Patterns of recurrence associated with specific types of inguinal hernia repair

[pinto]

Watchful, your echo here is pertinent. You have been in this hernia “business” most of your life, right? Although sometimes we have disagreed, we share much in point of view. However much I appreciate your view (though not always 🙂 ) your outstanding feature is not your knowledge, though considerable, it is your truthfulness. Corralling one’s bias is difficult for anyone, so I applaud you for being exceptional in this regard.

[pinto]

Both Good intentions and Watchful make reasonable statements from their particular standpoints here. GI is wanting specificity about claims of chronic pain for tissue repair. That is quite reasonable, quite.

Watchful in response does not directly satisfy but I am appreciative of Watchful’s overall view of tissue repair. Plain and simple is a fact irrefutable, I believe: All patients are not equal; some have conditions more difficult (or advantageous) than others. Generally surgeons say that obesity, for example, is less advantageous. So Shouldice Hospital has a restrictive policy in that regard. Logically therefore chronic pain may differ accordingly as well. Before the advent of mesh, it was generally recognized that IH surgery had imperfect results. Even Shouldice Hospital says per their website that mesh is sometimes unavoidable. So the debate will continue.

GI calls for supportive data in regard to chronic pain and tissue repair. Such may not be available unless I’m unaware of the contrary. It would be helpful if someone could offer some references of related sources.

Let me reply to @Mark T: Please be careful when calling someone arrogant when you yourself at times appear out of your depth when dealing with technical material. While it is true that one could reasonably fill-in the terminological gap in Netto et al.’s report, it would be in the case of like-minded readers or as known in scientific circles, “sympathetic readers.” Science is not exclusively for sympathetic supporters—-rather it also includes those non-sympathetic. That’s the hallmark of science: Researchers must spell things out. Readers are not mind-readers. They should not have to do mental gymnastics to disambiguate key scientific terms. Unfortunately Netto et al. require it and so makes the study inconclusive.

[Good intentions]

How do you know that guy knew what he was talking about? He’s just one guy. There was probably another guy right down the hallway that would have a completely different opinion.

The guy said that they were “seeing new chronic pain cases on a weekly basis”? What does that mean? How new, like one week old, or one year since surgery? How does he know that lap mesh has a lower rate if they don’t know what the rate is for Shouldice? The conversation has the hallmarks of somebody who wanted to seem knowledgeable, but was not. Or somebody who gets their knowledge from General Surgery News.

Anyway, it’s good that the people at Shouldice seem to be continuing to learn about hernia repair in general. If they are quantifying recurrence rates then you’d think that they would be quantifying all of the “new chronic pain cases”.

In the big scheme of things, the lawsuits will still have the biggest impact I think. Money will be the driver of change. I just found another new paper about “surveillance of medical devices” that I will post.

[Good intentions]

Watchful, your commentary doesn’t really say anything. It has little substance. You’re implying chronic pain equivalence based on a few forum stories and some comments from a few surgeons. “A number of people on this forum”? You know better, you spent all of that time using real research methodology before you chose Shouldice. Now you’re doing something else. Using vague words like “most” and “significant”. That is exactly what the mesh repair surgeons do.

Post up the studies you mentioned. The numbers matter. People get killed riding bicycles but that doesn’t mean that bicycles are just as dangerous as cars.

” Chronic pain is a significant issue with tissue repair as well as with mesh. It’s hard to know the exact chronic pain numbers for different types of mesh procedures, and tissue repair procedures, but it is known that tissue repair has a significant incidence of chronic pain and discomfort. There are a number of people on this forum with that problem after tissue repair (including me), studies show this problem, and most tissue repair surgeons (including the Shouldice Hospital) admit that this is an issue.”

[Mark]

Since the original post by Good intentions is regarding “recurrence and repair”, I am posting this statement from Dr William H Brown, who performed my hernia surgery, and is one of the many reasons I chose to go with him;

Most Surgeons argue for the use of mesh because of the lower recurrence rate. But their argument is flawed. If you look at the numbers, the chance for a recurrent hernia after a mesh repair is 3%. The chance for a recurrent hernia after a non-mesh repair is about 4%. But to achieve this 1% lower recurrence rate the patient runs about a 15% chance of chronic pain.

The argument for a hand-sewn repair (i.e., no mesh), is that there is no foreign body placed in the body. It is common for people to develop scar tissue around the mesh. This fibrosis causes the mesh to become stiff and hard. Then when you bend and twist, and the mesh does not bend and twist with you, the sheer stresses causes pain. Sometimes one of the nerves or spermatic cord gets stuck to the mesh, and severe pain can result. Then exercise becomes impossible because of pain, and ejaculation causes a severe burning sensation in the spermatic cord and testicle. Chronic pain after mesh hernia repairs affects 15% of patients. A significant number of those patients with pain have to have the mesh removed with another operation. Even after removing the mesh, the patient is often only about 80% better.

