The Shouldice Method: an expert’s consensus

[Good intentions]

This abstract might be linked already in one of the several Shouldice focused Topics or maybe it was in Mr. Sea’s mysteriously disappeared Topic. I am creating a new Topic just in case one of the others disappears too. Maybe when they get too long they’re automatically deleted. Who knows.

It appears to be an instruction set for how to do the Shouldice procedure properly, for use by surgeons outside the Hospital who want to use it.

EXPERT CONSENSUS
Published: 08 August 2022
The Shouldice Method: an expert’s consensus
Marguerite Mainprize, Fernando A. C. Spencer Netto, Cassim Degani & Peter Szasz
Hernia (2022)

https://link.springer.com/article/10.1007/s10029-022-02658-y

“Conclusion
The results of this consensus provide a step-by-step approach to the Shouldice Method, as well as information that is timely and can be utilized by surgeons incorporating non-mesh hernia repairs into their practice.”

[Watchful]

@good-intentions

I read the full paper. I think the most controversial aspect of the procedure as they do it there is completely cutting the cremaster and the genital nerve branch. Most surgeons outside the Shouldice Hospital don’t do this.

It’s interesting that there’s some disagreement on this within the Shouldice Hospital as well. The paper shows that 73% of the responding surgeons there agreed that this was needed, 9% were neutral, and 18% disagreed. Hence, this was not considered to be within the consensus. Cutting some parts of the cremaster was within the consensus, however.

The use of steel sutures was also outside the consensus – 55% agreed, and 45% were neutral.

• This reply was modified 1 year, 1 month ago by Watchful.

[dave11]

Ah, two of my favorite contributors start a post on the Shouldice method of repair. Thanks for your input. I had the Shouldice 2 layer done by Dr. Yunis just over one year ago. I would classify my surgery as a total success. After a massive amount of research of various no mesh repairs and surgeons, I chose Yunis over Kang because of the travel distance and covid restrictions. I loved Yang’s minimal area and sutures surgery approach to speed the healing process, but was impressed by Yunis’ varied surgical techniques and much closer proximity. Both doctors have excellent success rates. Kang encouraged the 2 layer versus the 4 layer since he believed the latter added unnecessary material for no absolute benefit. Ardent 4 layer doctors mention the reduction of tension using a 4 layer method, but I had no tension using the 2 layer. As for wire sutures, I would never place hardware store like material in my body. Yunis did use non-absorbable sutures, but eventually they help form beneficial good scar tissue that creates a more natural barrier. Also, he does not cut the cremaster. Well, I thought after a year I would let people know how the Shouldice 2 layer held up because it seems like a lot of people on HT just get the initial info and fade. However, that could never be said for Watchful and Good Intentions since you are ever present to help those in need. I certainly hope you realize how much help you provide.

• This reply was modified 1 year, 1 month ago by dave11.

[dave11]

I had the Shouldice 2 layer done by Dr. Yunis just over one year ago. I would classify my surgery as a total success. After a massive amount of research of various no mesh repairs and surgeons, I chose Yunis over Kang because of the travel distance and covid restrictions. I loved Kang’s minimal area and sutures surgery approach to speed the healing process, but was impressed by Yunis’ varied surgical techniques and much closer proximity. Both doctors have excellent success rates. Kang encouraged the 2 layer versus the 4 layer since he believed the latter added unnecessary material for no absolute benefit. Ardent 4 layer doctors mention the reduction of tension using a 4 layer method, but I had no tension using the 2 layer. As for wire sutures, I would never place hardware store like material in my body. Yunis did use non-absorbable sutures, but eventually they help form beneficial good scar tissue that creates a more natural barrier. Also, he does not cut the cremaster. Well, I thought after a year I would let people know how the Shouldice 2 layer held up because it seems like a lot of people on HT just get the initial info and fade. I hope this helps in deciding.

[Wim]

Did he uses also local anesthesia like Kank and Shouldice hospital?

[David M]

So, does Yunis only do the two layer, or did he offer the choice?

How does the two layer work- is it just a double breasting of the transversalis fascia and then a closure of the external oblique?

