13 Questions to Ask Before Inguinal Hernia Shouldice Repair
11/10/2020 at 5:20 pm #28202
I am 3 weeks out from my Shouldice repair from Dr. Yunis in Sarasota, Florida. I have had an extraordinarily smooth recovery and I am very happy with my repair.
I talked to a large number of surgeons while watchful waiting for 5 years. By the time I met Dr. Yunis I had prepared a rather intense written cross-examination. I think I gave the impression of being very nervous, but the result of having all my questions answered in advance was that I felt very relaxed on the day of surgery and confident in my choice of surgeon.
Here is my slightly revised list of questions for those considering an Inguinal Hernia Repair, along with roughly what I wanted in response.
Questions for Surgeons Prior to INGUINAL Hernia SHOULDICE Repair
1. Will it be an option to choose local anesthesia with I.V. Conscious Sedation instead of General Anesthesia?
— I had to specifically request it at the surgical center, but I did receive I.V.C.S. It was not my surgeon’s preference but the anesthesiologists were more than happy to do it and told me it would reduce my post-operative nausea. I asked about General Anesthesia being safer for monitoring the airway and was told that this would only be a factor to consider if I were 200 pounds heavier (I have BMI ~23-24).
2. Do you routinely transect any of the three nerves (genital branch of the genitofemoral nerve, ilioinguinal nerve, or iliohypogastric nerve)? For what reason(s) would you transect any of these?
— The answer should be that they never routinely cut any of the nerves. I liked Yunis’s response — roughly, ‘no one does that any more!’ — which while untrue conveys that he’s not going to transect any nerves without reason.
3. Do you routinely ligate and resect the hernia sac? Under what circumstances would you do this?
— Answer should at least show awareness that there’s research correlating this with post-operative pain. I accepted that the sac would be ligated and resected depending on the gestalt.
4. What type of suture material would you use for the reconstruction portion of the Shouldice repair?
— I wanted Prolene. I believe this is the material used for Shouldice repairs by Towfigh, Muschaweck, Yunis, and Wiese. My understanding is that Brown uses silk, Sbayi and Shouldice Hospital use stainless steel 32 or 34 gauge, and Grischkan uses Polybutester.
5. Is there potential that during a planned tissue repair you would need to use mesh? What type of mesh would you use under those circumstances?
— I agreed to a Nyhus-type posterior placement from an open repair flat polypropylene mesh if my hernia turned out to be femoral. I had been assured by another surgeon that it was definitely not femoral so I felt the risk of this was low. I felt this approach and type of mesh was safer than a laparoscopic posterior mesh which would have been contoured and larger (Bard 3D).
6. Females only: Do you routinely transect the round ligament? I am aware that most surgeons consider it vestigial.
— I decided to accept this being transected, but I think it’s good to ask. Patients with high risk of uterine prolapse might want to make the case for it to be saved.
7. For the reconstruction portion of your Shouldice repair, how many lines of sutures do you run over the posterior wall of the inguinal canal? Are you running 4 lines formed by two sutures as in the Shouldice repair described in Glassow (1973: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941165/pdf/canmedaj01661-0043.pdf) and Bendavid (1997: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952996/) or are you running two lines formed by one suture on the posterior wall as in various modified 2-layer Shouldice repairs?
— Answer I wanted: 4 lines formed by two sutures.
8. For your first two lines on the posterior wall, which structures are being sutured? Do you double-breast the transversalis fascia, or is the remaining flap of transversalis fascia not included in the second line?
— Answer I wanted: that the transversalis fascia is sutured first to the back side of the superior wall (conjoint tendon) and then to the inferior wall at the inguinal ligament. The terminology varies by surgeon so it can be hard to parse.
9. If you’re placing a 3rd and 4th line on the posterior wall, which structures are sutured? (Only in general terms. I realize that the structures on the superior wall vary over the length. I am most interested here in the inferior wall as I find it curious that in Bendavid’s reconstruction (cited above) his third and fourth line are to the external oblique aponeurosis just above the inguinal ligament while Glassow and other descriptions I’ve encountered suture to the inguinal ligament itself.)
— Answer I wanted: confirmation that the 3rd and 4th lines are part of the reconstruction and that the surgeon understood the question.
10. For the closing of the external oblique aponeurosis on the anterior wall do you use an absorbable suture?
— Answer I wanted: confirmation that they’re not going to add a Desarda repair on top! I wanted to know that this would be an absorbable suture. Answer I got was short term vicryl.
11. What type of incision do you make? What type of skin closure?
— I wanted an oblique incision and running subcuticular skin closure.
12. Does your Shouldice repair include “two sutures to close the gap between the transverse muscle and the femoral ligament”? (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1235020/pdf/annsurg00046-0039.pdf)
— Answer I got and don’t really understand: Rarely-because of the risk of femoral vein compression.
13. Men should ask about partial vs. complete loss of the Cremaster muscle.
11/10/2020 at 5:31 pm #28203
I found the six-sided box model to be very helpful for gaining a rough understanding of the inguinal canal:
I also found watching YouTube videos of Shouldice Repairs to be very helpful for visualizing the surgery:
a more recent 2-layer Shouldice:
an older 4-layer Shouldice:
- This reply was modified 5 months ago by Thunder Rose. Reason: tweaked a line break to improve URL appearance
11/12/2020 at 12:27 pm #28210
Great posts, just in time for me as I am scheduled to talk to Dr Yunis later this month. Thank you! How big was your incision? How long have you experienced post-op pain and what meds did you use for it? If you experienced nausea and bloating prior to the surgery (I have a low-grade nausea and bloating over the last month or so), do you still have it?