[pinto]

To @Mark T, in the spirit of community and sake of discussion, I shall address questions you posed to me. Because of the flurry of posts by other members, I’m just getting to it now.

First you say you know what a scientific abstract is: “I [Mark am] well aware of what an abstract i[s]…and what it is not.” Are you sure? I must say frankly you do not know. You did not recognize how really unusual is the style of the journal, Hernia. Let’s look at what is considered “standard” style.

From “Scientific Literature” (google), it states the standard format for scientific papers is as follows:
• Abstract: a one paragraph explanation of what the paper covers. Readers will use this to decide if they want to read the whole paper.
• Introduction: why the problem is important, and a summary of what progress has been made on it.
• Main body: what they did to solve the problem.
• Evaluation / Results: experimentally determine how well they solved the problem.
• Conclusions & future work: what remains to be done on the problem.
• References: citations to prior work. These are essentially hyperlinks, but are designed to survive for the 100+ year lifetime of the paper. They’re often a good way to find more good papers.”
https://docs.google.com/document/d/1giquxftXXTF0V1c3qEDZdcLaJzSxkjsOuS3LUmxVo-0/edit

Two points notable: the abstract tends to be a paragraph and does not include sections such as “Conclusions” or other Sections. The journal Hernia is quite different in having an “abstract” in report style that includes main sections of a scientific paper (e.g., Methods, Results, etc.). I almost never have seen another journal style like Hernia’s. From the standpoint of scientific journals, surely experienced readers would view Hernia’s abstract style more as a report than an abstract. However, Hernia’s style is more informative than typical abstracts, which invites critiques where appropriate (of course).

According to you, did I misrepresent the research in question? Absolutely not. Never did I attempt to. As I explained in a previous post, I reacted to this thread’s presenting this so-called “abstract” as possibly matching surgery methods/types of hernias and outcomes. Moreover I was strictly focused on only their use of a single medical term—“open.” As my previous post stated,
“unsurprisingly the summary medical report being considered fails in the same way. Perhaps the actual, full article does better
Repeat: “Perhaps the actual, full article does better.” That of course indicates my statement is limited by not having the entire, full article in view. However, considering the Shouldice Hospital’s own use of the term “open” I questioned,
[https://www.shouldice.com/natural-tissue-vs-mesh-hernia-repair-surgery.html]
then the authors most of whom are with SH, MIGHT not do any better in their full write-up. Your false claim about my using an abstract is completely unfounded (abstract here meaning the standard one).

You ask me, “How are tissue and mesh being lumped together under ‘open’ if the categories they used in this study to classify primary repairs included ‘Shouldice’, ‘open mesh’, and ‘open tissue’? A fair question.
You above all, a former patient of SH and posting at HT about SH should know as I previously indicated in the thread that SH performs both mesh and non-mesh surgeries. Thus the single category of “Shouldice” (as you presented it) is unscientific because of impreciseness——the category does not specify which type of surgery——mesh or non-mesh. This however was not part of my original critique. I offer this as a good example for conflating terms.

As an example of proper use of terms, I pointed to the article “Mesh versus non-mesh repair of groin hernias: a rapid review,” the link previously provided, in which is stated: “recurrence rates between open mesh repairs and open non-mesh repairs.” As you can see “open” is not a single term but a compound one that distinguishes whether the surgery uses mesh or not. In what I am calling a “report,” Netto et al. in that single webpage use the term, “open” 12 times; only once do they distinguish whether it refers to mesh or non-mesh. Of course sometimes “open” refers to both surgeries and is fine to use that way. A problem occurs because as we all know SH performs both types of surgeries. If you are interested as this thread is in outcomes related to TYPES of surgery then obviously references to “open surgery” by SH must indicate which type——mesh or non-mesh is involved. Not doing so conflates the terms. I checked with the SH webpage and I found no better use of terms. It is unlikely Netto et al’s full paper is any better because the centrality of the term “open” behooves the researcher to be precise——a hallmark of scientific writing——but they fail to do so in their report as I have tried to show.

I believe I have sufficiently shown that the journal Hernia abstracts are more like reports than abstracts (even though termed that way in the said journal), thus inviting critique within reasonable limits, as well as indicating how the term “open” was misused in the report critiqued by being imprecise, resulting in a conflating of terms.

Please note I am not the one who created this thread focused on Netto et al.’s report; it was Good intentions. He did state that the report was not the actual full article. However, in my opinion GI did not read the report (not the full article) sufficiently enough to recognize the conflating of the core concept of “open,” thus likely making the research inconclusive. The article seems promising particularly linking surgery methods and outcomes—-and may actually do so—-but I believe we need to read such more intently than what might seem to be the case.

• This reply was modified 11 months, 2 weeks ago by  pinto.

