Reply To: High rates of pain with pure tissue repair?
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I pulled a copy of the 2007 British study
Results (median 52 months follow-up)
Shouldice (74 repairs): six recurrences, eight cases of suprapubic numbness, and one of scrotal numbness.
Lichtenstein (76 repairs): one recurrence, one case of suprapubic numbness, and 10 cases of scrotal numbness.
TAPP (81 repairs): one recurrence and one case of lateral cutaneous nerve damage.
We’re talking about rather small sample sizes here.
“The increased rate of recurrence after Shouldice hernia repair during long-term follow-up has been reported in several studies 15–17.”
The first of those citations is a study whose purpose was “to investigate whether an alteration in type I and type III collagen synthesis, amounts of MMP-1 and MMP-13 and the expression of fibronectin were associated with the development of inguinal hernia”. They looked at the hernia sacs of 23 patients. No full article…but this is not a primary source discussing recurrences after Shouldice repairs.
The second citation is a study concerning short- and long-term absorbable meshes, and I was able to pull a full copy. The word ‘Shouldice’ is not found in the entire article and their experiment involved comparing short- and long-term absorbable mesh in rats…?
The purpose of the third was “to investigate the collagen matrix in recurrent inguinal hernias”. I pulled a full copy of this one too. Again, the word “Shouldice” does not appear in the entire article. They do refer to six studies that discuss repairs and recurrences, but I’m just not willing to pull all six of those to get details.
The authors should be citing the primary sources and then noting the secondary ones citing those sources. It is extremely lazy to send the reader on a chase to verify those claims, especially when there cited studies in turn (allegedly) point to other studies that supposedly state what they are claiming.
“A recent 10-year follow-up study showed a recurrence rate of 7·7 per cent after primary hernia and 22 per cent after recurrent hernia repair 18”.
I pulled that citation too, since those figures seem high. It was a retrospective study that looked at 229 patients who had 293 inguinal hernias repaired in 1992 by the Shouldice technique in University Hospital Aachen, Germany, with a 10yr follow-up period.
Only 31 patients had a recurrent hernia repair…so the 22% figure cited is based on 7 out of 31 people experiencing a recurrence. This does not seem like a terribly representational study from which a recurrence rate should be attached to the Shouldice technique…but there seems to be more.
The authors of that study state their repair details were described in a previous paper…so I pulled that one too. Unfortunately, the full text was in German, but the English abstract included: “For all primary hernias and indirect or small recurrent hernias a modified two-layer Shouldice repair of the transversalis fascia using a monofilament running suture (Polypropylene 0) is recommended.”
So they use a modified two-layer repair? Is that is what the originally stated recurrence rates for ‘Shouldice’ are based on?