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13 Questions to Ask Before Inguinal Hernia Shouldice Repair
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.
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46 Replies
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Hi Thunder Rose,
Sorry to bother you again however I am in a bit of emergency situation as on top of my inguinal and umbilical hernia they now found a famoral hernia as well! I have been looking for any info on famoral hernia but can’t find much . I know you were preparing for eventuality of your hernia being famoral hernia. Did you ever consider tissue repair if your inguinal hernia was actually famoral hernia? If not could you please tell me why not? And what sort of repair were you prepared to have if it was famoral hernia. I really don’t want to go with mesh .
Would really appreciate any feedback you may have .
Monika -
I have Monika but I can’t find any reviews about his tissue repairs and I believe he cuts cremaster etc.
He did do one of the strictly dancing celebs “hernia” but suspect it was sports hernia. I only found that in a local paper online.
Apart from that cant find much about him
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Thanks William . Did you think about contacting Dr Bailey in Uk ?
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Monika, Ive re-read it, and it relates to a mesh repair.
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Hi William ,
Where did you find this review? I guess no one will have perfect reviews. You could always try consider the surgeon in the Uk Dr Bailey or one of the surgeon in Germany as it very short flight away . One of the reason I struggle to fly far away for the op is that something might go wrong and it would be better to have the doctor close by . -
Just as Dr Yunis was sounding like good option I’ve found a bad review sadly so like Dr Kang, the Germans, Shouldice etc. Not 100 percent. This person had to have osteomy bag after bowel damaged and still has hernia.
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I think what some people don’t like about Desarda is that a flap is cut from an unrelated muscle (external oblique aponeurosis) and used in the repair. However, tissue is cut in the Shouldice procedure as well – flaps from the transversalis fascia. It involves pretty extensive dissection. Also, the cremaster and its nerve in men (in the unmodified procedure), and the round ligament in women.
I’m also considering Dr. Yunis among others. He seems very capable and has a few Shouldice success stories here. On the other hand, he does primarily mesh, and relatively few Shouldice and Desarda. My impression has been that he actually prefers Desarda to Shouldice due to its relative simplicity.
I’m surprised that there are no reports here of surgeries with Dr. Sbayi who has done more Shouldice procedures.
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The 6-sided box model of the inguinal canal is really helpful for understanding the options. The hernia is on the back side of the box (posterior wall), either because the wall blew out (direct hernia) or because the opening (deep inguinal ring) for the stuff that passes through the canal (spermatic cord / round ligament plus two nerves) became enlarged (indirect hernia).
Both repairs start by cutting open the anterior (front) wall in order to get into the box (inguinal canal).
A Shouldice repair is quite involved: it carefully reconstructs the posterior/back wall using the tissues that are already part of the back wall, by pulling them across twice like a double-breasted suit jacket and suturing them to structures on the walls on either side (the superior and inferior walls i.e. the floor and roof). It makes sense because it takes the material that’s already healthily composing the back wall and uses that to build a well-engineered patch.
The Desarda repair pulls tissue from the anterior/front wall down to the OPPOSITE side of the box (back/posterior), sutures it down there and then cuts it loose. It’s like a mesh repair but with your own tissue providing the material. It’s easier (faster) to perform and lower tension on the back wall.When I watch videos of Desarda doing the surgery it turns my stomach, because the spermatic cord is pulled outside of the “box” while the front is being stitched to the back. He cuts the front flap loose and sutures it entirely to the back side, then he has to pull the front closed with a big piece missing (i.e. tension on the front wall where there previously was no damage).
You could think of it like a damaged Amazon box with a tear on the bottom side. You could pull the sides of the tear together to overlap them and stitch it up extremely well (Shouldice). Or you could pull the top of the box down through the interior to the bottom, stitch it to the bottom while holding the contents on top, then cut a chunk of the top loose so you can finish patching the bottom and put the contents back inside, then have to close the top with a chunk of the top missing (Desarda). All while avoiding damaging the contents of the box.
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Yes I am thinking of outside UK possibly, Monika. Even though I’m not a good traveller.
