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Shouldice technique versus other open techniques for inguinal hernia repair

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Referencias

References to studies included in this review

Ir a:

Barth 1998 {published data only}

Barth RJ, Burchard KW, Tosteson A, Sutton JE, Colacchio TA, Henriques HF, et al. Short‐term outcome after mesh or Shoudice herniorrhaphy: a randomized, prospective study. Surgery 1998;123(2):121‐6.

Beets 1997 {published data only}

Beets GL, Oosterhuis KJ, Go PMNYH, Baeten CGMI, Kootstra G. Longterm follow up (12‐15 years) of a randomized controlled trial comparing Bassini‐Stetten, Shouldice, and high ligation with narrowing of the internal ring for primary inguinal hernia repair. J Am Coll Surg 1997;185(4):352‐7.

Butters 2007 {published data only}

Butters M, Redecke J, Koninger J. Long‐term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs Br J Surg 2007;94(5):562‐5.. Br J Surg 2007;94(5):562‐5.

Danielsson 1999 {published data only}

Danielsson P, Isacson S, Hansen MV. Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training. Eur J Surg 1999;165(1):49‐53.

Hay 1995 {published data only}

Hay JM, Boudet MJ, Fingerhut A, Pourcher J, Hennet H, Habib E, et al. Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients. Ann Surg 1995;222(6):719‐27.

Hetzer 1999 {published data only}

Hetzer FH, Hotz T, Steinke W, Schlumpf R, Decurtins M, Largiader F. Gold standard for inguinal hernia repair: Shouldice or Lichtenstein?. Hernia 1999;3:117‐20.

Kingsnorth 1992 {published data only}

Kingsnorth AN, Gray MR, Nott DM. Prospecitive randomized trial comparing the Shouldice and plication darn for inguinal hernia. Br J Surg 1992;79:1068‐70.

Kovacs 1997 {published data only}

Kovacs JB, Gorog D, Szabo J, Fehervari I, Jaray J, Perner F. Prospective randomized trial comparing Shouldice and Bassini‐Kirschner operation technique in primary inguinal hernia repair. Acta Chir Hung 1997;36(1‐4):179‐81.

Kux 1994b {published data only}

Kux M, Fuchsjager N, Schemper M. Shouldice is superior to Bassini inguinal herniorrhaphy. Am J Surg 1994;168:15‐8.

McGillicuddy 1998 {published data only}

Mc Gillicuddy JE, Nyhus LM. Prospective randomized comparison of the Shouldice and Lichenstein hernia repair procedures. Arch Surg 1998;133(9):974‐8.

Miedema 2004 {published data only}

Miedema BW, Ibrahim SM, Davis BD, Koivunen DG. A prospective trial of primary inguinal hernia repair by surgical trainees. Hernia 2004;8(1):28‐32.

Nordin 2002 {published data only}

Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G. Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice. Br J Surg 2002;89:45‐9.

Paul 1994 {published data only}

Paul A, Troidl H, Williams JI, Rixen D, Langen R, Cologne Hernia Study Group. Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. Br J Surg 1994;81:1531‐4.

Thapar 2000 {published data only}

Thapar V, Rao P, Deshpande A, Sanghavi B, Supe AN. Shouldice herniorrhaphy versus Moloney's darn herniorrhaphy in young patients (a prospective randomised study). J Postgrad Med 2000;46(1):9‐12.

Tran 1992 {published data only}

Tran VK, Putz T, Rohde H. A randomized controlled trial for inguinal hernia repair to compare the Shouldice and the Bassini‐Kirschner operation. Int Surg 1992;77:235‐7.

Zieren 1998 {published data only}

Zieren J, Zieren HU, Jacobi CA, Wenger FA, Muller JM. Prospective randomized study comparing laparoscopic and open tension‐free inguinal hernia repair with Shouldice's operation. Am J Surg 1998;175:330‐3.

References to studies excluded from this review

Ir a:

Aust 1993 {published data only}

Aust JB. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia. Br J Surg 1993;80(6):807.

Bay‐Nielsen 2004 {published data only}

Bay‐Nielsen M, Nilsson E, Nordin P, Kehlet H. Chronic pain after open mesh and sutured repair of indirect inguinal hernia in young males. Br J Surg 2004;91(10):1372‐6.

Bergin 1998 {published data only}

Bergin FG, Devlin HB, Gilliland EL. Shouldice inguinal hernia repair revisited: a prospective, randomized trial of non‐absorbable versus absorbable suture. Br J Surg 1998;85(Suppl 1):35.

Carter 1993 {published data only}

Carter P. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia. Br J Surg 1993;80(4):536.

Cunningham 1996 {published data only}

Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM, Hagen NA. Cooperative hernia study. Pain in the post repair patient. Ann Surg 1996;224(5):598‐602.

Deysine 2006 {published data only}

Deysine M. Inguinal herniorrhaphy: 25‐year results of technical improvements leading to reduced morbidity in 4,029 patients. Hernia 2006;10(3):207‐12.

Kawji 1999 {published data only}

Kawji R, Feichter A, Fuchsjager N, Kux M. Postoperative pain and return to activity after five different types of inguinal herniorrhaphy. Hernia 1999;3(1):31‐5.

Kingsnorth 1995 {published data only}

Kingsnorth AN. Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. Further comment. Br J Surg 1995;82(3):420‐1.

Koninger 2004 {published data only}

Koninger J, Redecke J, Butters M. Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg 2004 Oct;389(5):361‐5.

Manson 1993 {published data only}

Manson WG, Reed MW. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia. Br J Surg 1993;80(4):536.

Negro 1997 {published data only}

Negro P, Gossetti F, Catarci M. Prospective randomized trial comparing postoperative pain and return to physical activity after transabdominal preperitoneal, total preperitoneal or Shouldice technique for inguinal hernia repair. Br J Surg 1997;84(5):728‐9.

Paul 1993 {published data only}

Paul A, Troidl H, Rixen D, Williams J. Inguinal hernia surgery after Shouldice or Bassini: results of a controlled randomized trial. Langenbecks Archiv fur chirurgie 1993;suppl kongessbericht:302‐4.

Wayman 1996 {published data only}

Wayman J, Ahmed SM, Stock SE. A study of postoperative pain in patients undergoing repair of inguinal hernia by the Lichtenstein and Shouldice techniques. Br J Surg 1996;83(Suppl 1):36.

