Chronic pain after Shouldice versus Lichtenstein inguinal hernia repair: a systematic review and meta-analysis

PURPOSE: The Lichtenstein (mesh) and Shouldice (non-mesh) techniques are the main options for open inguinal hernia repair. This systematic review and meta-analysis compared the prevalence of chronic postoperative pain between them. METHODS: A systematic search was conducted in Medline, Embase and Cochrane databases for studies comparing the prevalence of chronic pain after Shouldice and Lichtenstein techniques in adult patients undergoing inguinal hernia repair. Meta-analysis was performed using RevMan and the effect model was determined based on heterogeneity, assessed by the I² statistic. Subgroup analyses were conducted by mean follow-up duration and study design. RESULTS: Ten studies with 4,122 patients (59.8% Lichtenstein) were included. Shouldice repair was associated with a 34% relative risk reduction in chronic postoperative pain compared to Lichtenstein (RR 0.66; 95%CI 0.56-0.78; p < 0.00001; I² = 5%). Conversely, the Shouldice technique demonstrated a higher risk of long-term hernia recurrence (RR 2.54; 95%CI 1.15-5.63; p = 0.02). There were no statistically significant differences between the two techniques regarding early postoperative complications (RR 1.01; 95%CI 0.85-1.19; p = 0.95) or mean operative time (MD 5.96 min; 95%CI -0.79 to 12.71; p = 0.08). CONCLUSION: Although the Lichtenstein repair is more widely practiced, the Shouldice technique yields significantly lower rates of chronic postoperative pain, albeit with a higher risk of long-term recurrence. This trade-off highlights Shouldice as a potential alternative in selected patients.