguinal hernia repair: A comparison of the shouldice and cooper ligament repair of the posterior inguinal wall

Abstract

The basic principle of the Cooper ligament repair is the closure of the deficiency in the posterior inguinal wall effected by suturing the upper margin of the defect, represented by the aponeurosis of the transversus plus its investing fascia, downwards to its insertion on to Cooper's ligament along the superior ramus of the pubis lateral to the pubic tubercle. Because of tension, a relaxing incision in the anterior rectus sheath is frequently necessary. The basic principle of the Shouldice repair of the posterior inguinal wall is an overlapping repair utilizing the transversalis fascia, previously divided from internal ring to pubic tubercle. The lateral (or lower) transversalis flap is anchored upwards, underneath the medial (or upper) flap, being attached medially to the edge of the rectus and laterally to the arching fibers of transversus and internal oblique. The medial flap is then attached to the deepest part of the shelving surface of the inguinal ligament. Tension is a less significant factor and a relaxing incision is not used. In two large well-documented series, each using one of these technics exclusively, the recurrence rates are used to compare these two methods of repair. In Halverson and McVay's twenty-two year series of 263 repairs for primary direct inguinal hernia, using the Cooper ligament method throughout, this rate was 4.9 per cent. In my personal twenty-one year series of 4,812 primary direct inguinal hernia repairs using the Shouldice method exclusively, a recurrence rate of 0.7 per cent was achieved. These results suggest that the Shouldice repair is superior.