There is evidence that, despite advances in hernia surgery, the rate of hernia recurrence has remained the same, hovering at about 14% worldwide, with a range of 10% to 22% (Tables 7.1, 7.2 and Figure 7.1). By advances we mean the several varieties of prosthetic meshes, the numerous kinds of implantable, one size fits all gadgets which flood every surgical meeting, and the still controversial laparoscopic techniques. It may be that in the hands of surgeons sub-specializing in hernia surgery, the results are better but the overwhelming majority of hernias are repaired by general surgeons who, on average, do 50 cases a year only!. Statistics from the Shouldice Hospital point to the fact that 65% of the failed herniorrhaphies are due to an inadequate search for a hernia or simply due to a grossly inadequate knowledge of anatomy. Much to the regret of the surgical community, the Shouldice Hospital has not come forward, in the last 20 years, with meaningful peer reviewed publications or statistical data to support the claims which they put forth at conferences; nor have their statistics ever been presented with a seal of approval by a bona fide statistician. For those reasons, the comparative results must come from older series as well as from older reports, albeit from competent surgeons. It must also be kept in mind, in all fairness, that pure tissue repairs do not get the approval and support of an industry which is geared to produce and sell what it manufactures. We shall revisit these ethical issues.

The Shouldice Hospital was established in 1945 by Earle Shouldice. Its accomplishment is not in having designed a new operation. It did not. It simply carried out the steps of the Bassini operation faithfully. These steps were introduced by one of the staff surgeons, Ernie Ryan. Three differences stand out between the classic Bassini operation and what is done at the Shouldice Hospital today: The use of stainless steel wire as a suture material, as opposed to the cotton and silk which were available in Bassini’s days; a continuous suture rather than the interrupted sutures which Bassini inserted;

the exclusion of the periosteum from the first suture as was suggested by Bassini. The Shouldice Hospital, can be said to have been the heir of Bassini in having honored and respected each and every step of his legacy. The Hospital, still in existence today, performs upwards of 7,000 operations a year, which are carried out by a staff varying from 10 to 12 dedicated surgeons.

Local anesthesia became, very early, a standard practice. That possibility was convincingly established by Halsted and Cushing 50 years earlier. Early mobility became the norm as soon as surgery is terminated when the patient walks to the recovery room and ambulation is encouraged when the effects of the preoperative sedation have dissipated. This trend was begun when Earle Shouldice observed that children could not be kept in bed following herniorrhaphies and that their early activity never resulted in any ill after-effect.

The groin is unquestionably an area of the human anatomy which has long been recognized as a difficult area of study. This is probably due to the four dimensions of an anatomy which changes as one proceeds askew from front to back and from the midline to the side. A crab might have an easier time of it! Still, some important concepts must be retained which will ease the understanding of the complexities.

Without a doubt, the most complete study of the anatomy of the groin is provided by H. Fruchaud. His book, published in 1956 by Doin Publishers in France was difficult to find and the work had not been translated into English until 2006. As a result, very few authors had previously quoted from him in a limited manner. With Astley Cooper and Jules Cloquet, the Fruchaud has been one of the cornerstones in understanding the anatomy of the groin. A review of Fruchaud’s text reminds us that the groin anatomy must always be referred to in the vertical, time honored position and tradition! Not with the patient in the supine position as in the dissection room cadaver so that the floor of the inguinal canal is the pubic ramus (with the patient in the erect position) and NOT the so-called “transversalis fascia.” The transversalis fascia is the posterior wall of the inguinal canal with the patient in the standing position as well as in the supine position in this case. Another unfortunate deformation and confusion in the teaching of the anatomy of the groin is the definition of the transversalis fascia. The problem arose with Astley Cooper when he called the transversus muscle the transversalis muscle so that its continuation inferiorly became the transversalis aponeurosis or transversalis fascia. It should instead have been called transversus aponeurosis or transversus fascia which goes on to contribute to the posterior wall of the inguinal canal.

The true transversalis fascia is in fact the endoabdominal fascia which is continuous with the endopelvic fascia and the rest of the abdominal cavity. It is a very thin layer, marked by a profuse cellularity which differentiates it from the aponeurotic, sparse cellularity of the extensions infero-laterally of the transversus abdominis and internal oblique muscles. These last two fascial layers form the true posterior wall of the inguinal canal.

Another feature of Fruchaud’s inguinal description is the elimination of the inguinal ligament. There is no such ligament! It is simply a continuation, a reflection of the external oblique aponeurosis. What Fruchaud refers to as the inguinal ligament is in fact, the iliopubic tract (the ligament of Thomson), a structure seen at the lower edge on the deep surface of the divided posterior wall of the inguinal canal. It is not always a solid structure, especially at its lateral end. That is why the reflection of the external oblique aponeurosis must be included in the Bassini and the Shouldice inguinal hernia repair. Since usage has forced us to call “Transversalis Fascia” the posterior aspect of the inguinal canal, we will continue to do so to avoid confusion. It follows therefore that the lower extension of the transversalis fascia joins the inner aspect of the recurved and lower portion of the external oblique aponeurosis to continue inferiorly over the pubic ramus.