[Mark]

I did not write the comment that Pinto has responded to and I have no medical background. I did, however, have no-mesh inguinal hernia surgery in 2020, which was not performed at Shouldice Hospital. I researched the topic, talked to friends that had mesh hernia surgery, read comments from patients that had mesh surgery that went wrong, viewed photos of mesh-repair surgery, and read about the many lawsuits involving the use of mesh. Then I consulted with the local mesh surgeon who I was referred to by my provider, and with a very experienced no-mesh sports hernia surgeon (of which there are very few) and concluded that the no-mesh surgeon was much more qualified. He also recommended pre/post-op herbal therapy, which I was very impressed with. The surgery went smooth, there was little pain and I resumed athletic activity within a week. 2 1/2 years later, I have had zero issues involving this surgery and the scar has disappeared.

[Watchful]

MarkT,

Thanks for the information from the paper.

This is consistent with what I was told there when I asked what to do if my hernia recurs. As I mentioned before, I was told that lap mesh would most likely be the best choice if this happens.

This is a fairly big change for them. There are other changes as I mentioned before (suture material, cremaster/nerve resection).

It’s good that they are now open to move away from their prior orthodoxy based on evidence, but it makes you wonder what other surprises are coming now that they are re-examining things. For example, I wonder if they’ll start being more reluctant to recommend Shouldice for larger hernias. That is, move closer to the German guidelines.

[pinto]

@Mark T, if you critique someone make sure you read what they said. When you state, 1) “Keep in mind an abstract provides only a small amount of *some* key information”; 2) “It is quite inappropriate to make assumptions about (never mind critique), a study from the contents of its abstract, “you can’t be possibly suggesting your statements apply, are you? This thread has not involved the reading of an “abstract”; nor I for one have made assumptions based on any one particular abstract.

Rather than an abstract the article would be more properly described as a “report.” It is intended by the authors to have essential information about their research. I made clear that my critique was based on their report not their full paper and therefore necessarily limited to that extent. However, my critique quite squares with the Shouldice Hospital’s website in regard to the authors misuse of the term “open.” The fact it is a core concept, it is quite remarkable that the authors imprecisely used it in their report (as it imprecisely used at SH’s website).

Before I clarify further, let me make an important point clear—-the necessity for precisely using “open.” The reason? SH performs mesh surgery as well as well pure tissue repair. If SH did no mesh, then I would not have challenged the authors’ research. So the fact is that SH does both mesh and non-mesh surgery which necessitates distinguishing what “open” means—-mesh or non-mesh. Just as the example from another journal shows: “recurrence rates between open mesh repairs and open non-mesh repairs” https://onlinelibrary.wiley.com/doi/10.1111/ans.17721,
authors Netto et al. were not as careful but should have been.

But the problem does not stop there. If @Mark T’s report here correctly represents Netto et al.’s use of “open,” then there is a BIG problem.
From @Mark T: “‘Open inguinal hernia repair includes any technique of primary open inguinal hernia repair excluding Shouldice and mesh repair, performed in patients above the age of 16 years.’ For the purposes of this study, they categorized the primary surgeries as: Shouldice, open mesh, open tissue, laparoscopic, and childhood (all types).”

Someone—@Mark T or the authors concerned or all of them—conflates mesh and non-mesh together. What? In the present thread titled “Patterns of recurrence associated with specific types of inguinal hernia repair” the concern is identifying types of repair with outcomes. Obviously mesh and non-mesh are quite distinguished as differing if not opposing repair types. Your conflating them in the case of doing “open” surgery contradicts the purpose of the research and therefore invalidates the study as far as matching type with surgery outcome.

If anyone has made misassumptions, it is you sir, @Mark T. I never said I was critiquing the full research paper by the authors but rather their report, the basis of the present thread. Moreover my critique was of the report not the research paper. Although it is fine for you to point out that the full paper gives greater explanation of “open” than does their report, you have no grounds for claiming I misrepresented the research in question (if you were directing your post in response to the post immediately before yours, namely mine.) In regard to the term “open,” you actually do disservice to the original authors, by not realizing the conflating of terms–possibly due to your inadequate reporting. Someone conflated the terms–you or they–and you should have realized it.

My original critique of the Springer report stands in as far as the term “open” is imprecisely used by the authors, which negates the original purpose of the research in question.

• This reply was modified 11 months, 2 weeks ago by  pinto.

[MarkT]

Keep in mind an abstract provides only a small amount of *some* key information that is essentially meant to allow a reader to determine if an article is likely to be relevant for their interests/purposes (i.e., if they should read the whole study).

It is quite inappropriate to make assumptions about (never mind critique), a study from the contents of its abstract.

I pulled a copy of the article and will try write up a more coherent summary later, but some points:

The authors are rather clear what ‘open’ means when you actually read the article instead of making assumptions:

“Open inguinal hernia repair includes any technique of primary open inguinal hernia repair excluding Shouldice and mesh repair, performed in patients above the age of 16 years.” For the purposes of this study, they categorized the primary surgeries as: Shouldice, open mesh, open tissue, laparoscopic, and childhood (all types).