Woodward 1995 {published data only}

Woodward A, Carr ND, Beynon J. Randomized trial of modified Bassini versus Shouldice hernia repair. Br J Surg1995; Vol. 82, issue 3:419‐20.

Wyatt 1995 {published data only}

Wyatt JP, Kingsnorth AN, Gray MR, Nott D. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia. Br J Surg 1993;80(3):403.

References to studies awaiting assessment

Ir a:

Koninger 1998 {published data only}

Koninger JS, Oster M, Butters M. Managemet of inguinal hernia ‐‐ a comparison of current methods. Der Chirurg 1998;69(12):1340‐4.

Kux 1994 {published data only}

Kux M, Fuchsjaeger N, Feichter A. Lichtenstein patch versus Shouldice technique in primary inguinal hernia with a high risk of recurrence. Chirurg 1994;65:59‐62.

Mittelstaedt 1999 {published data only}

Mittelstaedt WE, Rodrigues Junior AJ, Duprat J, Bevilaqua RG, Birolini D. Treatment of inguinal hernias. Is the Bassani's technique current yet? A prospective, randomized trial comparing three operative techniques: Bassini, Shouldice and Mc Vay. Rev Ass Med Bras 1999;45(2):105‐14.

Panos 1992 {published data only}

Panos RG, Beck DE, Maresh JE, Harford FJ. Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique. Surg Gynecol Obstet 1992;175:315‐19.

Porrero 2005 {published data only}

Porrero JL, Bonachia O, Lopez Buenadicha A, Sanjuanbenito A, Sanchez, Cabezudo C. Repair of primary inguinal hernia: Lichtenstein versus Shouldice techniques. Prospective randomized study of pain and hospital cost [Reparacion de la hernia inguinal primaria: Lichtenstein frente a Shouldice. Estudio prospectivo y aleatorizado sobre el dolor y los costes hospitalarios]. Cir Esp 2005;77(2):75‐8.

Pyka 2003 {published data only}

Pyka P, Grabowski K, Biernacki A, Dassbrowiecki S. Three‐ layer modification of Shouldice's method in the surgical treatment of inguinal hernias ‐ Its usefulness. Polski Przeglad Chirurgiczny 2003;75(9):858‐70.

Schmitz 1997 {published data only}

Schmitz R, Treckmann J, Shah S, Schneidr K. "Tension‐free technique" in open inguinal hernia repair. A prospective, randomized study of postoperative pain perception ("tension‐free reconstruction" vs. Shouldice technique). Der Chirurg 1997;68(3):259‐63.

Stanislawek 2003 {published data only}

Stanislawek J, Gluszek S, Wysocki A, Dabrowiecki S. Comparison of the efficacy of inguinal hernia surgical treatment using Shouldice's and Prolene Hernia System methods. Polski Przeglad Chirurgiczny 2003;75(8):741‐57.

Strand 1998 {published data only}

Strand L. Randomized trial of three types of repair used in 324 consecutive operation of hernia. A study of the frequency of recurrence. Ugeskrift for læger 1998;160(7):1010‐3.

Altman 1998

Altman DJ. Confidence intervals for the number needed to treat. BMJ 1998;317:1309‐12.

Arlt 2002

Arlt G, Schumpelick V. The Shouldice repair for inguinal hernia‐technique and results. Zentralbl Chir 2002 Jul;127(7):565‐9.

Arvidsson 2005

Arvidsson D, Berndsen FH, Larsson LG, Leijonmarck CE, Rimback G, Rudberg C, Smedberg S, Spangen L, Montgomery A. Randomized clinical trial comparing 5‐year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia. Br J Surg 2005 Sep;92(9):1085‐91.

Bassini 1887

Bassini E. New method about radical treatment of inguinal hernia [Nuovo metodo sulla cura radicale dell'ernia inguinale.]. Arch Soc Ital Chir 1887;4:380.

Bay‐Nielsen 2004

Bay‐Nielsen M, Nilsson E, Nordin P, Kehlet H, Swedish Hernia Data Base the Danish Hernia Data Base Danish Hernia Data Base. Chronic pain after open mesh and sutured repair of indirect inguinal hernia in young males young males. Br J Surg 2004 Oct;91(10):1372‐6.

Benard 1986

Benard F, Chiotasso P, Legrand G, Lezorthes F. Inguinal hernia. The Shouldice parietal repair. Presse Med 1986 Jul 5‐12;15(27):1276‐80.

Bendavid 1997

Bendavid R. Shouldice Herniotomy. Chirurg 1997 Oct;68(10):965‐9.

CC Handbook 2008

Higgins JPT, Green S (editors). Assessment of study quality. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]; Part 2. The Cochrane Collaboration, 2008. Available from www.cochrane‐handbook.org.Sept 2008.

Deeks 2001

Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta‐analysis. In: Egger M, Davey Smith G, Altman DG editor(s). Systematic reviews in health care: meta‐analysis in context. Second Edition. London: BMJ Books, 2001:285‐312.

Deeks 2006

Deeks JJ, Higgins JPT, Altman DG, editors. Assessment of study quality. Cochrane Reviewers' Handbook 4.2.5 [updated May 2005]; Section 6. In: The Cochrane Library, Issue 1, 2006. Chichester, UK: John Wiley & Sons, Ltd..

DerSimonian 1986

DerSimonian R, Laird N. Meta‐analysis in clinical trials. Controlled Clinical Trials 1986;7(3):177‐88.

Devlin 1986

Devlin HB, Gillen PH, Waxman BP, MacNay RA. Short stay surgery for inguinal hernia: experience of the Shouldice operation. Br J Surg 1986 Feb;73(2):123‐4.

Fingerhut 1993

Fingerhut A, Hay JM, Hennet H, Boudet MJ. Shouldice or not Shouldice? Late results of a controlled trial in 1593 patients. 7th annual meeting of the French Association for Surgical Research (ARC) and 1st French‐German joint meeting with the permanent working party on clinical studies (CAS ) of the German Surgical Society, March 1993, Paris France. Theor Surg. 1993; Vol. 8:163‐7.

Glassow 1986

Glassow F. The Shouldice Hospital technique. Int Surg 1986;71:148‐53.

