2003 study of TEP compared to Shouldice

Hernia Discussion Forums Hernia Discussion 2003 study of TEP compared to Shouldice

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    • #30727
      Good intentions

      Occasionally I find an old study that makes me wonder how laparoscopic mesh implantation took over the field of hernia repair. Here is one. It seems that people were striving to find the benefits and just weren’t finding them. Shouldice was better, by the numbers, in this paper even though the conclusion says “the same”. More recurrences and pain for TEP. Even back then there was some sort of “EU Hernia Trialists Collaboration” working on what looks like mesh promotion. Hard to understand.

      There is a table in the document that shows things clearly. I don’t know what “sensibility” is.


    • #30730

      GI—good find….do you know why Towfigh keeps mindlessly repeating that LAP TEP is the best in terms of chronic pain and recurrances…she says this over and over and over…it must be based on something…keep in mind there are studies that show shouldice has a 26 percent long term pain rate…not sure what to believe….

    • #30734
      William Bryant

      Is it because mesh is easier that it caught on? That and promoting mesh as strong probably.

      The recurrence rate is also often cited.

    • #30740

      The 2003 study is terribly flawed.

      – It was performed at a time when surgeons were not skilled in laparoscopic repair. In this study, the surgeons only had to do 10 laparoscopic cases before entering patients. My residents have done more than that in their first few years of training. That number is way below the number needed to get beyond your learning curve. Meanwhile, the surgeons were already experts in the Shouldice tissue repair
      – nevertheless, the findings still show no statistically significant difference between lap TEP and the Shouldice. P>0.05. They only compared 130 patients in each arm, so possibly a larger study may have teased out differences in outcome.
      – To interpret that the study did show a difference (Eg higher recurrence with TEP) is statistically incorrect.
      – to claim the study nefariously promotes mesh based repairs is also not fair for this prospective randomized trial.
      – sensibility means sensation.

    • #30742
      Good intentions

      I posted it mainly as an example of studies over the years, and what seem like efforts to make mesh repairs look better than they are.

      Dr. Towfigh, you often make statements but never supply your references. Could you supply a reference or two that support your statements? One of the studies you mentioned in the other thread.

    • #30751
      Good intentions

      Here is a good discussion from 2018, between Dr. Bendavid and Dr. Voeller, about the use of mesh compared to pure tissue repairs. Dr. Voeller speaks of studies but does not list any. And he is a professor at the University of Tennessee Knoxville Medical Center. He says that the improvement in recurrence rate cannot be argued, it is supported in “most every study”, but Dr. Campanelli, in his editorial, says that the data about recurrences is unclear.

      There does not seem to be any consensus at all about what is best for the patient. The only consensus is that mesh is here and predominant.



    • #30752
      Good intentions

      Actually Dr. Voeller is at the UT Health Science Center.


      Dr. Bendavid was a surgeon at the Shouldice Hospital but has died.


    • #30753

      Personally I think the other study that you linked to, published by Kockering and Koch in 2018 that compares Shouldice to other methods is more informative. It is a much larger sample size, was done at a time when laparoscopic was better known, and looks at patient populations on an apples to apples basis (ie similar age, bmi, etc).

      I would be very curious what Dr Towfigh, an honest to goodness expert, thinks.

      To a layman the studies, particularly the better one in 2018 show a) the results for Shouldice vs Tapp and Tep are not statistically different; b) ongoing pain can be an unfortunate side effect with Shouldice too, it is not a risk free operation either.

      That said, you make a good point in other posts that Shouldice does not close a door, while the laparoscopic techniques do. And these studies are at only a 1-2 year follow-up. There doesn’t seem to be good data on how mesh ages over decades, people just say “surgical mesh has been used for decades” and leave it at that.

      Any thoughts from our Moderator?

    • #30754

      Hi Dr Towfigh,
      I have developed an umbilical hernia, it’s a small size. I only want to use stitches and wondered if soluble stitches can be effective or do they have a very high recurrence risk? Also, I wanted to ask you what technique you use or have used for repairing such a hernia without mesh?
      I have noticed your posts that people can help reduce small hernias without surgery and what things I could do to try and achieve this – I’m already slim, I don’t smoke or drink but I’m hoping there are further things I could be doing?
      Would really greatly appreciate your help.

    • #30758
      William Bryant

      Monika, as far as I know umbilical hernias are less problematic repair wise than inguinal as the inguinal canal has a lot of stuff, muscles, nerves etc (even more stuff if male) in a small space) so if I have it right umbilical is less problematic than inguinal and you have umbilical not inguinal that may be a bit of good news for you. Hopefully a brainier person will tell us both soon if that’s the case!!!