Keep in mind this is a retrospective study…data was pulled from existing medical records) rather than a prospective study where they could have chosen exactly what data to collect over its course (and this might explain why lap repairs were not broken down further?)

As an aside, they provide some insight into how Shouldice Hospital allocates recurrence cases:

“As this is a group-based practice, more complex cases are directed to surgeons according to their experience. In this categorical system, recurrent hernias are recognized as more complex than primary hernias. Among the recurrent inguinal hernias, previous primary hernia operations in childhood or via laparoscopy are considered low complexity, open (non-Shouldice) tissue repair is medium complexity, and open mesh repair or Shouldice repair is classified as high complexity.

When facing difficult cases, sometimes intra-operative consultations were required. In this situation, a surgeon may request another of equal or higher seniority to come to the operating room to discuss options. The consultant surgeon may assist by providing directions/opinions, scrub in to assist or take over the role as main surgeon to finish the case, according to the circumstances. Senior surgeons have many years of experience in hernia repair and at least 1000 cases of inguinal hernia repair at this institution”.

Among their findings was that “…open recurrent surgeries for previous open mesh and Shouldice repair were associated with higher intra-operative difficulties but not with worse early outcomes.” They hypothesize that this may be partly due to the way they allocate cases to more senior surgeons, and they conclude that “This information may allow adequate allocation of surgeon experience and choice of method (laparoscopic or open) based on the initial surgery”.

Higher proportion of direct hernias in recurrent group vs. primary group…i.e. more likely to see direct hernias recur, which is in line with other research, and this was true for all groups regardless of previous primary repair type.

Higher number of indirect recurrences were found only in group who had prev lap repair, which is also in line with prev research. “This may be due to case difficulty, technical errors during surgery (including missing small indirects or lipomas) and learning curve exploring the inguinal canal by laparoscopy…The higher incidence of direct recurrences for most of the
patients is likely related with the primary characteristics of connective tissue from hernia patient”.

In the discussion, they remind us that Shouldice is a high-volume specialized center..surgeons performing ~600 repairs per year, 85% of which are inguinal…while most repairs around the worlds are NOT performed in such a context, and that recurrence has been reported to be linked with volume (i.e. higher rates among low-volume surgeons). Given this, “…we agree with the general idea of laparoscopic surgery following open hernia repair recurrences (tissue or mesh repair)…The laparoscopic surgeon will find virgin territory and be able to perform a relatively easy operation. The degree of difficulty found by our senior surgeons in reoperations after Shouldice repair or open mesh repairs has triggered an internal reflection and will lead to further discussion about the surgical management of these cases”.

There is prob still more to discuss…I’ll try to write more later.

[pinto]

So?? The authors chose not to pay the journal for publishing it. Nothing wrong with that. Some of the publishing fees can be hefty. Thus your statement in out of line: “It is a pay-per-view paper (you’d think that the Shouldice Hospital could afford to make it open access) so only the summary is shown.”

In fact, instead of a bare abstract, non-paying readers are afforded a great deal of information by not only a substantial summary but the list of references. Incredibly you complain that you are not given free the entire product of their research. Good intentions, you are owed nothing—-but granted quite a lot FREE. Maybe change your handle, to @Free intentions?

• This reply was modified 11 months, 2 weeks ago by  pinto.

[Good intentions]

Here it is. The authors choose whether or not to pay for open access. Dr. Netto and his co-authors, most of who work at Shouldice, chose the paywall.

https://www.springer.com/journal/10029/how-to-publish-with-us

“Hernia is a Transformative Journal (TJ). Once the article is accepted for publication, authors will have the option to choose how their article is published:

Traditional publishing model – published articles are made available to institutions and individuals who subscribe to Hernia or who pay to read specific articles.

Open Access – when an article is accepted for publication, the author/s or funder/s pay an Article Processing Charge (APC). The final version of the published article is then free to read for everyone.

Hernia is actively committed to becoming a fully Open Access journal. We will increase the number of articles we publish OA, with the eventual goal of becoming a fully Open Access journal. A journal that commits to this process is known as a Transformative Journal.”

[Good intentions]

Shouldice can publish the paper on their own web site. And the Hernia journal also publishes open access articles. If you want to add to the discussion, find out out how the decision is made to publish as a pay-per-view versus open access. Who makes that decision?

https://www.shouldice.com/

I am actually disparaging the hernia repair industry in whole. “They” (the people involved in the industry) have created a narrative of “informed consent” but the information that the patients need to be informed is often hidden behind paywalls.

[pinto]

This medical journal article greatly disappoints because its authors misuse terminology, such that it must remain inconclusive or indeterminant about its purpose. It concerns the term, “open,” for which the authors use carelessly.