Grant 2002

Grant AM, EU Hernia Trialists Collaboration. Open mesh versus non‐mesh repair of groin hernia: meta‐analysis of randomised trials based on individual patient data [corrected]. Hernia 2002;6(3):130‐6.

Higgins 2002

Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta‐analysis. Statistics in Medicine 2002;21:1539‐58.

Hoffmann 1991

Hoffmann R, Frick T, Attinger B, Platz A, Largiader F. Bassini or Shouldice operation?. Helv Chir Acta 1991;58:207‐12.

Jadad 1996

Jadad A, Moore R, Carroll D, Jenkinson C, Reynolds J, Gavaghan D, et al. Assessing the quality of reports of randomised clinical trials: is blinding necessary?. Controlled Clinical Trials 1996;17(1):1‐12.

Kingsnorth 1992

Kingsnorth AN, Gray MR, Nott DM. Prospecitive randomized trial comparing the Shouldice and plication darn for inguinal hernia. Br J Surg 1992;79:1068‐70.

Kux 1994

Kux M, Fuchsjaeger N, Feichter A. Lichtenstein patch versus Shouldice technique in primary inguinal hernia with a high risk of recurrence. Chirurg 1994;65:59‐62.

Lichtenstein 1987

Lichtenstein IL. Herniorrhaphy. A personal experience with 6321 cases. Am J Surg 1987;153:553‐9.

Lichtenstein 1989

Lichtenstein IL, Schulman AG, Amid PK, Montllor MM. The tension‐free hernioplasty. Am J Surg 1989;157:188‐93.

Mc Vay 1978

Mc Vay C. Hernia. 2nd Edition. JB Lippincott, 1978.

Moloney 1972

Moloney GE. Darning inguinal hernias. Arch surg 1972;104(2):129‐130.

Nilsson 1993

Nilsson E, Anderberg B, Bragmark M, Erikson T, Fordell R, Haapaniemi S. Hernia surgery in a de.ned population. Improvements possible in outcome and cost effectiveness. Ambulatory Surg 1993;1:150‐3.

Nordin 2002

Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund G. Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice. Br J Surg 2002;89:45‐9.

Oosterhuis 1986

Oosterhuis KJ, Greep JM. Bassini or Shouldice, a comparative study on inguinal hernia repair. Tagung Vereinigung Niederrheinisch‐Westfaelischer Chirurgen Congres von Chirurgischer Lehrstuhl der Universitaet zu Koeln. 1986.

Panos 1992

Panos RG, Beck DE, Maresh JE, Harford FJ. Preliminary results of a prospective randomized study of Cooper's ligament versus Shouldice herniorrhaphy technique. Surg Gynecol Obstet 1992;175:315‐19.

Paul 1994

Paul A, Troidl H, Williams JI, Rixen D, Langen R, Cologne Hernia Study Group. Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. Br J Surg 1994;81:1531‐4.

Rutkow 2003

Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am 2003 Oct;83(5):1045‐51.

Schippers 1996

Schippers E, Peiper C, Schumpelick V. Pro‐Shouldice: primary tension‐free hernia repair‐‐conditio sine qua non?. Swiss Surg 1996;Suppl 4:33‐6.

Schulz 1996

Schulz KF, Grimes DA, Altman DG, Hayes RJ. Blinding and exclusions after allocation in randomised controlled trials: survey of published parallel group trials in obstetrics and gynaecology. BMJ 1996;312:742‐744.

Schumpelick 1994

Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994;344:375‐9.

Scott 2001

Scott N, Go PMNYH, Graham P, McCormack K, Ross SJ, Grant AM. OpenMesh versus non‐Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3. [DOI: 10.1002/14651858.CD002197]

Shouldice 1945

Shouldice EE. Surgical treatment of hernia. Ont Med Rev 1945;4:43.

SHR 2002

Swedish Hernia Register. Swedish Hernia Register (Svenska Brackregistret). 2002 May. [http://www.sos.se/mars/kva002/kva002.htm/ [3 March 2003]]

Simons 1996

Simons MP, Kleijnen J, van Geldere D, Hoitsma HFW, Obertop H. Role of the Shouldice technique in inguinal hernia repair: a systematic review of controlled trials and a meta‐analysis. British Journal of Surgery 1996;83:734‐738.

Smythe 1977

Smythe HA, Helewa A, Goldsmith CH. "Independent assessor" and "pooled index" as techniques for measuring treatment effects in rheumatoid arthritis. J Rheumatol 1977;4(2):144‐52.

Thompson 2001

Thompson SG. Why and how sources of heterogeneity should be investigated. In: Egger M, Davey Smith G, Altman DG editor(s). Systematic reviews in health care: meta‐analysis in context. Second Edition. London: BMJ Books, 2001:157‐75.

Tons 1991

Tons C, Klinge U, Kupczyk‐Joeris D, Rotzscher VM, Schumpelick V. Controlled study of cremaster resection in Shouldice repair of primary inguinal hernia. Zentralblatt für Chirurgie 1991;116:737‐43.

Tran 1992

Tran VK, Putz T, Rohde H. A randomized controlled trial for inguinal hernia repair to compare the Shouldice and the Bassini‐Kirschner operation. Int Surg 1992;77:235‐7.

Wantz 1989

Wantz GE. The Canadian repair: personal observations. World J Surg 1989;13:516‐21.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Ir a:

Barth 1998

Methods

Multicenter, two arms RCT of Shouldice vs Lichtenstein.
Randomization: methods not stated.
Maximum follow up: 7 days.
Exclusions after randomization: not reported.
Protocol violations: 2 patients randomized to Shouldice received Lichtenstein(analysed in Shouldice group).
Analyses by protocol.
Jadad quality score: 1.

Participants

Country: USA.
Setting: 2 centres not specialized in hernia repair.
Total enrolled patients: 105 (105 hernias) 51 Shouldice vs 54 Lichtenstein.
Mean age (SEM): Shouldice 51 (2,4); Lichtenstein 53 (2,2).
Gender: 104 M; 1 F.
Inclusion criteria: age> 18, inguinal primary hernia, only elective repair.
Exclusion criteria: not reported.
Demographic and baseline data reported: comparable for hernia duration (months), age, hernia type and diameter, employment.

