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2-layer Shouldice
I think that almost everyone who visits here comes to the conclusion that there are a lot of gaps in how complete and accurate the information is on the different aspects of hernia surgery.
I wish, for instance, there was more information on the pros and cons of a 2-layer Shouldice. Here is an old study from about 1994 that drew a loosely supported conclusion that a 2 layer Shouldice that only did the double breasting of the transversalis fascia had statistics of recurrence comparable to the 4-layer. While this study was too small and had poor follow up after one year, it made me wonder about a few things.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502350/1)Wouldnt it be less complicated to go in and add a mesh at a later date in the event of failure with a 2 layer than a four layer?
2) Perhaps problems With scar tissue would be less. The anatomical tissues of the inguinal canal that touch each other in 2 layer are the same as in a normal canal, with the spermatic cord and external oblique above it laying on the transversalis fascia (now double breasted) same as before. With the four layer, otoh, some muscle structure is pulled over and the tissues are differently and (more crowdedly?) sandwiched together.
3)A little less suture material.
Just some thoughts. If you want a tissue repair and even if a 2-layer has a slightly greater chance of recurrence, if any of the above works in favor of a 2-layer, are there enough pros to balance out that greater chance of recurrence.
Sadly, it doesn’t seem like much attention has been paid to follow up on the above study.
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14 Replies
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Regarding creating weakness in other areas. This is something that I’ve been wondering about too. Can the tissue manipulation of Shouldice cause weakness in other areas? It seems to be extensive enough to have potentially direct or indirect impact on a pretty large area.
For example, if you have a Shouldice repair on one side, are you more likely to get a hernia on the other side than if you had Lichtenstein? I’ve never seen studies of this sort of thing.
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That is an interesting perspective. Another of those things that doesn’t seem to be discussed in depth – how does one method affect recurrence repairs? Generally, like many of the complex questions, it seems to be oversimplified. Open or lap. Mesh or non-mesh.
I haven’t studied or thought much about the pure tissue methods. But, these “layered” techniques have to be creating weaknesses in other areas of the abdominal wall. The body does not create “free” spare tissue, ready to be moved to some other part of the body. A person should consider the time factor involved for the area around the layer that has been removed to regain its strength or to fill in.
It would be very interesting to hear an expert in the various repair methods describe what method they would choose for repair and how they would handle the healing process. Would they trust the method to bring them back to full strength in a week or two? Or would they have a plan to take months or even years to work their way back to full strength?
In the early days of ACL repair of the knee, recurrences (re-ruptures) were pretty common because the athletes tried to get back in to action too quickly. Now, it’s not uncommon for an athlete to expect a year of time to recover after an ACL operation. They’ve learned.
It’s a good idea to think past the initial repair. Really, a person should plan out the rest of their life. Include financial realities, time available, responsibilities, etc. before choosing a hernia repair. It’s not really just outpatient surgery. Good luck with the research.
The Cleveland Clinic has an interesting page about the layers involved in pure tissue repairs.
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I was talking about re operation with Lichtenstein after an open 2 or 4 layer failure. I realize standard practice currently is to do the opposite side from what was done originally, but that’s assuming levels of scarring with Lichtenstein mesh or the more layered tissue repairs. Maybe it wouldnt be as bad if the original was just transversalis fascia repair. Also, not everyone can do the general anesthesia, in which case you’d want a lesser scarred site to reenter.
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When you say “reoperation with mesh” do you mean open mesh? Lichtenstein? Plug and patch (still popular)? Or laparoscopy? Placing mesh on the backside would be easy I think. Just cover it all up.
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The higher degree of recurrence by skipping the 3rd and 4th layers actually seems probable, despite there being no indication one way or the other in the limited study.
However, the question I would ask given the closeness of the study is whether there a pick your poison question involved I may be totally off base, but it would seem like scarring would be less with the 2-layer than the 4-layer. So, let’s say a 2-layer has a 10% chance of recurrence and a 4 has a 5% chance, but the re operation with mesh on a 2 layer is much easier with less scar tissue. Which is the better initial operation then?
