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Thanks for the feedback. I’ve done some reading today on the 2-layer method (which I think is very common amongst surgeons who do that repair outside of the actual Shouldice clinic), which came from some initial experimentation with 3 layers (because some patients just don’t have enough good tissue for so many layers). Ultimately it seems that it’s been determined that the primary strength comes from the first 2 layers, and the second two are largely redundant. Recurrence rates with a properly performed 2-layer repair are very similar to 4-layer repairs (at least according to one study). Which is why I think many surgeons who do a Shouldice will opt for the 2-layer repair, because it’s obviously easier but also a shorter operating time and more than sufficient in most cases. More evidence perhaps that Shouldice is a little more invasive than necessary and probably just a carrying on of tradition more than anything else.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502350/
I also stumbled upon some research suggesting both absorbable and non-absorbable are fairly similar. The former perhaps increases the chance of recurrence very slightly but not by much. I’ll let my surgeon determine what’s best if a full repair is needed. I think at this point I just want to avoid mesh because of the prior issues I had with it resulting in removal. And permanent sutures lack most of the three dimensional negatives that come from mesh. My issues felt like they were caused by tightness from the large and inflexible surface area of the mesh. I think permanent sutures, while continuous, are more two dimensional and allow for much more flex. And with a 2-layer versus a 4-layer, probably much less plastic material. I don’t think my issues were directly related to the presence of the plastic itself so much.