[David M]

Yes, thanks for the attention of those who have been through this and still find time to make a return and give advice.

[David M]

Was your hernia indirect or direct and how big was it?

[Good intentions]

Here is another reference to Dr. Koch and one of the “modified” Shouldice methods.

Indirect Hernia no-mesh repair by Dr. Koch

[Bob]

Hi dave11. I’m 8 weeks out with the shouldice method and still have pain down the inner leg and numbness and pain gets worse when Im talking loud or coughing and walking.Its below incision area down to base of penis over too inner thigh like a triangle area.It has gotten better, but is still there.The worse part now seems to be constant pain in my testicles. It doesn’t go away and is very difficult to fuction with it daily and very hard to sleep. How long was it before you felt normal again and did you have any pain in your testicles.

[William Bryant]

Hello Bob, I googled and Boston hernia has an info pdf that says it’s common after shouldice repair. And will ease with time.

But I can’t see an exact timeframe given. If it’s getting better maybe give it a bit more time.

Have you contacted surgeon or centre where it was done?

[Watchful]

Bob,

Sad to hear that. It doesn’t sound “normal” for the procedure, but who knows how many patients suffer from something like this and how long it lasts. In reality, no one collects and publishes such information in any reliable or detailed manner.

Do you have pain in both testicles, or just the one on the side where the surgery was done?

Was your surgery done in the US?

[Good intentions]

It would be interesting to compare your surgeon’s notes with the Consensus Method. There might be a clue there. At the least it might offer a distraction from the pain.

Here is your other Topic where you originally discussed the problem. It looks like you had what is known as a “pantaloon” hernia.

Open no mesh inguinal surgery. Is this normal?

Pantaloon Hernias

[William Bryant]

Hello Bob, which surgeon did your surgery?

[MarkT]

Just FYI, this is a different paper than what was discussed in the now-deleted Mr. Sea thread. This one is by Shouldice docs…the other one was by Lorenz and others (including two Shouldice docs):

https://pubmed.ncbi.nlm.nih.gov/33502639/

I summarized a lot of it in that deleted thread, so I’m disappointed to see that all gone…but in addition to describing a standardized Shouldice repair it too surveyed a group of docs, including Lorenz, Koch, and Conze, plus two Shouldice docs, and others from Canada and Europe.

Amongst the 12 docs surveyed, the only item that didn’t result in a good consensus was when cremaster resection should be included…five said always, five said sometimes, and two said never.

Some of the other questions:

No one was married to ‘only wire’ sutures with nine saying ‘wire or non-resorbable’, while three believed long-term resorbable were ok. I’ve heard it said that continuing to use wire is essentially a financial decision…big spools of stainless steel wire are apparently cheaper than prolene. AFAIK, there has been no evidence that wire is ‘bad’ and ought not to be used though.

Nine advocated for “always four continuous suture lines” (including some of the docs who routinely perform fewer), while two said “always three or more” and one said “always two or more”.

In response to which tissues exactly, nine said “exact original protocol always”, three said “small modifications allowed” and zero said “modifications allowed”, which suggests the importance of fidelity to the orignal protocol, while recognizing that some cases may warrant minor deviation (perhaps that is linked with the many responses of ‘sometimes’ for cremaster resection, for example).

[Watchful]

Good summary, MarkT.

There is no evidence that steel wire sutures are bad, but there are issues with them. They sometimes prick the hand of the surgeon, which can cause blood-borne diseases to be transmitted between patient and surgeon. Patients at the Shouldice Hospital are sometimes asked to do a blood test after surgery when the surgeon got pricked during surgery. Also, steel sutures have a tendency to break. In his later years as a surgeon, Dr. Bendavid actually switched from steel to prolene for these reasons when performing the Shouldice procedure.

The fact that the cremaster cutting issue isn’t settled is the most disturbing thing about the Shouldice procedure. Cutting it completely is not supported by most surgeons outside the Shouldice Hospital. This is a radical step which includes cutting the genital nerve branch, and the cremasteric blood and lymphatic vessels, which include the collateral (not primary) testicular blood supply. Seems like there would need to be a really good justification for doing something this radical, but nothing particularly compelling has been provided – the justification seems weak. It’s along the lines of somewhat better visibility and an expectation of slightly lower recurrence rates with this step.