When they say, “open,” readers cannot know whether it refers to mesh or non-mesh surgery because the authors fail to make the distinction. That the distinction is necessary is shown in this random sampling from another medical journal:
“recurrence rates between open mesh repairs and open non-mesh repairs”
https://onlinelibrary.wiley.com/doi/10.1111/ans.17721

This problem of misused terminology is incidentally found at the website for Shouldice Hospital in which it states that “open” can refer to either mesh or non-mesh surgery, but unfortunately fails to distinguish which in later uses of the same term. For this reason, unsurprisingly the summary medical report being considered fails in the same way. Perhaps the actual, full article does better–but I doubt it considering the same at the Shouldice website.

@Good intentions, let me point out that you wrongly disparage medical doctors when you write for example as you did above: “It is a pay-per-view paper (you’d think that the Shouldice Hospital could afford to make it open access) so only the summary is shown.” Neither the hospital nor the authors might own the copyright! If so, it would not be their decision to make. In fact all that you see there is owned not by the authors but by Springer. GI, you tend to overlook such and make insinuations at HT about MDs wrongfully selling their research when in fact it is the publishers doing it–not the doctors. (There are some bad docs just as there are some bad plumbers, but not all doctors are as bad as you think.)

• This reply was modified 11 months, 2 weeks ago by  pinto.

[Good intentions]

It is saying that the type of recurrence is indirect more often for laparoscopic. The type, not the quantity. In other words, the surgeon is more likely to find an indirect recurrence in a patient that had laparoscopic surgery than in a patient that had open mesh or Shouldice.

The terminology is not very good in that strictly interpreting “recurrence” should mean that the same type of hernia re-happened. If the patient started with a direct hernia then came back with an indirect hernia that would, strictly speaking, be a new hernia. Not a recurrence. “Recurrence” is imprecise.

They also take the lax approach of, as far as can be told from the short summary, lumping all types of lap surgery and all types of mesh in to one pile of “lap mesh”. It seems wasteful to compile all of that data then do such a poor job of learning from it.

It is interesting though that Dr. Netto, who seems to have the urge to get involved in the hernia repair narrative, chose this topic to research. Trying to define the type of recurrence (or occurrence) to be expected from the type of repair. Not really clear why he thought that was important.

[William Bryant]

If, and it’s a big if, as I’m not best on deciphering these studies, I am right it’s saying laproscopic has higher rate of recurrence, indirect at least.

Again I thought consensus was the opposite.

So if its more likely to cause chronic pain (Dr Sadler) and likely to recur (Shouldice), why do popular?

[Watchful]

I agree, but there isn’t much point really because mesh took over the world. There’s little to no tissue repair offered for adults in most countries. Some in Canada as long as the Shouldice Hospital survives, a few old-timer surgeons in Germany, very little in the US, Kang in S. Korea.

In a decade or two, the transition to a lost art will likely complete.

Meanwhile, I think the Germans (Conze, Lorenz, Wiese, Koch) have the best handle on assessing patients and tailoring an open surgery for them based on tissue repair or mesh. This is the reason I’ve been recommending that path here for a long time.

I picked a different path (Shouldice Hospital), which turned out to be a mistake for my particular case, but I think it’s very reasonable for those with a run-of-the-mill hernia and anatomy. It’s not always clear if that’s the situation, though, so the Germans are a safer bet because they attempt to diagnose and tailor.

[MarkT]

It would be nice if it were possible to establish some reliable diagnostic criteria, given that most surgeons are not able to perform all types of repairs with the highest degree of skill (rather than have surgeons just impose whichever repair they do best or where individual surgeons tailor repairs to their patient, despite not being the ‘most’ skilled in all of them).

With a diagnosis of what the ‘most appropriate’ repair might be, patients could then choose a surgeon to do that repair.

Maybe that is wishful thinking though…

[MarkT]

“A difficult and long surgery is more likely to cause chronic pain and other complications.”

While this seems logical, we still need better data to flesh out the details, because that relationship may depend (change) based upon certain factors (as is thought to be the case in this study).

While it is undoubtably much easier to deal with short-term issues like surgical site complications vs. long-term issues like chronic pain, it would still be really nice to get some nuanced data to see what sort of variables (like surgeon skill/experience) might influence those outcomes and therefore inform policy in both high-volume specialty centres vs. the broader hernia repair space.

[Watchful]

Indeed, all cases aren’t equal. Weight can be a factor, and so can the size of the hernia, the tissue quality, and the particular anatomy of the individual. Certain tissue repairs (like Shouldice or Desarda) may not be a good fit for some individuals.

The problem is that if you go to Shouldice (and you aren’t overweight), you will get that repair regardless of the difficulty of the surgery in your case (as long as your tissues aren’t disintegrating). A difficult and long surgery is more likely to cause chronic pain and other complications.

If you go to Tomas, you will get Desarda. If you go to a mesh surgeon, you’ll get mesh. There are extremely few surgeons who can tailor the repair, and most of them don’t have a lot of tissue repair volume. I think a few German surgeons are the exception, but even they have their limitations. For example, the ones with a lot of tissue repair experience don’t do lap or robotic mesh, just open mesh.

Things are further complicated by the fact that the surgeon may not be able to tell in advance what the best approach would be in your particular case, and this may become evident only after they cut you open.

