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13 Questions to Ask Before Inguinal Hernia Shouldice Repair
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So glad you’re doing well. Wow. Very informative. It seems that you did a tremendous amount of research. Can I ask what your reasons were to use Dr Yunis or dr. Sabyi and others? Thank you
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This is a fantastic thread. Thanks for sharing.
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Has Dr Yunis succeeded sparing all the nerves or some had to be cut?
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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.
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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?
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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.
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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).
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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?
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I found the six-sided box model to be very helpful for gaining a rough understanding of the inguinal canal:
https://en.wikipedia.org/wiki/Inguinal_canal#Walls
I also found watching YouTube videos of Shouldice Repairs to be very helpful for visualizing the surgery:
a more recent 2-layer Shouldice:
https://www.youtube.com/watch?v=DWW-ohDn8zsan older 4-layer Shouldice:
https://www.youtube.com/watch?v=NIJaYVmLzO8-
This reply was modified 4 years, 1 month ago by Thunder Rose.
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This reply was modified 4 years, 1 month ago by
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How is it going now Eu?
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Sometimes there is even an additional step in Shouldice which is a relaxing incision with the goal (I believe) of bringing closer together tissues that need to be stitched and reducing the tension. I don’t know the details. I guess this would depend on the quality of the tissues and the size of the defect. Shouldice is not a simple technique.
A big problem with hernia surgery is that insurance companies don’t pay much for it, and this leads to preferring simpler and faster procedures which can be higher volume.
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This reply was modified 2 years, 9 months ago by Watchful.
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This reply was modified 2 years, 9 months ago by
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The external oblique aponeurosis (EOA) is cut in both Shouldice and Desarda. It’s the anterior wall of the canal: it is cut to gain access to the inguinal canal in both repairs. See my response to William above for why I’m against the Desarda repair.
Unlike a general surgeon, Yunis is only doing hernia repair: “relatively few” Shouldice and Desarda is still a high raw number of tissue repairs annually.
I had to practice cognitive flexibility to accept that Yunis preferred Desarda repairs. I was focussed on achieving the end result — an out-patient, conscious-sedation, Prolene 4-line 2-running-suture Shouldice repair — that I wanted, and ultimately determined that with Yunis I could have my desired outcome.
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William, I suggest watching the surgical videos for both Desarda and Shouldice on YouTube and considering the 6-sided-box model of the inguinal canal. Being able to visualize the repairs helps a lot. The Posterior and Anterior (back and front) walls are opposite each other, the Inferior and Superior (floor and roof) walls are opposite each other.
The hernia sac comes through a defect or enlarged ring on the Posterior Wall – the back wall. In Shouldice the faulty Posterior wall is first cut and then rebuilt using the structures on either side of the Posterior Wall (from the Inferior and Superior walls, the floor and roof of the box, where they are adjacent to the Posterior wall) to create the “double-breasting” like a fancy jacket.
The Desarda Repair takes the Anterior wall, that is the FRONT wall or opposite side of the box, the External Oblique Aponeurosis, cuts it into a giant flap and pulls it underneath the Spermatic cord and everything else that passes through the canal, and then stitches that to the BACK wall to make a flap that functions like a flat mesh would.
I believe surgeons like Desarda repairs for the same reason they like mesh: it’s a big flap that is easy to fix in place and cover a defect. It’s an easy to teach repair.
Yes, both repairs cut into healthy tissue. Shouldice is a clever bit of double breasting using structures immediately adjacent to the defect. Desarda is borrowing tissue from the top of the box and tacking it onto the bottom of the box, creating a mesh-like tissue repair.
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I was influenced by the idea that for the majority of people it’s not reaction to the mesh itself but badly placed mesh that causes the problems, hence mesh plugs and system meshes causing issues with such frequency. I extended that thinking to even the flat meshes bunching/migrating over time: perhaps there’s no such thing as well-placed mesh. It’s the quick, easy, literally band-aid-like solution, but not a good choice for an enduring pain-free repair.
Yes, there’s a large body of material in my Shouldice repair’s four lines of running sutures. Prolene sutures are used internally throughout medicine without the level of issues we see with Polypropylene mesh, which leads me to think the problems primarily arise from the form (mesh) not the material (polypro).
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That’s a reasonable concern, at least in theory – thanks. Whether it happens in practice or not, who knows… Since the advantages of steel when compared to Prolene aren’t clear either, I can see why going with Prolene can seem more reasonable.
On the other hand, there’s all this fear of foreign body reaction with Prolene mesh, and I’m not sure why the same wouldn’t happen with Prolene stitches. The amount isn’t the same, of course, but there’s still a significant amount of material even with the stitches.
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I didn’t research this.
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I love that I’m getting called out for personal biases. I made crafts a few years ago with my kids using a similar gauge of stainless steel to what they use at Shouldice Hospital (32 or 34 gauge): tiny posable beaded animals using seed beads. Here’s a link that’s very similar https://stuwahacreations.com/2014/08/20/how-to-make-tiny-beaded-geckos/. They lasted a few weeks and my kids played with them and eventually that wire snapped with not much bending back forth. So I have an image of those tiny bifurcated gecko bodies with tiny sharp metal points jabbing out their middles that I cannot forget.