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Hi William,
I was thinking about Dr Conze from hernia clinic in Munich . I’ve seen very positive reviews of him on hernia talk . He dose Shouldice repair and Desarda . I will email him with some question . It’s super hard to make a decision when it comes to the technique or doctor . I really like the way Yunis seems to listen to patient wishes. I am in a super fortunate position where the money is not an issue and to be honest I just want to get this done really well and minimise risk of any complications ect. Are you thinking of going somewhere outside of Uk ? -
Thunder Rose, could I just ask ref Desarda… Why didn’t it make sense anatomically? Is it because it cuts good tissue?
I’m not as good with the biology/anatomy as you and other posters.
I understand Desarda repair cuts a piece of good tissue?
However isn’t it an easier repair? Shouldice is very complex?
I’m not denigrating either or any but at some point, like everyone, I have to choose
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Monika, who in German were you thinking of? I’ve considered Drs Koch/Weis/Lorenz. And also Dr Kang and Prod Desarda.
Still not chosen!!!Like Dr Kang and the German Drs there are a couple of less than positive reviews for Dr Yunis.
Not sure it is possible to find a surgeon with 100 percent good reviews!
So difficult to decide.
Then there’s cost!!!
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Hi Eu,
Great to hear your op went so well with Dr Yunis . Please do come on hernia talk again and share with us your experience. It seems like everyone on hernia talk really has great experience with dr Yunis . I was actually considering going to Germany for the surgery however now I am seriously considering dr Yunis -
Please EU, do keep us updated as it means a lot to those considering surgery to hear from the really good, successful ones.
And thanks to Thunder Rose for posting 2 years later! Appreciated
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Hi Thunder Rose,
First, I wanted to thank you for all the research you’d done and then shared with the forum and for your detailed responses to my questions. This info became the basis for my research and decision making. I had a Shouldice repair by Yunis 4 days ago. The day of surgery I walked 3 miles and the next day started driving. I want to wait for two full weeks to see if there are any significant side effects to share with the forum. As of now, I am happy with the results. I believe Yunis is an exceptionally good surgeon, who is deeply passionate about what he does. I hope to share more soon. -
Hi Thunder ,
That’s really great to hear that your repair is doing so well . Thank you for sharing with us all of your research, it has been super helpful . I’ll definitely look at the YouTube . -
Hi Thunder Rose,
The information in your thread has been very helpful. It looks like you got a great result from your surgery with Dr. Yunis – a good repair without issues. I wish more people reported their experience and results here.
One question is why you wanted to avoid steel sutures. I think you mentioned somewhere that you were afraid that they would break. Was there a reason to expect this, or to be concerned about this? The suture material is one of those aspects of the surgery where it’s not clear if the Shouldice Hospital is doing things just because of historical reasons (why mess with a winning formula?), or whether it’s indeed the best way of doing things. I think in terms of sensitivity or allergies, there are rare cases of Prolene reactions, and there are rare cases of reactions to metals in steel. I don’t know if one is better than the other, if steel elicits less inflammatory response, etc.
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Hi Thunder Rose ,
Thank you so much for getting back to me . I have noticed you had the surgery way back . I haven’t found any doctors who perform Marcy repairs as yet however I understand that it’s not invasive . I live in Sydney and unfortunately the only surgeon who does tissue repair performs Desarda technique . I know you have done lots of your own research on it and I thought I might ask you for your opinion on a Desarda method and any cons you might have . I am considering going to Florida for Shouldice . I understand you are still happy with the repair ? Again thanks so much for your reply . -
This is such a great list, you really did your homework. Obviously only an issue for males, but is resecting the cremasteric muscle, per the Shouldice Hospital technique really a cause of sagging down there? I gather it’s done to give the surgeon a better view of other possible hernias. I wonder what the impact on patient is as it seems like many who modify the a Shouldice technique (like the surgeon you went to) leave this out.
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Hi Thunder Rose , I understand you went for Shouldice repair , did you ever consider any other technique like Desarda or Marcy at all. Would you mind telling me what made you go with Shouldice technique?
Would really appreciate your reply -
Correction. Can I ask what your reasons were to us Dr. Yunis over Dr. Saybi or others? Thanks
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