    • #30765

      Hi William , I actually have three hernias ! Lucky me . One is inguinal , the second one is umbilical and third one is epigastric. I think they happened from lifting weights at the gym. I need to sort them all out. The epigastric one is very small only 3 mm so I am not too worried about that just yet . I do need to fix the umbilical one and inguinal hernia . You are absolutely right that the inguinal hernia is a lot more complex one and that’s why I would be willing to travel to another country to have this fixed really well.I only consider tissue repair for this . I read dr Towfigh mentioned once that you can make umbilical hernia somehow smaller I was wandering how could I work on it . That way maybe I would just need to fix my inguinal hernia .

    • #30766
      William Bryant

      Wow! Not sure that’s appropriate. But hope you get my drift… And I thought I was hard done by!

      I know for inguinal some people say light yoga (certain) exercises, lose weight. Maybe same for umbilical.

    • #30769

      I’ve heard of yoga:) can’t loose anymore weight as I am already very slim hence looking for ways to somehow reduce the hernia . Planning to go and see physiotherapist maybe they might be able to give me some exercise . Trust me I feel super sorry for myself at the moment and stressed out about it all. The surgeon I saw in Sydney is not too worried about them so I guess that gives me some time to find the best method to deal with each one of them .

    • #30780
      William Bryant

      Hello Monika

      The first part relates to hiatal but after that umbilical… It lists the selected yoga exercises that can improve umbilical hernias. Also some other exercises like bicycle legs I think it said…. I don’t know if all (or any) will be suitable with an inguinal hernia though. I wouldn’t want to help one and make other worse.

      If you Google hernia bible, there are exercises there for non surgery cure of inguinal. However of the two testimonials (besides the author) that it worked for them, one later had to have surgery it’s claimed. But at least the exercises it lists you know should be ok with inguinal. From memory they are essentially ones on your back I think.

      Yoga for umbilical

      3 Ways To Treat Umbilical Hernia Without Surgery

      Hernia bible can be found by googling I expect as that’s how I stumbled non it.

    • #30788

      Another caveat with that study:

      The Shouldice repairs were not performed by surgeons at the Shouldice Hospital…and the study describes a modified Shouldice technique.

      i.e., the outcomes for the ‘Shouldice group’ in the study are unlikely to be representational of outcomes for Shouldice Hospital patients.

      • This reply was modified 11 months, 1 week ago by MarkT.
    • #30794

      I agree with MarkT’s comments. There are many studies that compare Shouldice to other repair procedures, but they don’t use cases performed by the Shouldice hospital, which has high volume and high quality control, and therefore the studies may be flawed. I think this is true for the meta studies Dr Hanniford cited on the recent Hernia Talk Live where he said mesh techniques performed better than Shouldice for pain. I wish Shouldice Hospital would publish (if they even have?) their own data on chronic pain, using what most researchers in the US deem pain, ie any pain more than three months post surgery. In another Hernia Talk live episode Dr Spencer of Shouldice Hospital says they are studying it and he thinks by the modern definition (ie inclusive of what doctors used to call post surgery discomfort and not only truly debilitating pain) he thought Shouldice’s pain rate was about 5 percent (which he suggested was better than mesh). There don’t seem to be good numbers. I do think the study from three countries in Europe in 2018 by Kockering and Koch that Good Intentions posted here is probably pretty good in that high number of cases, and probably many/most of the Shouldice cases performed in Germany where there are a handful of high volume Shouldice experts (including one of the two lead authors). And this study basically said in terms of pain and recurrence Shouldice and TAPP/TEP were equal. If that is true than Shouldice technique (for a person who qualifies based on bmi and size of defect) seems less about pain and more about eliminating the really awful (and probably low probability) mesh complications that require explant, ruin a patient’s quality of life.

      Thoughts? Dr Towfigh? Would love to have doctors weigh in rather than us laypeople.

    • #30796

      Right, but the question is what is the probability of bad mesh complications in the hands of a top hernia surgeon? Is it meaningful, or is it extremely miniscule?

      You mentioned size of defect. I don’t think the Shouldice Hospital limits itself to small or medium size hernias.

    • #30799

      Yes I think you’re right Watchful, that Shouldice Hospital takes on bigger hernias, their main restriction I think is body mass.

      And I’d be very interested what a top hernia surgeon achieves for chronic pain and other complications in his/her series. There’s a guy who seems very well respected, many of his lectures are on YouTube, named David Chen of UCLA and he says the goal of hernia surgeons should be to get recurrence and pain to .5%, because it can never be zero. But what does a doctor at his level actually achieve today? Does/can he even know given our multipayor health system where beyond the 2 week checkup most patients probably don’t report back to their surgeon?

      People on this board, what does your mesh using surgeon say his/her pain rate is?

    • #30803

      I spoke with shouldice hospital last week . Up to the size of a grapefruit they are comfortable repairing. They also said if the hernia cannot be seen with a virtual consult you would need to be seen in-person.

    • #31022
      Good intentions

      Here is an interesting new article, 2021, about Shouldice, with some comments about modified methods. Dr. Campanelli, who wrote the Hernia letter about the reality of chronic pain, is a co-author.


      Excerpt –

      “Conclusion: After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.”

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