[MarkT]

@gohaiga (Watchful), I would like to see more research on the cremaster.

The claim is improved visibility to detect secondary hernias and weak spots, which can be addressed at the same time as the main repair…and that the way the cremaster is resected, with the stump included in one of the suture lines, helps reduce the likelihood of recurrence. There seems to be some allusion to it being relevant to detection of sliding hernias too in the 2nd link below, but it is not clear (wasn’t that Pinto’s problem with their initial Kang repair, btw?)

From the Shouldice site:

“As part of the Shouldice procedure, we do a thorough search for other hernias, or weaknesses, in the area and repair them as well. This aspect of our technique is unique and not commonly practiced elsewhere, as most natural-tissue techniques (including Desarda), or virtually all open mesh techniques, do not go deep enough into the pre-peritoneal space to allow exploration of the whole area. Research has shown that up to 13% of people with hernias have a second weak spot in their muscles, or a “hidden” hernia. Our skilled surgeons have the expertise to find these hidden threats; in fact, it‘s one of the most important benefits of the Shouldice repair, by avoiding the need for a potential second surgery.”

From Dr. Bendavid (https://basicmedicalkey.com/the-shouldice-method-of-inguinal-herniorrhaphy/):

“Resection of the Cremaster
This important step seems to have been entirely forgotten. Few students have seen it performed, and fewer surgeons practice it. This step was clearly described and emphasized by Bassini, repeated by Catterina, and perpetuated by Shouldice. The resection of the cremaster and lateral retraction of the cord bring into view the posterior inguinal wall in a manner that can best be described as a “revelation.” It becomes impossible, then, to overlook a direct or indirect inguinal hernia. The transversus abdominis aponeurosis (i.e., the posterior inguinal wall) is now in full view. Whenever possible, the cremasteric vessels should be doubly ligated separately from the cremasteric muscle.”
…
“Search for Multiple Hernias
Statistics show that a second, simultaneous, ipsilateral hernia was found, if adequately searched for, in 12.8% of the patients who underwent operation. This search in all instances must rule out an indirect hernia, a direct hernia, a femoral hernia, an interstitial hernia, a prevascular hernia, a Laugier hernia (through the lacunar ligament), a prevesicular hernia (anterior to the bladder), and, lastly, lipomas, which on occasion perforate through the internal oblique and transversus muscles at the deep inguinal ring. The search must be established as a routine.”

“https://basicmedicalkey.com/the-shouldice-method-of-inguinal-herniorrhaphy/

Now whether that is enough to justify the accompanying risks associated with cremaster resection is another story and remains perhaps the hottest topic of debate with the traditional Shouldice repair.

It would be expensive and time-consuming to carry out a well-designed study, with a large sample, a sufficiently long follow-up period, and controlling for all potentially relevant variables (notably, surgeon expertise) to compare the traditional protocol with a modified one where the only modification relates to the cremaster not being resected…but one can hope!

[Jtk2]

Just had a right inguinal repair with Dr Yunis. Prior to surgery he said if it was a direct he would do Shouldice and if indirect Desarda. Did a local because I have BPH and was concerned about retention which did not become a problem post surgery. Was woken up 3/4 of the way through the surgery because I was moving my arms. Very painful! Afterwards, he said it was a large indirect so he did a 3 layer Shouldice. 36 hours out now. Have moderate pain, plus constipation and only able to walk for a few minutes. Does anyone know what a 3 layer Shouldice is vs 4 layers?

[Watchful]

@Jtk2

You should ask him what layer he skipped. I’m guessing he didn’t want to dissect your posterior wall because you didn’t have a direct hernia.

The local anesthesia is supposed to take care of the pain, so I’m a bit surprised it was very painful when they woke you up during surgery. I guess it’s pretty tricky to get the local just right.

How large was your hernia? Do you know the defect size and/or hernia sac size?

[Jtk2]

OPERATIVE FINDINGS: Large greater than 3cm indirect inguinal hernia with mild bulging of the posterior inguinal wall and no evidence of femoral hernia.