I also think Grischkan made a comment to me about the stainless steel sutures snapping as a reason why he uses polyester sutures despite having close ties to Shouldice Hospital.
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Yes I’m still happy with my repair. I live in Wyoming and since my repair have done nearly two full ski seasons (Alpine and Nordic) and quite a bit of running, hiking, and biking. I don’t have any pain with exercise.
Very rarely when at rest I get a twinge or brief ache of scar tissue pain at or near the surface of my skin, but I don’t have any pain deeper down at the site of the repair in the inguinal canal.
Sorry, I don’t feel qualified to give more specific critique of the Desarda repair. I suggest watching the YouTube video of Desarda himself demonstrating the technique. My memory is that it gave me the willies watching him pull tissue under the spermatic cord that should have been over it.
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I never talked to Peterson. I piggybacked on another HerniaTalk user’s research in ruling him out (that was privately shared with me). The info I received was that he uses individual sutures instead of running lines, and I knew I wanted running lines.
I don’t have informed opinions on mesh removal, but my uninformed opinion is that it’s a more specialized surgery than a tissue repair, and I’d be more willing to spend the money to see someone like Towfigh to have a chance of getting my health back without the solution being worse than the problem.
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Hey Chuck: Wiese vs. Koch: I know that Wiese uses Prolene for his Shouldice repairs because of this thread: https://herniatalk.com/forums/topic/my-meshless-hernia-repair-in-germany/ I’m not clear if Koch uses Prolene or Stainless.
I almost went to Wiese because I had to make a family trip to Ulm in spring 2020. I was going to have my hernia surgery before flying home from Frankfurt. Then COVID hit and I cancelled my surgery. My hernia became much worse in Summer 2020 and that’s when I found HerniaTalk and did a lot more research.
So there’s some random geographical bias in my mentioning Wiese. I sent BioHernia better-informed questions in fall 2020 for both Koch and Wiese but I didn’t get any answers, just a response from Nahom that he realized I still couldn’t get into Germany at that time on a US passport. These are the questions I sent Nahom, copied from my email:
…is it possible to ask Dr. Wiese or Dr. Koch some questions about the particulars of their repairs? I’ve come to understand that not all Shouldice repairs are equivalent. For instance,
1. Do you transect the genital branch of the genitofemoral nerve routinely? Do you identify and protect the ilioinguinal nerve or is it transected?
2. Do you transect the round ligament routinely?
3. Do you ligate and resect the hernia sac routinely? In what circumstances would you do so?
4. Does your Shouldice repair always include 4 lines of sutures on the posterior wall (2 sutures each reversed to make 4 lines total) or do you place 2 lines on the posterior wall? Which structures are being sutured together in the reconstruction on the posterior wall?
5. What kind of suture material do you use for the posterior wall reconstruction? For the closing of the external oblique aponeurosis? For the skin closure?Also, is it possible to request a Shouldice and not a Desarda repair, or is it up to the surgeon to select the repair type during the operation?
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Watchful: you’re correct: I made an error above. Sbayi uses conscious sedation, though my notes show he told me that he “may introduce general aneasthesia to let muscles relax” although I believe he said that’s rare.
As you say Yunis prefers GA but allows for patients to choose MAC. I was able to choose at a private conversation with the anesthesiologist immediately pre-op at the facility.
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I’m surprised Dr. Sbayi wanted general anesthesia. Was this because of anything specific to your case? He normally uses local+sedation. Dr. Yunis actually prefers general, but will do local if you insist.
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Hi Monika, I was interested in a Marcy repair until a surgeon said my hernia was most likely Direct (based on its shape and size). It did turn out to be a Direct Hernia.
Have you found a surgeon who will do a Marcy repair for an adult without reinforcing with Desarda? I suppose Kang does.
Watching YouTube videos of the Desarda repair ended any interest I might have had. It doesn’t make sense to me anatomically, and I think I was influenced by comments Towfigh has made about not doing Desarda repairs and the absence of evidence for the procedure. I only went to Yunis given reassurance that he would honor my choice not to have a Desarda repair.
I haven’t been thinking much about hernia repairs for over a year. I have not been following new research and opinions on these repair options.
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Hi Debbie, Sbayi uses metal sutures and insisted on General Anesthesia. I decided I wanted Prolene and Monitored Anesthesia Care (MAC) / Conscious Sedation. Yunis uses Prolene and offered MAC in an outpatient surgical facility instead of a hospital setting. I could have had the same (Prolene Shouldice repair w/MAC in outpatient facility) from Dr. Wiese in Germany and probably would have gone that route if not for COVID. Yunis was out of network for my insurance but the facility and anesthesia were in-network: it wound up being less money out of pocket even than the flat rate for Wiese, so it worked out in my favor.
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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.
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