Permanent or absorbable sutures for Shouldice repair?

[ajm222]

Yep. I’ve noticed that recently with several posts, from a number of new members.

[Good intentions]

Pretty sure that Amelia Aria is somebody using a Chat Bot on the site. A word salad that is vaguely related to the topic of the thread. All of AA’s posts are like this. It’s not a real person.

[Amelia Aria]

The choice of permanent or absorbable sutures for a Shouldice repair may depend on a variety of factors, including the surgeon’s preference, the patient’s medical history, and the specific details of the repair. Both types of sutures have their own advantages and disadvantages, and there is no one-size-fits-all approach.

[pinto]

@Good intentions, thank you again. Let me challenge you, however, about your primary source and interpretation because this involves so crucial a matter–healing. Originally your statement was it takes “months to years,” invoking my response of “years?” 😀 You assured us that is the case.

That really does contradict numerous statements by surgeons including my own as to how physically active I can be. If a baller, myself included, who must so jump to his fullest yet its pivot point (groin) might still be healing into the years (?), then obviously I’ve got to curtail my playing. Maybe even most like golfing, dancing, whatever and well, maybe even household cleaning!

So what does your primary source say about it?
“Chapter 1 Overview of Wound Healing in Different Tissue Types
John D. Stroncek and W. Monty Reichert.” https://www.ncbi.nlm.nih.gov/books/NBK3938/

Partly true—-but only about brain tissue and the years-time part–bone. We cannot apply that to the groin especially since it doesn’t involve bone tissue (I believe); thus the source wouldn’t support the claim that IH healing can stretch into the years.

Required time for healing is a big issue. It remains open for discussion. I welcome any clarification about it.

• This reply was modified 1 year, 2 months ago by  pinto.

[pinto]

Thank you both.

[Good intentions]

Here is a link showing T-Line mesh. It’s funny how the product is designed to fix the problem of tension in a “tension-free” repair material. Mesh. The attempts just go on and on. 510(k).

Sorry ajm22, I’m not trying to divert away from your subject. Just filling out my comment about suture pullout and tissue strength. Good luck.

https://www.deepbluemedical.com/t-line-hernia-mesh

[Good intentions]

I don’t think that being back to 100% tissue strength is necessary to get back to normal living. I am not arguing for or against anything just showing some different perspectives.

You can find quite a bit in the mesh repair literature about “burst strength”, where the surgeon/scientist is considering the mesh as prosthetic tissue. A patch over the hernia defect. In theory, the defect area is “tension-free”. But the edges of the mesh do feel tension. Otherwise there would be no need to worry about burst strength. You can also find literature about “small bites” for closing wounds, to avoid suture pullout. That was a hot topic a couple of years ago. There is even a new type of suture material called T-Line that is being promoted for its width, apparently for the benefit of avoiding suture pullout. There is discussion about using a running suture (a single filament passed through the edges of the wound to close it), as opposed to a series of separate sutures. But, like many of the many things to consider in hernia repair the final decision is left up to whatever the surgeon feels comfortable doing.

As far as healing after a suture repair, here is a good review of the healing process. It covers a wide area of healing responses, but it is well-written and understandable. It has an interesting comment about the size of the gap between the two surfaces that are expected to knit together. It made me wonder about how the two surfaces of the layers in a Shouldice procedure knit together. What is the impetus for the body to realize that the pristine surfaces are damaged? Only the edges have been cut. What parts actually form new collagen?

Anyway, it’s easy to get lost in the fine elements of what actually happens during healing of a pure tissue repair. But those fine elements might help explain why surgeons using what seems to be the same technique get different results.

The article doesn’t use the word years, but it does use months.

https://www.ncbi.nlm.nih.gov/books/NBK3938/

“Chapter 1
Overview of Wound Healing in Different Tissue Types
John D. Stroncek and W. Monty Reichert.”

”’
“1.4.1. Non-CNS Tissue
The first stage of tissue repair is stabilization of the discontinuity created by the injury. Traditionally, there are two broad classifications of healing. Tissue that has little to no gap separating the wound boundaries will undergo “primary healing” from the apposed edges of the tissue. Tissue that is unstable with a large gap or discontinuity injury will undergo “secondary healing,” where excess ECM is produced to secure and fill the lesion. The ECM of secondary healing, which subsequently becomes vascularized, is referred to as granulation tissue—a term arising from its appearance. In general, the amount of granulation tissue formed is proportional to the eventual level of scarring.”