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Skipping the 3rd and 4th layers will likely make the repair more vulnerable to recurrence. These layers cover the medial part of the repair which is susceptible to recurrence (according to the Shouldice Hospital).
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Ok, so here are a few thoughts for Dr Towfigh concerning the comments about 2-layer Shouldice on the recent program.
First of all, the name. I don’t think what the Joneses are doing should be called a 2-layer Shouldice, because the differences are too great. I’m not sure, though, that there is better thing to call the one mentioned in the above mentioned paper. To make that point, let me quote the surgeon from the following biohernia 4-layer demonstration,starting at the 21:40 mark.
He says after finishing the first two layers: “And that’s the most important part of the Shouldice operation, the double breasting of the transversalis fascia, which you can see, has cured the hernia.”
He repeats:”And that’s the most important part of the Shouldice repair. So that’s the double breasted posterior wall….feel that Peter. The transversalis fascia feels like it would feel in you.
“The premise of the Shouldice operation is that the transversalis fascia is the most important structure holding hernias back…preventing hernias from recurring”
From there he goes on to sew the third and fourth layers and finish up.
My point here is that, for the particular operation in the 1994 study, if they’ve done the actual main part of the Shouldice operation similar to what was done in this video and they stop at 2 layers instead of four, the name 2 layer Shouldice, in this particular case, isnt deceptive. To use your car analogy, a car with a four piston engine is still a car as much as a car with a 6 piston engine, even though it might not be as fast.
Ok, more importantly than the name, though, does it work? And just because nobody expanded the study, that’s not a sufficient reason to believe it doesn’t. The results from the study, however limited, suggests that it very well might.
Granted, an expanded study might could be “guessed” to prove otherwise. That actually seems to be one conclusion to draw here, that hernia experts could see without testing further that despite whatever this study said, it must be wrong.
But another possibility might have to do with the timing of factors of hernia surgery progrssion, inertia and conservatism within the industry, coupled with the fact that this study came out in 1994, well past the advent of mesh, such that few people would be willing to actually think about it. There aren’t that many of you guys specializing in hernias, so something that seems like such a throwback question could have been overlooked.
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Maybe simplified Shouldice or modified Shouldice?
I’m not sure but I have a recollection Simon Bailey does 3 layer.
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I think I saw the one on “technique”. The main part of which was the fault of the keyhole mesh for lap repairs of inguinal hernia. That part was very informative. I think you also mentioned the Shouldice naming problem there.
However, can I point out a possible point that maybe it is similarly smart for Dr kang to call his indirect something different than a Marcy, if in fact his repair does differ from the actual Marcy? Not that I understand whether that is true or not.
I am now looking forward to watching your latest video if more of this is covered.
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We discussed this on the last 2 HerniaTalk LIVE sessions, if you’re interested to watch/listen.
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They really shouldn’t call these 2-layer procedures “Shouldice”. That’s a specific procedure which is a 4-layer repair.
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Yes he was trained by them, you’re right David. I didn’t know they differed from the Shouldice original in any other way though so it would be useful to know.
It more or less shows a lot of surgeons modify established repairs to some degree.
Whether that’s good or bad I don’t know.
But I read that quite early on there were over 70 modifications to the Bassini. !!!
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William,
Thanks for pointing this out. Elsewhere on the forum, it says that Simon Bailey was trained by the Joneses, who seem to do their two layer in a different way than the 4 layer Shouldice first two layers of double breasting.I’m not a medical professional, but I have my doubts about the technique that the Joneses employ in their Youtube video. I’ll try to find a way to explain what makes me wonder about it’s relative value.
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I think Simon Bailey in the UK does a 2 or 3 layer. His view is that 4 layer is unnecessary and adds not much to the repair.
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