Interventions

Shouldice standard (n=51) performing 4 layers. Polypropylene 2/0.
Lichtenstein standard (n=54). Polypropylene Mesh. Polypropylene 2/0.

Outcomes

Lenght of postoperative stay.
Wound infection.
Haematoma.
Duration of operation.

Notes

Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear
Beets 1997

Methods

Single centre, four arms RCT ‐ comparisons: Shouldice vs Bassini (considered in this review); Bassini vs Ring Narrowing (the two arms are not considered in this review).
Randomization: generation of sequence not stated; allocation concealment using sealed envelopes.
Maximum follow up: 13.7 years.
Exclusions after randomization: 6 hernias (reasons not specified).
Protocol violations: 49 Shouldice repairs converted to Bassini (reasons: surgeon not familiar with Shouldice technique or not aware about patient's enrolled in the trial).
Analyses by protocol.
Losses to follow up (data collapsed for all arms): 30 patients (11,4%).
Jadad quality score: 4.

Participants

Country: Netherlands.
Setting: centre not specialized in hernia repair.
Total enrolled patients (four arms): 375 (hernias 425). Two interest arms: 263 hernias, 103 Shouldice and 160 Bassini.
Mean age (SD): Shouldice 57 (13); Bassini 57 (14).
Gender: 375 M.
Inclusion criteria: age>18, primary inguinal hernia, elective repair.
Exclusion criteria: life expectancy <2 year, major concomitant operation.
Demographic and baseline data reported: comparability for activities, COPD, prostatism, constipation, bilaterality, experience of operating surgeon; unbalance between arms for previous repair of inguinal hernia (Shouldice 11% vs Bassini 22%).

Interventions

Bassini modified by Stetten (n=160). Non Mesh. Nylon 2/0.
Shouldice modified (n=103) performing 3 layers. Nylon 2/0.

Outcomes

Recurrence (lump in groin not necessarily re‐operated).
Chronic pain.
Wound infection
Testicular atrophy.
Haematoma.

Notes

Recurrence at 13.7 follow up years assessed by an independent surgeon in 179/194 hernias (four arms); 15/194 by telephone interview. 89 patients (100 hernias) died during the study.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate
Butters 2007

Methods

Single centre, three arms RCT ‐ Conparisons: Shouldice vs Lichtenstein vs TAPP (not considered). Randomization: generation of sequence not stated, Allocation concealment using sealed envelopes. Maximum follow up: 52 months. Exclusion after randomization: no. Losses to follow up: Shouldice 19, Lichtenstein 17 (9 deaths, 5 moved to other places and 22 refused to continue). Analyses by protocol

Participants

Country: Germany. Setting: centre specialized in hernia repair. Total enrolled patients: 186 (93 Shouldice vs 93 Lichtenstein). Mean age: Shouldice: 53; Lichtenstein 56. Gender: 186 M. Inclusion criteria: age >18, primary inguinal hernia, elective repair. Exclusion criteria: no known. Demographic and baseline data reported: comparability for age, type of hernia.

Interventions

Shouldice (n=93). Technical notes not specified. Lictenstein standard (n=93).

Outcomes

Recurrence (definition of recurrence not reported). Chronic pain (data from Koninger 2004).

Postoperative satisfaction level

Testicular atrophy

Notes

52 months follow up assessed by a resident surgeon by physical examination in 150 patients (80.6%)

Conflict of interest: not reported.

Sources of funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate
Danielsson 1999

Methods

Single centre, two arms RCT of Shouldice vs Lichtenstein.
Randomization: methods not reported.
Maximum follow up: 1 year.
Exclusions after randomization: 22 (reasons not specified).
Analyses by protocol
Losses to follow up: 8 patients.
Jadad quality score: 2.

Participants

Country: Sweden.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 200; 178 hernias (89 Shouldice vs 89 Lichtenstein).
Mean age (SD): Shouldice 56 (16); Lichtenstein 58 (14).
Gender: 200 M.
Inclusion criteria: age> 18, inguinal primary hernia, only elective repair.
Exclusion criteria: incarcerated hernias and emergency operations.
Demographic and baseline data reported: comparable for activities (data not provided) and age.

Interventions

Shouldice standard (n=89) performing 4 layers. Non‐absorbable monofilament.
Lichtenstein standard (n=89). Polypropylene Mesh.

Outcomes

Recurrence (symptomatic lump in groin and re operated).
Lenght of postoperative stay.
Wound infection.
Duration of operation.

Notes

Recurrence at 1 year follow up assessed by surgeon or patient himself in 170 patients (84 Shouldice; 86 Lichtenstein).
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear
Hay 1995

Methods

Multicenter, four arms RCT ‐ comparisons: Shouldice steel and Shouldice polypropylene (pooled together) vs Bassini vs Mc Vay.
Randomization: generation of sequence not reported; allocation concealment by un stapling corner of the questionnaire.
Maximum follow up: 8,5 years.
Exclusions after randomization: 57 patients (most were foreigners who returned their countries).
Intention to treat analyses.
Losses to follow up: 86 patients (5,6%).
Jadad quality score: 3.

Participants

Country: France.
Setting: centres not specialized in hernia repair.
Total enrolled patients: 1578(1706 hernias); 1521patients (1647 hernias) (829 Shouldice, 420 Bassini, 407 Mc Vay).
Mean age (SD): Shouldice 52,5 (15,6); Bassini 55 (15,2); Mc Vay 54,2 (14,8).
Gender: 1578 M.
Inclusion criteria: age> 15, inguinal primary hernia, elective or emergency repair.
Exclusion criteria: Females, foreigners, femoral ipsilateral hernia associated.
Demographic and baseline data reported: comparable for sex, age, activities, COPD, constipation and dysuria, healing influencing factors (all data reported).

Interventions

Shouldice steel (n=401). 4 layers. Steel wire and polypropylene.
Shouldice polypropylene (n=419). 4 layers. Polypropylene.
Bassini modified (n=420). Polypropylene.
Mc Vay modified (n=407). Polypropylene.