[ajm222]

My understanding (and I’ve seen it reported in studies and journals and mentioned here by doctors) is that it takes about a year to achieve maximum strength after tissue damage of the sort involved in hernia surgery, but that within a couple or a few months the great majority of the strength is there. After a year there will often be remodeling of scar tissue and such that could indeed go on for multiple years.

[pinto]

@Good intentions, writes
“It takes months or years for the collagen
to fully convert to the strongest form.
Permanent sutures could be considered as a
backup…”
Years? How does it square with the many surgeons who say patients will soon be back to their normal living after surgery. If the strongest form takes so long healing then hardly could surgeons make such promises.

• This reply was modified 1 year, 2 months ago by  pinto.

[ajm222]

Thanks!

And I think I knew there were some
options when it came to absorbable sutures but didn’t realize there were so many.

[Herniated]

https://doi.org/10.1007/s10029-020-02365-6 may be helpful regarding the issues you raised.

Also, some may not be aware that “absorbable sutures” come in many flavors with widely varying dissolution rates (from days-weeks to months-years). There are also hybrid sutures made with a permanent core coated with an absorbable outer layer.

[ajm222]

Definitely. And thanks. I think I’ve decided that if I go through with this surgery, and all goes well, I’m going to convert from running for exercise to brisk walking. And will take extra care whenever I do anything very strenuous. I’m almost 47 and after everything I‘ve been through I will just be thrilled if I am mostly pain free and hernia free. I’ve never needed to be extremely active, and just want to take care of myself in order to avoid any further complications in this area. So exercise is important but I think my running days may be over. Add back issues and plantar fasciitis, and I think it’s time for some changes. As long as I can mow the yard and rake leaves and walk a few miles, I think I’ll be happy. So absorbable may be fine. But again, I’ll check with my surgeon and get his thoughts just to be sure.

[Good intentions]

You might consider the strength of the new tissue/collagen that is holding the layers together. It takes months or years for the collagen to fully convert to the strongest form. Permanent sutures could be considered as a backup or insurance against accidental extreme exertions or increases in abdominal pressure.

[ajm222]

some more discussion about the 2-layer repair and some other alternatives

https://herniatalk.com/forums/topic/desarda-vs-grischkan-s-two-layer-shouldice-etc-d15/

Desarda vs Grischkan’s two-layer Shouldice, etc…

[ajm222]

Thanks for the feedback. I’ve done some reading today on the 2-layer method (which I think is very common amongst surgeons who do that repair outside of the actual Shouldice clinic), which came from some initial experimentation with 3 layers (because some patients just don’t have enough good tissue for so many layers). Ultimately it seems that it’s been determined that the primary strength comes from the first 2 layers, and the second two are largely redundant. Recurrence rates with a properly performed 2-layer repair are very similar to 4-layer repairs (at least according to one study). Which is why I think many surgeons who do a Shouldice will opt for the 2-layer repair, because it’s obviously easier but also a shorter operating time and more than sufficient in most cases. More evidence perhaps that Shouldice is a little more invasive than necessary and probably just a carrying on of tradition more than anything else.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502350/

I also stumbled upon some research suggesting both absorbable and non-absorbable are fairly similar. The former perhaps increases the chance of recurrence very slightly but not by much. I’ll let my surgeon determine what’s best if a full repair is needed. I think at this point I just want to avoid mesh because of the prior issues I had with it resulting in removal. And permanent sutures lack most of the three dimensional negatives that come from mesh. My issues felt like they were caused by tightness from the large and inflexible surface area of the mesh. I think permanent sutures, while continuous, are more two dimensional and allow for much more flex. And with a 2-layer versus a 4-layer, probably much less plastic material. I don’t think my issues were directly related to the presence of the plastic itself so much.

[Watchful]

Shouldice is a 4-layer repair. There are surgeons who do 2 of these with permanent sutures, and 2 with absorbable. Dr. Wiese, for example. I think Dr. Koch does it that way too. They claim good results.

I don’t know about “2-layer Shouldice”.

Not sure this is something that’s worth obsessing about too much. My understanding is that a clinically significant reaction to the sutures is extremely rare.