DESCRIPTION OF PROCEDURE: The patient was placed under mild sedation, an ultrasound-guided ilioinguinal nerve block was performed with 8mL of 0.5% Marcaine. An oblique incision was made over the right inguinal canal after infiltrating the skin and was carried down to the external oblique fascia, which was opened direction of its fibers. The cremasteric muscle fibers were split and a long indirect sac was dissected away from the cord structures into the internal ring. The cord structures and lateral bundle of the cremasteric were retracted laterally. The shelving edge was well exposed. The posterior wall _____ of transversalis fascia was divided and the posterior preperitoneal fat was dissected posteriorly. The first layer of the Shouldice repair was begun with 0 Prolene suture, suturing the lateral leaflet of the transversalis to the rectus tendon and running this toward the internal ring and running it back using shelving edge of the inguinal ligament to the internal oblique and tying at the pubis. A third and fourth row of 2-0 Prolene was used to reflect the external oblique over the inguinal floor. The lateral external oblique was closed with running 2-0 Vicryl suture. Scarpa’s fascia was closed with running 3-0 Vicryl suture and the skin was closed with running subcuticular 4-0 Monocryl suture. Dressings were applied.

[William Bryant]

I think one of the English surgeons does 3 layer as standard. 3 layer is adequate he feels.

Hopefully the pain issue subsides Jtk2, 36 hours after isn’t too long, still recovering.

Some people take laxatives after.

Moving during op has always concerned me too if local.

[Jtk2]

Dressings were applied.

• This reply was modified 1 year ago by Jtk2.

[Jtk2]

Currently supplementing with Raw Organic Fiber. Do you know the name of the English surgeon? Please disregard my reply to you above. Site will not let me delete.

• This reply was modified 1 year ago by Jtk2.

[William Bryant]

Are you on any bph medication Jkt2?

[Jtk2]

No

[Watchful]

@markt

Regarding the cremaster… There’s a difference between the perspective of the provider and the patient.

We’re talking about a high-volume provider which has done hundreds of thousands of surgeries. From that perspective, reducing overall recurrence by a couple of percent (say from 3.5% to 1.5%) makes a difference of thousands of cases that don’t bounce back to them with recurrence.

From the perspective of the individual patient, though, the picture may be very different. It may not be worth taking the damage of this part of the procedure for lowering recurrence from very unlikely to even more unlikely. Also, maybe at least a tailored approach is better where it’s cut completely only in some patients.

There’s also the alternative practiced by some tissue repair surgeons in Germany where they perform a thorough dynamic ultrasound rather than chopping everything up to look for “hidden” hernias. That’s the approach that should really be compared to.

• This reply was modified 1 year ago by Watchful.

[MarkT]

I see what you are saying, though we must not make assumptions that there is inherently a problem between provider vs. patient perspectives. There *could* be, but we can’t evaluate whether that is the case unless we know the probabilities associated with various outcomes and the nature of those outcomes.

A drop in recurrence rate doesn’t just benefit the provider…it obviously benefits patients as well. No one wants to experience a recurrence. Not only is a patient again absorbing all the usual risks associated with hernia repair, but some of those risks may be elevated when repairing a recurrence.

Where there could be a disconnect in provider vs. patient is if the drop in recurrence and missed hernias is accompanied by an elevated risk of other negative outcomes, and particularly if some of those are severe…but again, ‘it depends’.

For example, let’s just say the risk of recurrence and missed hernias/weak spots associated with cremaster resection is a 2% reduction…but that is accompanied by a 0.5% increase in the risk of chronic pain. A provider may indeed see that tradeoff as ‘worth it’ in the overall numbers, while an individual patient may not. As you note, that also depends upon the initial risk too.

It is tempting to conclude that a ‘50% reduction in risk’ of anything sounds *incredible*…but whether that has practical significance depends, in part, on whether the initial risk is high or low. A 50% reduction (or increase) when the initial risk is 10% may be quite significant, while a 50% reduction (or increase) when the initial risk is 0.1% seems less significant (but again, even that depends upon the nature of the outcome, as a 50% drop in risk from 0.1% down to 0.05% when the outcome is ‘death’ is suddenly not so insignificant!)

