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Shouldice technique shown to be better than mesh – but still not recommended
I think that I’ve posted this paper before. I just looked through it again and was struck by how the authors seemed afraid to just say directly what their own analysis showed. Instead, they fell back on the old canard that more work needs to be done. I respect the fact they could not twist the data to support the use of mesh but am disappointed that they were afraid to just come out and say what the analysis showed – Shouldice should be used for select patients.
The paper is linked from the Herniamed web site. Herniamed seems to bge a group put together by the mesh makers to promote mesh. The front page has most of the logos for the big mesh makers. It almost looks like an advertisement for device makers, which, in a way, it is.
Notice the mesh design used as the background for the web page.
https://www.herniamed.de/en/publications
https://link.springer.com/article/10.1007%2Fs00268-017-4433-5
Instead of saying “should be used” because it gives better results, they say “can be used”. And they use “comparable” instead of “better”. It is progress though. Maybe the giant ship is turning.
“Results
The most important characteristics of the Shouldice patient collective were younger patients with a mean age of 40 years, a large proportion of women of 30%, a mean BMI value of 24 and a proportion of defect sizes up to 3 cm of over 85%. For this selected patient collective, propensity score matched-pair analysis did not identify any difference in the perioperative and one-year follow-up outcome compared with TAPP, fewer intraoperative (0.5 vs. 1.3%; p = 0.009) but somewhat more postoperative complications (2.3 vs. 1.5%; p = 0.050) compared with TEP and advantages with regard to pain at rest (4.6 vs. 6.1%; p = 0.039) and on exertion (10.0 vs. 13.4%; p < 0.001) compared with the Lichtenstein technique.Conclusion
For a selected group of patients the Shouldice technique can be used for primary unilateral inguinal hernia repair while achieving an outcome comparable to that of Lichtenstein, TEP and TAPP operations.” -
9 Replies
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Well, mesh methods are the established ones, that’s the reality in North America and Europe, mesh are the overwhelming majority of procedures. Personally I wish there was more choice and less of a “default” to mesh, but if you want good tissue repair it’s relatively few surgeons who really have the training and volumes to do it properly. Surgeons tend to be biased on which method is best, they all seem to feel their method is best even though most don’t seem to have a great insight into what their patient results are measured even a year post-op (at least not in the USA). That’s why I like this study, because it has real numbers.
Again, I think your point about Shouldice not closing a door is a really good one. I don’t think the risk of chronic pain with a Shouldice repair is zero. This study shows that and one of the authors when he was on Hernia Talk live said his pain rate with Shouldice (which is most of his practice) is 2 percent. That we don’t hear more about this could be due to the bad cases not being as horrific as the mesh bad cases. It’s also due to the fact that there are relatively few Shouldice operations performed a year. All that said, my gut tells me it’s maybe the better option. But I’m not sure it’s a slam dunk.
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And here is the latest summary of the Guidelines for those who don’t want to read the whole document (by “those” I mean surgeons). Notice how they say that Shouldice gives good results but should only be considered if mesh is not available. There seems to be much talking out of both sides of the mouth. And, no signs that they would revise the Guidelines if new studies show different results. And, most telling of all, all forms of mesh are classified as one – “mesh”.
If you track the development and growth of mesh in hernia repair you find these inconsistencies all along the way, and the same companies involved in promoting them.
This is one the first summarized facts in the whole summary document. Use mesh if it’s available, only consider pure tissue if the patient asks or mesh is not available.
Excerpt –
“NON-MESH REPAIR
Non-mesh repair is an option if mesh is not available or in shared decision situations with patients that do not want mesh. The Shouldice is best tissue repair although in general practice the recurrence rate is higher than mesh repair and risks of pain are comparable. More research is needed into the value of non-mesh in cases where risk of recurrence is low (for example young men with indirect hernia) and into the results of expert clinics.”
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Here is a paper discussing the Guidelines, by Kockerling, just a few months after the paper discussed in this thread.
https://pubmed.ncbi.nlm.nih.gov/29888245/
And here is a post about a fairly recent study of the Guidelines. It just seems like the Guidelines were shoved through and published with financial help from the major mesh-makers.