Outcomes

Recurrences (lump in groin not necessarily re operated) ‐ data not extractable
Lenght of postoperative stay
Chronic pain
Wound infection
Testicular atrophy
Haematoma

Notes

Recurrence at 8,5 years follow up assessed by an independent surgeon or patient himself or physician.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate
Hetzer 1999

Methods

Multicenter, two arms RCT of Shouldice vs Lichtenstein.
Randomization: Day of intervention. Allocation concealment inadequate.
Maximum follow up: 3 months.
Exclusions after randomization: 562 hernias (randomization performed before evaluation of inclusion criteria).
Analyses by protocol.
Losses to follow up: none.
Jadad quality score: 1.

Participants

Country: Switzerland.
Setting: centres not specialized in hernia repair.
Total enrolled patients (two arms): 385 patients; number of hernias: 410 (171 Shouldice vs 239 Lichtenstein).
Mean age (SD): Shouldice 53 (16,77); Lichtenstein 58 (17,36).
Gender: 385 M.
Inclusion criteria: age>18, primary inguinal hernia, elective repair.
Exclusion criteria: incarcerated hernia, previous operation in the inguinal region, coagulopathy, diabetes, prostatic hyperplasia, wish for general anaesthesia.
Demographic and baseline data reported: comparability for age, type of hernia(all data reported).

Interventions

Shouldice Standard (n=171). 4 layers. PDS 2/0.
Lichtenstein (n=239). Polypropylene meshes. Polypropylene 2/0.

Outcomes

Lenght of postoperative stay.
Wound Infection.
Duration of operation.

Notes

Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate
Kingsnorth 1992

Methods

Single centre, two arms RCT of Shouldice vs Plication Darn (Bassini modified).
Randomization: generation of sequence not stated, allocation concealment: randomization just before skin incision.
Maximum follow up: 2 years.
Exclusions after randomization: no.
Intention to treat analyses.
Losses to follow up: 98 (reasons not specified).
Jadad quality score: 3.

Participants

Country: UK.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 322; 322 hernias (151 Shouldice vs 171 Plication Darn).
Mean age: Shouldice 58,3; Plication Darn 57.
Gender: 304 M; 18 F
Inclusion criteria: age>18, primary inguinal hernia, elective repair.
Exclusion criteria: no known.
Demographic and baseline data reported: comparability for age, type of hernia, sex (all data reported).

Interventions

Shouldice (n=151). Technical notes not specified.
Plication Darn (Bassini modified) (n=171).

Outcomes

Recurrence (definition of recurrence not reported).
Lenght of postoperative stay.
Wound infection.
Haematoma.

Notes

Recurrence at 2 years follow up assessed by a consultant or a surgical registrar or pro forma in 224 patients.
Recurrence at 4 years follow up only in 61 (18,9%) patients so data from this follow up will not be considered.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate
Kovacs 1997

Methods

Single centre, two arms RCT of Shouldice vs Bassini‐Kirschner.
Randomization: date of birth, allocation concealment not specified.
Maximum follow up: 1 year.
Exclusions after randomization: no.
Losses to follow up: Shouldice 18, Bassini‐Kirschner 26 (reasons not specified).
Jadad quality score: 2.

Participants

Country: Hungary.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 129 (63 Shouldice vs 66 Bassini‐Kirschner).
Mean age: Shouldice 52; Bassini‐Kirschner 54.
Gender: 129 M.
Inclusion criteria: age>18, primary inguinal hernia.
Exclusion criteria: no known.
Demographic and baseline data reported: comparability for age, bilaterality and sex.

Interventions

Shouldice standard (n=63) performing 4 layers. Non‐absorbable monofilament.
Bassini‐Kirschner (n=66). Suture in Mersilene 0.

Outcomes

Recurrence (lump in groin and re operated).
Lenght of postoperative stay.
Wound infection.
Testicular atrophy
Haematoma.
Duration of the operation.

Notes

Recurrence at 1 year follow up assessed by a hospital staff surgeon in 85 patients (66%).
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate
Kux 1994b

Methods

Single centre, four arms RCT ‐ comparison: Shouldice vs Bassini (Bassini with absorbable sutures and two‐layers Shouldice not considered).
Randomization: methods not stated.
Maximum follow up: 2 years.
Exclusions after randomization: not reported.
Analyses by protocol.
losses to follow up: 50 (reasons not specified)
Jadad quality score: 2.

Participants

Country: Austria.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 400. 307 primary hernia repair. (Shouldice 4 rows 160; Bassini unabsorbable 147).
Mean age (SD): not reported.
Gender: data not clear.
Inclusion criteria: Inguinal hernia (also recurrent hernias).
Exclusion criteria: not reported.
Demographic and baseline data reported: comparability for sex, type of hernia, recurrence, obesity, bronchitis, hernia sac >8 cm (all data reported).

Interventions

Shouldice standard (n=160). 4 layers. Polypropylene.
Bassini modified (n=147). Polyester.

Outcomes

Recurrence (lump in groin not necessarily re operated).

Notes

Recurrence at 2 years follow up assessed by a hospital staff surgeon in 683 patients(93,6%).
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear
McGillicuddy 1998

Methods

Single centre, two arms RCT of Shouldice vs Lichtenstein.
Randomization: coin toss, allocation concealment inadequate.
Maximum follow up: 5 years.
Exclusion after randomization: 31 (patients decided to undergo a laparoscopic repair).
Intention to treat analyses.
Losses to follow up: 251(35,5%)
Jadad quality score: 1.

Participants

Country: USA
Setting: private centre specialized in hernia repair.
Total enrolled patients: 672. 717 hernias.
Mean age (SD): data not reported
Gender: 672 M.
Inclusion criteria: inguinal hernia.
Demographic and baseline data reported: comparability for sex, age, activity (data not reported).

Interventions

Shouldice standard (n=337) performing 4 layers. Non‐absorbable monofilament.
Lichtenstein standard (n=371). Polypropylene Mesh.

Outcomes

Recurrence
Chronic pain
Wound infection
Testicular atrophy

Notes

Recurrence at 5 years follow up assessed by the operating surgeon in 99% of patients.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate
Miedema 2004

Methods

Single centre, three arms RCT of Shouldice vs Lichtenstein vs Mc Vay.
Randomization: generation of sequence by random digit table; allocation list maintained by a person unassociated with the study.
Follow up: 7 years.
Exclusions after randomization: not reported.
Losses to follow up: 29 (could not be contacted).
Analyses by protocol.
Jadad quality score: 4.