11/12/2020 at 1:27 pm #28211
Hi Eu, Answering your questions one by one:
1. How big was your incision?
— Yunis told me ahead of time it would be larger, but it’s only 6 cm (just under 2.5 inches). I am extremely fine-boned so my best guess is he adjusted the incision to my frame.
2. How long have you experienced post-op pain and what meds did you use for it?
— I did not fill my prescription for pain meds (I think it was a codeine with acetaminophen). I used the maximum dose of over the counter Tylenol and Ibuprofen for about a week, and then a lower dose for another week. I walked two miles the evening after my surgery and two to three miles including uphill hiking every day after that. I had some bloating after the surgery and some swelling with a healing ridge. Superficially I only had one small bruise about an inch across and then a second one-inch bruise appeared three days post-op.
We stayed 8 days in Florida for a bit of vacation so I had an in-person follow-up and they did comment that many patients have much worse bruising and swelling, and larger incisions, than what I experienced.
I have been doing some light jogging starting at 2.5 weeks post-operatively. I think everyone’s pain tolerance is different, and my bulge had grown so large and bothersome that the nuisance of a healing surgical wound was immediately an improvement for me over the hernia.
3. If you experienced nausea and bloating prior to the surgery (I have a low-grade nausea and bloating over the last month or so), do you still have it?
I didn’t have nausea, but I did have a feeling of needing to lie down to reduce the bulge and my ascending colon would feel bloated and gassy. Every digestive complaint I had before the operation (mainly sluggishness) has been resolved. My bulge had grown to roughly tennis-ball sized and my defect turned out to be direct.
For me, the decision to go to Yunis was predicated on confirmation I would only receive a Shouldice repair, not a Desarda, independent of my defect type (direct vs. indirect).
11/12/2020 at 2:22 pm #28213
TBH my husband did all the cooking, cleaning, and managing kids for a week. Walking, hiking, even getting in and out of a car repeatedly for hours while going birding at a state park was fine but I didn’t want the kids bumping me (I have very active 7-year-old twin boys). I was doing computer work (designing catalog layouts) (while on vacation) starting the day after my operation, but only in bursts of thirty minutes on, thirty minutes off, and against doctor’s orders to wait until day three to return to office work.
11/12/2020 at 5:49 pm #28214
Thanks for your detailed answers. My understanding is that you had a chance to speak with anesthesiologist re the type of sedation you wanted. At the Shouldice Clinic they use a combo of a 18-hr med. and a short lasting ones. Was it what you’ve got? Did Dr Yunis recommend any physical therapy after the surgery? If mesh had to be used, what options did he give you?
11/12/2020 at 6:55 pm #28215
Anesthesia: I don’t know the specific meds. At the surgical center I first signed a paper where the two main options were General Anesthesia or Monitored Anesthesia Care (MAC, i.e. IVCS) and I only signed permission for MAC. Then I spoke to the anesthesiologist and finally to the anesthesia nurse. If you want to know the specific meds you could try calling Sarasota Physicians Surgical Center. I shadowed a pulmonologist during an endoscopy under IVCS years ago so I felt like I knew what I was agreeing to. Apparently typical patients are awake but then have amnesia, but they told me afterwards that I was atypical and snored through my procedure.
Yunis did not recommend PT. For the days immediately following the procedure he recommended walking rather than biking (in contrast to Shouldice Hospital). I followed the advice reported in reviews of the German surgeons like Wiese and Koch and tried to do a lot of walking immediately.
Regarding mesh I was pretty confident mine wasn’t femoral so I wasn’t too concerned Yunis would place mesh. His office has separate paperwork to sign allowing a tissue repair and not permitting mesh placement so I think one can go in confident mesh will not be placed unless the patient has given specific permission. My understanding is Yunis does not use polyester mesh like Parietex Progrip and does use Polypropylene mesh (smaller flat for Nyhus, Bard 3D Max for laparoscopic).
Sbayi surprisingly offered lots of different mesh and honors patient request for mesh material– we discussed Ovitex, “thicker biologics”, and Phasix synthetic absorbable. With Sbayi we discussed a “complete blow-out” of the inguinal canal floor and using G.A. or relaxing incision first before turning to mesh. I believe Yunis was more confident indicating he can do a Shouldice for inguinal defect of any size.
11/12/2020 at 8:00 pm #28216
Has Dr Yunis succeeded sparing all the nerves or some had to be cut?
11/13/2020 at 10:37 am #28228
My understanding is none of the nerves were cut and I have no reason to think otherwise.
One surgeon who told me he would transect the genital branch nerve told me it would take 6-24 months to grow back and I would have numbness. I have nothing like this. Another surgeon told me he would transect both the genital branch and the ilioinguinal nerves. My understanding is Yunis does not take nerves in a primary repair.
11/13/2020 at 1:02 am #28220drtowfighKeymaster
This is a fantastic thread. Thanks for sharing.
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