[MarkT]

The study is not ‘inconclusive’…you don’t know what you are talking about.

[Watchful]

I don’t think he knows, or anyone knows – there is no definitive answer to the chronic pain risk question. The point is that it is a significant problem even with tissue repair (namely Shouldice in this case). It is telling that he thinks the risk is lower with lap mesh regardless of whether that’s really established or not. It was clear from his reaction to my questions about this that chronic pain was an issue that was weighing on him, and he was sad to see such cases appear weekly, with some of them being debilitating.

I’m sure that by “new” he meant patients who didn’t already report chronic pain before. I don’t know how they define chronic. It’s probably 3 or more months post surgery. He told me that most of those cases improve significantly by one year, so that was one positive observation.

As I mentioned in another response (to MarkT), they are currently trying to quantify the chronic pain issue, but I don’t think they’re doing it well.

[MarkT]

Yes, recurrence has long been the primary barometer of success, they note…but of course recently chronic pain has become more widely acknowledged, especially the apparent underestimation of its prevalence.

That is disappointing to hear if the follow-up process is so tedious that it is discouraging participation. As it is, most long-term studies suffer from much participant attrition…every effort should be made to make it as simple and convenient as possible to keep people involved.

[Watchful]

GI,

I didn’t say anything about equivalence. Actually, I said that tissue repair appears to be a better approach (for primary repair) all things considered IF you are a good candidate and you can get the right surgeon.

Dr. Brown used to make claims about no chronic pain with tissue repair, and this is clearly wrong. We have such cases on this forum, and all the tissue repair surgeons that I asked (other than Dr. Brown) said that they do indeed have chronic pain cases. At Shouldice, I was told they see new chronic pain cases among their patients on a weekly basis. Dr. Lorenz said up to 3% of his tissue repair patients get chronic pain. Dr. Conze said he had a few such cases, but they were rare. Dr. Yunis said he had a few such cases among his Shouldice patients (I think he had done a bit over 100 by then). I didn’t ask Dr. Sbayi and Dr. Wiese about this, so I don’t know what their experience was.

I felt “holier than the pope” at Shouldice, because it seemed like I believed in the merits of this procedure more than my surgeon. In my consultation before the surgery, he said Shouldice is one of the two best procedures for my case, and maybe the best, so not the strongest endorsement. That’s also when he mentioned (in response to my question) that they were seeing new chronic pain cases among their patients on a weekly basis, and that lap mesh has the lowest rates of chronic pain, but it’s still a problem even with that.

When I came back for a follow-up, I had a long discussion with him. That’s when I asked about whether Lichtenstein would have been difficult too in my case, and he said no. Also, that’s when he said lap mesh would most likely be the best option in case of recurrence (as in the paper you posted), which shocked me a bit. I described the mesh options that I had explored, and mentioned that I felt that tissue repair would be better, and it’s worth going all the way there because they know how to do Shouldice right. He looked at me funny, and said that other modalities would have been ok. I felt like a bit of a sucker quite frankly because I got the strong impression from all of this that they currently view tissue repair (specifically Shouldice) as a very good, but not really superior option overall. Just one good option among a number of good options. Like I said, I was holier than the pope on tissue repair.

[Watchful]

Thanks, MarkT. The lack of study of chronic pain and discomfort has always been a weakness there. Recurrence and other complications have been the focus.

As I mentioned before, they are currently doing a study of pain. I think they’re doing it wrong, though. In order to participate, the patient has to fill out many pages of forms. I started doing it, but gave up, and others I asked didn’t bother at all. They really should have a way that’s less onerous for the patients. Also, they should follow up with patients regardless of whether they bothered to fill out all those forms before and during admission.

[MarkT]

Most importantly, this ‘alleged’ conflation would not appear to alter the results anyway…so terming the research inconclusive seems quite inappropriate.

The first study objective was to look at patterns of recurrences by primary repair type…and both Shouldice and open mesh are implicated as ‘higher difficulty’ on a series of markers, but neither were implicated with worse early outcomes. The actual numbers might shift slightly on these markers if a few mesh cases were lumped in with Shoudlice, but it would be *highly* unlikely to alter the broader results. There would need to both be a large number of mesh cases included AND those mesh cases would need to substantially differ from the ‘regular’ Shouldice cases.

Any potential conflation would actually have no bearing on the results for their 2nd purpose (looking at surgical site complications following recurrence repair, by primary repair type), because there was only one complication for the entire Shouldice group (and only one in the open mesh group).

I.e., IF there was a conflation, and IF there were mesh cases in the Shouldice group, it would only have mattered if there were a bunch of post-op complications and this exceeded what was seen for the other groups, because then we wouldn’t know whether to attribute that to the Shouldice repair type or the use of mesh in some cases.

Terming the research ‘inconclusive’ because of your perceived conflation is just not appropriate here, IMHO.

[MarkT]

More on your concerns…and follow-up improvements!