Participants

Country: USA.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 146. Three arms: 150 hernias (52 Shouldice, 49 Lichtenstein and 49 Mc Vay).
Mean age: 62 Shouldice, 63 Lichtenstein, 65 Mc Vay.
Gender: 146 M.
Inclusion criteria: Primary inguinal hernia.
Exclusion criteria: age <18 years, use of systemic steroids, incarcerated hernia, recurrent hernia, collagen or vascular disease, ASA 4 or 5, allergy to acetaminophen or codeine.
Demographic and baseline data reported: comparability for sex, COPD, prostatism and constipation.

Interventions

Shouldice modified (n=41). 4 layers. Polypropylene.
Lichtenstein standard (n=39).
McVay standard (n=41).

Outcomes

Recurrence (lump in groin not necessarily re‐operated).
Lenght of postoperative stay.
Postoperative satisfaction level.
Wound infection.
Haematoma.
Duration of the operation.

Notes

Recurrence at 6‐9 years follow up assessed by clinical examination in 121 patients(29 lost at follow up).
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate
Nordin 2002

Methods

Single centre, two arms RCT of Shouldice vs Lichtenstein.
Randomization: generation sequence by computer generated in blocks of ten patients, allocation concealment not specified.
Maximum follow up: 6 years.
Exclusions after randomization: 2 patients refused to continue, 1 hernia not found.
Losses to follow up: 9 (reasons not specified).
Intention to treat analyses
Jadad quality score: 3.

Participants

Country: Sweden.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 300. 297 hernias (148 Shouldice 149 Lichtenstein).
Age range: 25‐75.
Gender: 300 M.
Inclusion criteria: age >18, primary inguinal hernia.
Exclusion criteria: irreducibility of hernia, coagulation abnormalities or anticoagulant treatment.
Demographic and baseline data: comparability for age, type of hernia, activities, testicular preoperative size (data not reported).

Interventions

Shouldice Standard (n=148). 4 layers. Polypropylene 2/0.
Lichtenstein (n=149). Marlex meshes. Polypropylene 2/0.

Outcomes

Recurrence (lump in groin not necessarily re operated).
Lenght of postoperative stay.
Chronic pain.
Wound infection.
Seroma.
Testicular atrophy.
Haematoma.
Duration of operation.

Notes

Recurrence at 3‐6 years follow up assessed by an independent surgeon in 284 patients.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear
Paul 1994

Methods

Single centre, two arms RCT of Shouldice vs Bassini.
Randomization: balanced blocks, allocation concealment not specified.
Maximum follow up: 5 years.
Exclusions after randomization: no.
Losses to maximum follow up: 21 (reasons not specified).
Analyses by protocol
Jadad quality score: 2.

Participants

Country: Germany.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 265. (119 Shouldice vs 125 Bassini)
Mean age (SD): data not reported
Gender: 265 M.
Inclusion criteria: Primary inguinal hernia.
Exclusion criteria: Bilaterality, femoral hernias, incarcerated hernias, renal and liver failure.
Demographic and baseline data reported: comparability for constipation, obesity, bronchitis(data not reported).

Interventions

Shouldice modified (n=119). 4 layers. unabsorbable suture.
Bassini modified (n=125). 2 layers. interrupted stitches of unabsorbable suture.

Outcomes

Recurrence (symptomatic lump in groin and re operated).
Lenght of postoperative stay.
Duration of operation.

Notes

Recurrence at 3 years follow up assessed by clinical examination in 91,5%of Shouldice group and 92,6% of Bassini group.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear
Thapar 2000

Methods

Single centre, two arms RCT of Shouldice vs Moloney's Darn.
Randomization: generation sequence: Unclear; allocation concealment: randomization just before skin incision.
Maximum follow up: 2 years.
Exclusions after randomization: no.
Losses to follow up: none.
Jadad quality score: 2.

Participants

Country: India.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 50 (25 Shouldice vs 25 Moloney's darn).
Age range: 18‐40.
Gender: 50 M.
Inclusion criteria: age >18.
Exclusion criteria: bilaterality, recurrent hernias and inguinoscrotal pathologies
Demographic and baseline data: comparability for side and type of hernia (data reported).

Interventions

Shouldice standard (n=25). 4 layers. unabsorbable suture.
Moloney's darn (n=25). 2 layers. unabsorbable suture.

Outcomes

Recurrence (lump in groin not necessarily re operated).
Lenght of postoperative stay.
Wound infection.
Haematoma.

Notes

Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate
Tran 1992

Methods

Single centre, two arms RCT of Shouldice vs Bassini‐Kirschner.
Randomization: method not specified, allocation concealment not specified.
Maximum follow up: 2 years.
Exclusions after randomization: 5 (2 recurrent hernias, 1 femoral hernia, 1 refused the randomization and in 1 for technical matters).
Analyses by protocol.
Losses to follow up: 8 patients (reasons not specified).
Jadad quality score: 1.

Participants

Country: Germany.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 138. 142 hernias (70 Shouldice vs 72 Bassini‐Kirschner).
Mean age: Shouldice: males 55, females 62; Bassini‐Kirschner: males 54, females 47.
Gender: 114 M, 24 F.
Inclusion criteria: age >14, primary inguinal hernia.
Exclusion criteria: not specified.
Demographic and baseline data reported: comparability for age, sex, weight, height, type of hernia, qualification of operating surgeon (data reported).

Interventions

Shouldice unclear (n=70).
Bassini‐Kirschner unclear (n=72). Vicryl metric 1.

Outcomes

Recurrence (lump in groin not necessarily re operated).
Lenght of postoperative stay.
Wound infection.
Seroma.
Haematoma.
Duration of operation.

Notes

Recurrence at 24 months follow up assessed by a general physician or one of the author in 128 patients.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear
Zieren 1998

Methods

Single centre, three arms RCT ‐ comparisons: Shouldice vs Plug and patch vs TAPP (not considered for the analyses).
Randomization: computer generated. Allocation concealment not specified.
Maximum follow up: 25 months.
Exclusions after randomization: not reported.
Analyses by protocol
Losses to follow up: none.
Jadad quality score: 3.