Thank you for critiquing my reply above, I appreciate it. I have become very jaded over this whole situation.
https://herniatalk.com/forums/topic/new-article-questioning-the-validity-of-the-hernia-guidelines/
New article questioning the validity of the Hernia Guidelines
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I see that you are right, I should have went back and read the full paper again before my last reply.
I think their own discussion shows that they underemphasized the superiority of Shouldice in their short summary at the end. They could even have split the four in to two open methods and two laparoscopic methods. What’s fascinating is how they have completely flipped the narrative, talking about the mesh methods as the established ones and the Shouldice method as the “new” one, trying to displace mesh. When the reality is the complete opposite. Some of the same people were involved in the production of the Guidelines and they did the same thing. Stated flatly that mesh was the preferred repair method and that Shouldice should only be considered if mesh was not available. Kockerling is interesting because he seems to switch from side to side. It seems like he wants to believe in mesh but his logical side won’t let him.
Excerpt –
“The Herniamed data now demonstrate that this selected patient group can be operated on with a good outcome with the Shouldice technique and with no evidence of any major disadvantages coming to light up to the end of first postoperative year compared with TAPP. The Shouldice technique was even found to have advantages over the Lichtenstein operation thanks to lower rates of pain at rest and on exertion at one-year follow-up. Compared with TEP, the intraoperative complication rate was significantly lower, but the postoperative complication rate was somewhat higher. Similarly, an Austrian prospective randomized control trial did not find any significant difference between the Shouldice, Bassini, Lichtenstein, TEP and TAPP surgical techniques with regard to the recurrence rate and complications up to three years following surgery”
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If you’re talking about the last two statements in the “results” section of the abstract, those are comparing Shouldice to Lichtenstein. The results “did not identify any difference” between Shouldice vs TAP and vs TEP in terms of one year follow up outcomes.
Frankly I would have loved if Shouldice tested as much better than the laparoscopic techniques, that would make decisions about surgery for me personally much easier!
I think you make a good point about Shouldice not closing a door the way the mesh (especially Lap) techniques do, everyone says if something goes very wrong mesh removal is awful surgery.
I’m less suspicious of bias in a study like this. A Koch (who was interviewed on Hernia Talk Live) is one of the two lead authors and has most of his practice doing pure tissue repairs and speaks at Hernia conferences around the world (including one in Colorado this week) about Shouldice. I would not be surprised if hundreds of his personal cases were part of the Shouldice group data. The other lead author, Kockerling, looks like a laparoscopic/mesh surgeon.
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Pain at rest and pain on exertion were both better, the last two statements in the Results. Those are the reasons people get their hernias fixed, to stop the pain and to be safe from incarcerated hernias. Everything else being equal, less pain is a valid and significant reason to choose Shouldice over the mesh implantations they studied. Choose Shouldice and more of your patients will be pain free. Why would a surgeon choose the odds of more pain for their patients? It makes no sense that they did not say that.
But, the most significant reason to use a pure tissue repair is not mentioned in the paper – if there are long-term problems with a pure tissue repair they are much easier to deal with than with a mesh repair. Mesh is much riskier in the long-term. Even the surgery is riskier although that is not mentioned often either. General anesthesia has issues.
Look at the “Sponsors” for Herniamed. What happens to your sponsors if your work shows that mesh is not preferable to pure tissue? They probably stop sponsoring.
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This is an interesting paper, because it’s a good sized sample and tries to look at “apples to apples” (ie patients with similar age and bmi and other characteristics) comparisons of Shouldice vs the various mesh methods. At least one of the paper’s authors is a high volume, expert Shouldice practitioner. My reading is that after one year the pain for Shouldice vs TEP or TAPP is not significantly different. Do you have a different read?
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I think the real question is whether many of the next generation of general surgeons should (or even could) be trained how to do a good primary tissue repair as part of their armamentarium?
Even if someone is an excellent candidate for it, it’s just not an option right now it seems.
So many generations have been brought up on mesh based repairs that you probably don’t even have the experience among the faculty to teach this if you wanted?
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Wrote a lengthy response, only to have my login timed out, and the message lost.
I do not have the motivation to re type it.
Instead, I’ll just say thanks to @GoodIntentions for keeping the spotlight on this topic.
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