“Likely, the most important limitation of this study is the incom- plete story of postoperative long-term complications. The main marker of success in hernia operations is classically low recurrences rates, even though low rates of chronic pain and higher-quality life outcomes are recently gaining attention and are becoming equally important markers of long-term outcomes [35, 36]. A patient-reported outcome measures system (PROM) is in the implementation phase in this institution and may allow a more reliable update in all our outcomes in future studies.”

[MarkT]

Yes, there is a bit more info on that.

“Reoperations after Shouldice repair and open mesh repair presented markers for higher surgical difficulty (longer operative time, higher identification of heavy scarring, less nerve identification, and higher frequency of intra-operative consultation) when compared with other techniques (Table 3). Therefore, an empirical timeframe of five years from the index operation (0–5y: 109 patients; > 5y: 99 patients) was tested for the same markers.”

They looked at surgical site occurences of hemotoma, seroma, cellulitis, and wound infection (and the total for all of these post-operative combined complications). Despite the additional complexity associated with Shouldice and open mesh, there was only one post-op complication of a seroma with Shouldice and one case of infection with open mesh, neither of which equated to statistically significant differences from the recurrence repair outcomes of the other primary repair types.

They are indeed just talking about post-op complications, so this doesn’t include any long-term follow up for things like another recurrence, chronic pain, etc.

This is in line with their two study objectives: 1. pattern of recurrence by primary repair type and 2. surgical site occurrences following open recurrence repair by primary repair type.

[MarkT]

The article terminology is not imprecise…they distinguished between primary repairs of Shouldice, open tissue, and open mesh.

Shouldice very rarely uses mesh for primary inguinal hernia repairs (less than 0.1% of all cases, and almost never for primary indirect). When they do use mesh it is almost always for recurrent hernias, incisional hernias, most femoral hernias, and large umbilical hernias. This comes directly from them.

IMHO, it is far more reasonable to assume that they would have noted any cases of primary Shouldice repairs that recurred and which had used mesh than to assume both that are cases of mesh included in that category AND that they failed or chose to not differentiate between them and ‘proper’ Shouldice repairs.

What is particularly arrogant and dismissive though is your sweeping characterization “making the research inconclusive”.

I’m not getting into the rest…you’re repeating yourself and I already acknowledged that a summary may have been provided on the site rather than a transitional abstract, which I would not have known because I was logged in with my credentials and thus immediately see the full study. I apolgized for that oversight if it was indeed the case.

[Watchful]

Tissue repair does appear to be the better approach all things considered for a primary repair, but there are all kinds of caveats. You need to be a good candidate for this repair, and there are a bunch of factors that play a part in that. In some cases, mesh is the better solution. Also, there are very few surgeons to choose from for tissue repair.

The difference in recurrence rates between tissue repair and mesh is higher than 1% based on the studies that I’ve seen. Shouldice performed at the Shouldice Hospital is really the only tissue repair study that I’ve seen with a very large number of patients where the recurrence rates were similar between tissue repair and mesh. Many surgeons don’t really believe those numbers, saying that no other center has been able to reproduce these results in their practice, but the results were verified by data from Canadian insurance, so I tend to trust them. These were pretty old numbers. I don’t know where things stand today.

Dr. Brown believed that tissue repair doesn’t cause chronic pain and discomfort, but that’s not the case. Chronic pain is a significant issue with tissue repair as well as with mesh. It’s hard to know the exact chronic pain numbers for different types of mesh procedures, and tissue repair procedures, but it is known that tissue repair has a significant incidence of chronic pain and discomfort. There are a number of people on this forum with that problem after tissue repair (including me), studies show this problem, and most tissue repair surgeons (including the Shouldice Hospital) admit that this is an issue.

[Watchful]

I really wonder about the “not higher rates of complications when compared with other techniques” statement at the end of the Results section of the abstract. They say the difficulty of the recurrent hernia surgery is higher with Shouldice, but not the complications rate.

Do they actually substantiate that in the paper in some way? Seems like a difficult thing to figure out.

Based on my experience, they don’t actively follow up with their patients. No one ever contacted me after my surgery. I guess maybe they contacted their recurrent hernia patients (mine was primary). Even if they got that information somehow, not sure how they figured out what the complications rate would be with other techniques for repairing recurrent hernias after Shouldice and open mesh repairs.

[MarkT]

That makes sense – while they noted no difference in short-term outcomes between low- and high-complexity recurrence repairs, they suggest that may be at least in part to their allocating the more complex cases to senior surgeons, the in-op consult option for juniors, etc…however, that skill/experience is not available everywhere, so if an ‘easier’ repair option is available (and widely available), it makes sense to consider that option.

That same logic could indeed apply to more complex or higher risk primary repairs, like larger hernias. Patients should be made aware of how THEIR hernia and overall situation relates to various repair options so that they can make a more informed choice. From strictly a recurrence standpoint, I suppose one potential benefit of going with tissue repair, like Shouldice, is that a lap mesh recurrence repair would be considered ‘easy’? Whether the potential benefits of possibly avoiding mesh in the first place are worth any unique risks of complications going with the more complex repair to see if it ‘sticks’ is debatable and we don’t have any good data on that yet, AFAIK.