Participants

Country: Germany.
Setting: centre not specialized in hernia repair.
Total enrolled patients: 160 (80 for each group)
Mean age (SD): Shouldice 46 (15); Plug and Patch 47 (14).
Gender:147 M, 13 F.
Inclusion criteria: Primary inguinal hernia repair, age >18.
Exclusion criteria: incarcerated hernias, coagulation disorders, contraindication for general anaesthesia, cardiac insufficiency (NYHA 3‐4).
Demographic and baseline data: comparability for age, sex, type of hernia (Nyhus), occupation, BMI (all data reported).

Interventions

Shouldice modified (n=80). 4 layers. Unabsorbable monofilament.
Plug and Patch (n=80). Polypropylene meshes and plugs.

Outcomes

Recurrence (method not stated).
Lenght of postoperative stay.
Chronic pain.
Wound Infection.
Seroma.
Haematoma.
Duration of operation.

Notes

Recurrence at 25 months assessed for 96% of Shouldice group and 94% of Plug and Patch.
Conflict of interest: not reported.
Sources of funding: not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Characteristics of excluded studies [ordered by study ID]

Ir a:

Study

Reason for exclusion

Aust 1993

Comment to Kingsnorth 1992

Bay‐Nielsen 2004

Review

Bergin 1998

Comparison about different suture materials

Carter 1993

Comment to Kingsnorth 1992

Cunningham 1996

No comparisons between surgical techniques

Deysine 2006

CCT

Kawji 1999

CCT

Kingsnorth 1995

Comment on Kingsnorth 1992

Koninger 2004

Data considered in Butters 2007

Manson 1993

Comment to Kingsnorth 1992

Negro 1997

Comment to Schrenk 1996

Paul 1993

Data reprised in Paul 1994

Wayman 1996

Out of topic

Woodward 1995

Letter to Paul 1994

Wyatt 1995

Comment to Kingsnorth 1992

Characteristics of studies awaiting assessment [ordered by study ID]

Ir a:

Koninger 1998

Methods

RCT

Participants

280 patients

Interventions

Shouldice, Lichtenstein, TAPP

Outcomes

Recurrence, Duration of Operation, Wound infection, Complications

Notes
Kux 1994

Methods

RCT

Participants

209 patients

Interventions

Shouldice, Lichtenstein

Outcomes

Recurrence, Postoperative pain

Notes
Mittelstaedt 1999

Methods

RCT

Participants

119 patients

Interventions

Shouldice, Bassini, Mc Vay

Outcomes

Recurrence

Notes
Panos 1992

Methods

RCT

Participants

269

Interventions

Shouldice, Mc Vay

Outcomes

Recurrence

Notes
Porrero 2005

Methods

RCT

Participants

54 patients

Interventions

Shouldice, Lichtenstein

Outcomes

Duration of operation, Lenght of postoperative stay, Costs

Notes
Pyka 2003

Methods

No data available

Participants

No data available

Interventions

No data available

Outcomes

No data available

Notes
Schmitz 1997

Methods

RCT

Participants

64 patients

Interventions

Shouldice, Tension‐free

Outcomes

Postoperative pain, Complications

Notes
Stanislawek 2003

Methods

No data available

Participants

No data available

Interventions

No data available

Outcomes

No data available

Notes
Strand 1998

Methods

RCT

Participants

Shouldice, Bassini, Mc Vay

Interventions

324

Outcomes

Recurrence, Complications

Notes

Data and analyses

Open in table viewer
Comparison 1. Shouldice vs other techniques

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Recurrence Show forest plot

13

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only
Analysis 1.1
Comparison 1 Shouldice vs other techniques, Outcome 1 Recurrence.

Comparison 1 Shouldice vs other techniques, Outcome 1 Recurrence.

1.1 Shouldice vs mesh

6

1565

Peto Odds Ratio (Peto, Fixed, 95% CI)

3.80 [1.99, 7.26]

1.2 Shouldice vs non‐mesh

8

2865

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.62 [0.45, 0.85]

2 Lenght of postoperative stay (days) Show forest plot

8

Mean Difference (IV, Random, 95% CI)

Subtotals only
Analysis 1.2
Comparison 1 Shouldice vs other techniques, Outcome 2 Lenght of postoperative stay (days).

Comparison 1 Shouldice vs other techniques, Outcome 2 Lenght of postoperative stay (days).

2.1 Shouldice vs mesh

4

1045

Mean Difference (IV, Random, 95% CI)

0.38 [‐0.41, 1.18]

2.2 Shouldice vs non mesh

4

565

Mean Difference (IV, Random, 95% CI)

0.25 [0.01, 0.49]

3 Chronic pain Show forest plot

7

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only
Analysis 1.3
Comparison 1 Shouldice vs other techniques, Outcome 3 Chronic pain.

Comparison 1 Shouldice vs other techniques, Outcome 3 Chronic pain.

3.1 Shouldice vs mesh

5

1371

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.87 [0.55, 1.39]

3.2 Shouldice vs non mesh

3

1968

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.70 [0.40, 1.22]

4 Wound Infection Show forest plot

13

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only
Analysis 1.4
Comparison 1 Shouldice vs other techniques, Outcome 4 Wound Infection.

Comparison 1 Shouldice vs other techniques, Outcome 4 Wound Infection.

4.1 Shouldice vs mesh

7

1938

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.74 [0.37, 1.49]

4.2 Shouldice vs non mesh

7

2635

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.34 [0.70, 2.54]

5 Seroma Show forest plot

4

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only
Analysis 1.5
Comparison 1 Shouldice vs other techniques, Outcome 5 Seroma.

Comparison 1 Shouldice vs other techniques, Outcome 5 Seroma.

5.1 Shouldice vs mesh

3

1165

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.96 [0.37, 2.50]

5.2 Shouldice vs non mesh

1

142

Peto Odds Ratio (Peto, Fixed, 95% CI)

2.86 [0.39, 20.74]

6 Testicular atrophy Show forest plot

6

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only
Analysis 1.6
Comparison 1 Shouldice vs other techniques, Outcome 6 Testicular atrophy.

Comparison 1 Shouldice vs other techniques, Outcome 6 Testicular atrophy.

