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One reason I mentioned the size of the hernia as a criterion is that this paper uses the length and difficulty of the surgery as a motivation for re-thinking the use of Shouldice to repair recurrent hernias (after Shouldice or open mesh). The choice is between a particularly difficult Shouldice repair, and a normal lap mesh repair.
The same logic would apply to large hernias, at least based on my experience, and based on the German guidelines. The Shouldice surgery on my large hernia was twice the normal duration, and it was difficult even for my highly experienced surgeon. As I mentioned before, when I asked him if Lichtenstein would have been difficult as well, he said no. Now, the difficulty of the surgery shouldn’t be the only criterion, of course, but if that’s enough to prompt a re-think, then it seems that a re-think of Shouldice for large hernias would be reasonable as well.
You mentioned Dr. Kang – how he can be confident with applying his tissue repairs in all these cases that other tissue repair experts are struggling with is a mystery to me, and one of the reasons I never felt comfortable with going there.