I share that sense of mystery (a ‘healthy skepticism’, you might say) with Dr. Kang’s perspective. I’m all for whatever works best, so I do hope we see reliable, published data at some point.

[MarkT]

I couldn’t edit my prev post – if you are able to see a larger summary than just the typical abstract (as some journals offer that), then my apologies for referring to just the abstract.

I was already logged in so that I could access the full study, so I didn’t see whatever someone sees in front of the paywall.

[MarkT]

@pinto – I’m not sure what is being conflated in the study?

How are tissue and mesh being lumped together under ‘open’ if the categories they used in this study to classify primary repairs included ‘Shouldice’, ‘open mesh’, and ‘open tissue’?

I’m well aware of what an abstract it…and what it is not. My advice stands: If an abstract suggests a study may be of interest, then read the study. It is then appropriate to present whatever comments, criticisms, questions, ideas, etc. that you might have regarding it.

[MarkT]

@mark – glad to hear your tissue repair went well and has held up for 2.5 years and counting, with no ill effects. I had similar experiences, but a long time ago at Shouldice, and I too am glad that I did not proceed with a lap mesh repair from the general surgeon to whom my family doc initially referred me.

You might consider starting a new thread and (if you don’t mind) sharing the name/location of your surgeon and the type of repair you had. It might be helpful to those seeking a tissue repair as it can indeed be hard to find or travel to a good surgeon who offers them. Cheers!

[Watchful]

One reason I mentioned the size of the hernia as a criterion is that this paper uses the length and difficulty of the surgery as a motivation for re-thinking the use of Shouldice to repair recurrent hernias (after Shouldice or open mesh). The choice is between a particularly difficult Shouldice repair, and a normal lap mesh repair.

The same logic would apply to large hernias, at least based on my experience, and based on the German guidelines. The Shouldice surgery on my large hernia was twice the normal duration, and it was difficult even for my highly experienced surgeon. As I mentioned before, when I asked him if Lichtenstein would have been difficult as well, he said no. Now, the difficulty of the surgery shouldn’t be the only criterion, of course, but if that’s enough to prompt a re-think, then it seems that a re-think of Shouldice for large hernias would be reasonable as well.

You mentioned Dr. Kang – how he can be confident with applying his tissue repairs in all these cases that other tissue repair experts are struggling with is a mystery to me, and one of the reasons I never felt comfortable with going there.

[MarkT]

Watchful, I agree – I am glad to see that not only are they using data and evidence-based decision making to potentially shift their ideology and approach, but that their own surgeons remain actively engaged in the research.

With so many surgeries performed at Shouldice Hospital, there is a wealth of data and experience that should continue to be leveraged to help guide the field going forward, in conjunction with ongoing research, including what is coming from other highly skilled/experienced surgeons (like the Germans).

I do like that the view is changing on large hernias. It was interesting to note in the consensus paper that we have discussed here (https://doi.org/10.1007/s10029-020-02365-6) that only two of the 12 surgeons polled suggested that ‘all hernias’ was the ideal indication for a Shouldice repair, with the others being more conservative in their responses, suggesting the ideal is for smaller hernias, particularly for younger people. Also interesing that two of the 12 were from Shouldice, though we can’t know for sure if they were the two who said ‘all hernias’.

(Which is not to say that the majority feel it is inherently inappropriate for larger hernias, or even that it may not remain the ‘best’ option for larger hernias for some people…but, at minimum, that they believe its ideal indication is for smaller hernias…though this could even be true for all repair types, that larger hernias are less ‘ideal’ indications period – all of this nuance is very important to explore and acknowledge).

The nuance in this potential shift is interesting too…part of it, which is explicitly discussed in this most study by Netto and his colleagues, appears to be due to the fact that the majority of hernia repairs are not carried out in high-volume specialty centers like Shouldice Hospital…so a question remains as to how much of the shift is based upon ‘we don’t think a Shouldice repair is the best option in certain cases’ vs. ‘we recognize that the expertise of our senior surgeons, who can competently tackle high-complexity cases, is not found everywhere else, so it is better to advocate for a lower-complexity repair in the hands of a skilled surgeon that is more widely available’.

Your experience and conversations with your surgeon suggests that it is at least some mix of the two…that even internally, they are more recognizing that other options may be better in certain cases (which they have always done to *some* extent, even simply by virtue of their narrower patient profile, but this now seems to be shifting further based upon data and clinical experience).

Somewhat of a contrast, Dr. Kang seems to remain confident that his approach remains appropriate for all inguinal hernias (or has he said anything more on this?), even regardless of tissue quality, BMI and most other patient characteristics. I really hope we get some reliable data from his extensive work.

Interesting times in he tissue repair space…