6.1 Shouldice vs mesh

3

1155

Odds Ratio (M‐H, Random, 95% CI)

1.05 [0.04, 27.38]

6.2 Shouldice vs non mesh

3

1995

Odds Ratio (M‐H, Random, 95% CI)

1.09 [0.21, 5.50]

7 Haematoma Show forest plot

10

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only
Analysis 1.7
Comparison 1 Shouldice vs other techniques, Outcome 7 Haematoma.

Comparison 1 Shouldice vs other techniques, Outcome 7 Haematoma.

7.1 Shouldice vs mesh

3

562

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.64 [0.25, 1.64]

7.2 Shouldice vs non mesh

7

2797

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.84 [0.63, 1.13]

8 Duration of the operation (Minutes) Show forest plot

7

Mean Difference (IV, Fixed, 95% CI)

Subtotals only
Analysis 1.8
Comparison 1 Shouldice vs other techniques, Outcome 8 Duration of the operation (Minutes).

Comparison 1 Shouldice vs other techniques, Outcome 8 Duration of the operation (Minutes).

8.1 Shouldice vs Mesh

5

954

Mean Difference (IV, Fixed, 95% CI)

9.64 [6.96, 12.32]

8.2 Shouldice vs non mesh

3

372

Mean Difference (IV, Fixed, 95% CI)

10.10 [6.78, 13.42]

Comparison 1 Shouldice vs other techniques, Outcome 1 Recurrence.
Figuras y tablas -
Analysis 1.1

Comparison 1 Shouldice vs other techniques, Outcome 1 Recurrence.

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Comparison 1 Shouldice vs other techniques, Outcome 2 Lenght of postoperative stay (days).
Figuras y tablas -
Analysis 1.2

Comparison 1 Shouldice vs other techniques, Outcome 2 Lenght of postoperative stay (days).

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Comparison 1 Shouldice vs other techniques, Outcome 3 Chronic pain.
Figuras y tablas -
Analysis 1.3

Comparison 1 Shouldice vs other techniques, Outcome 3 Chronic pain.

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Comparison 1 Shouldice vs other techniques, Outcome 4 Wound Infection.
Figuras y tablas -
Analysis 1.4

Comparison 1 Shouldice vs other techniques, Outcome 4 Wound Infection.

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Comparison 1 Shouldice vs other techniques, Outcome 5 Seroma.
Figuras y tablas -
Analysis 1.5

Comparison 1 Shouldice vs other techniques, Outcome 5 Seroma.

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Comparison 1 Shouldice vs other techniques, Outcome 6 Testicular atrophy.
Figuras y tablas -
Analysis 1.6

Comparison 1 Shouldice vs other techniques, Outcome 6 Testicular atrophy.

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Comparison 1 Shouldice vs other techniques, Outcome 7 Haematoma.
Figuras y tablas -
Analysis 1.7

Comparison 1 Shouldice vs other techniques, Outcome 7 Haematoma.

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Comparison 1 Shouldice vs other techniques, Outcome 8 Duration of the operation (Minutes).
Figuras y tablas -
Analysis 1.8

Comparison 1 Shouldice vs other techniques, Outcome 8 Duration of the operation (Minutes).

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Table 1. Assessment of methodological quality: Jadad Scale

Study

Randomization

Double‐blinding

Dropout/Withdrawls

TotalScore

Barth

1

0

0

1

Beets

2

2

0

4

Butters

2

1

1

3

Danielsson

1

0

1

2

Hay

2

1

0

3

Hetzer

0

0

1

1

Kingsnorth

2

1

0

3

Kovacs

0

1

1

2

Kux

0

1

1

2

McGillicuddy

0

0

1

1

Miedema

2

1

1

4

Nordin

1

2

0

3

Paul

1

1

0

2

Thapar

1

0

1

2

Tran

1

0

0

1

Zieren

1

1

1

3
Figuras y tablas -
Table 1. Assessment of methodological quality: Jadad Scale
Ir a la tabla de la revisión
Comparison 1. Shouldice vs other techniques

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Recurrence Show forest plot

13

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

1.1 Shouldice vs mesh

6

1565

Peto Odds Ratio (Peto, Fixed, 95% CI)

3.80 [1.99, 7.26]

1.2 Shouldice vs non‐mesh

8

2865

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.62 [0.45, 0.85]

2 Lenght of postoperative stay (days) Show forest plot

8

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Shouldice vs mesh

4

1045

Mean Difference (IV, Random, 95% CI)

0.38 [‐0.41, 1.18]

2.2 Shouldice vs non mesh

4

565

Mean Difference (IV, Random, 95% CI)

0.25 [0.01, 0.49]

3 Chronic pain Show forest plot

7

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

3.1 Shouldice vs mesh

5

1371

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.87 [0.55, 1.39]

3.2 Shouldice vs non mesh

3

1968

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.70 [0.40, 1.22]

4 Wound Infection Show forest plot

13

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

4.1 Shouldice vs mesh

7

1938

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.74 [0.37, 1.49]

4.2 Shouldice vs non mesh

7

2635

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.34 [0.70, 2.54]

5 Seroma Show forest plot

4

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

5.1 Shouldice vs mesh

3

1165

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.96 [0.37, 2.50]

5.2 Shouldice vs non mesh

1

142

Peto Odds Ratio (Peto, Fixed, 95% CI)

2.86 [0.39, 20.74]

6 Testicular atrophy Show forest plot

6

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

6.1 Shouldice vs mesh

3

1155

Odds Ratio (M‐H, Random, 95% CI)

1.05 [0.04, 27.38]

6.2 Shouldice vs non mesh

3

1995

Odds Ratio (M‐H, Random, 95% CI)

1.09 [0.21, 5.50]

7 Haematoma Show forest plot

10

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

7.1 Shouldice vs mesh

3

562

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.64 [0.25, 1.64]

7.2 Shouldice vs non mesh

7

2797

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.84 [0.63, 1.13]

8 Duration of the operation (Minutes) Show forest plot

7

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 Shouldice vs Mesh

5

954

Mean Difference (IV, Fixed, 95% CI)

9.64 [6.96, 12.32]

8.2 Shouldice vs non mesh

3

372

Mean Difference (IV, Fixed, 95% CI)

10.10 [6.78, 13.42]
Figuras y tablas -
Comparison 1. Shouldice vs other techniques
Ir a la tabla de la revisión