In terms of catching hidden/secondary hernias and weak spots, let’s just grant the claim that ~13% of hernia patients present with one, which can be repaired at the same time. Questions I then have:

1. What proportion of that 13% are caught *specifically* because of the way Shouldice repairs hernias, including cremaster resection?
2. What proportion would still be caught by a modified Shouldice repair that left the cremaster alone?
3. How would #2 change if reliable imaging is also included (remembering that imaging does yield some false positives and negatives)?
3. What proportion of that 13% are likely to be missed with other repair options (with and without imaging)?

In terms of resection, I would also want to know:

4. What is the corresponding introduction or increase in risk for other negative outcomes (e.g. chronic pain) because of cremaster resection?
5. How does that compare with risks associated with other repair options, with or without imaging? (i.e., is the elevated risk with Shouldice *still* higher/same/lower as other options?)

It’s very complex to tease all of that out. To do so requires carefully designed studies, which are unfortunately difficult, expensive, and time consuming, particularly when there needs to be long-term follow up of large sample sizes.

[Watchful]

There was a study by Schumpelick and others which I cited a while back. It did indeed show a somewhat lower recurrence rate and higher pain rate when resecting the cremaster. The surgeries were performed at two different centers in Germany, so not exactly apples-to-apples.

It is bothersome that you can go back to the Shouldice Hospital in case of recurrence, and they’ll take care of it, but you’re on your own in case of chronic pain. Patients say that they are told that they are one of the unlucky, and that they need to live with it or go somewhere else for help.

Recurrence should not be the only focus. As you mentioned above, aspects of the procedure which reduce recurrence but increase chronic pain may not provide a good tradeoff for the patient. The patient should be the focus, not the provider. I don’t really know if the complete resection of the cremaster/nerve/etc. falls into this category, but there is some reason to believe that based on the paper I mentioned. If the hospital had to treat chronic pain as well as recurrence, maybe that would affect aspects of the procedure that they perform.

[William Bryant]

Dismissing chronic pain seems quite universal, certainly in UK. I’ve seen NHS and private consultants who say they refer you to pain clinic if you do get chronic pain.

One said he’s only had 1 case in last year then laughed and said but that doesn’t mean it won’t happen to you!

Thought that was callous and not to reassuring. That’s how light it seems it can be treated.

At least he didnt say it’ll all be in your head, not possible, internet rumours I suppose.

For me I’d think most would risk recurrence rather than chronic pain.

Obvious neither desirable.

[Bob]

Thanks for all the replies. Yes,report says there was a direct and indirect hernia found once I was opened up. Reading the report it doesn’t say any nerves were cut. It does say that the one nerve was injected with a nerve blocker to reduce pain. I also read this is common. The base of the penis and both testicles starting hurting a few days after surgery and still do about the same. Penis turned black and blue which I was told is normal. Color went back to normal after about a week. . It was done in the USA. I’m told that it will get better in time,but I haven’t really seen much improvement in that area yet. Burning pain in my upper thigh running up to area were I was cut was unbearable for about 3 weeks,but that has gotten alot better. Testicles have not.My relative had his done at the same place a few years ago and he didn’t experience any of this. He had one hernia. I know we r all different and I shouldn’t compare his to mine. I have other pain with it in a few spots and a big area of numbness. Still get pain down the inside of the inner thigh and area below incision still seems numb and I have pain sitting down or putting my leg up to far. I’m dealing with those issues,but the testicle pain is much harder to deal with at this point. It makes life very miserable and it makes my whole body feel sick. If u ever been kick down there,then you know what I mean. Some nights I have to take 2 advil just so I can sleep with it. It’s not a real stabing pain. It’s more of a constant medium dull pain. I read that testicles can hurt up to 2 months after this surgery. I’m heading into the 9 week,so I’m right at that 2 month point. So I’m a little concerned.

[William Bryant]

Have you spoken with surgeon at all about it for some medical guidance?

Discoloration of the penis/testicles is not uncommon from what Ive read.

I really hope it resolves soon for you.

[Watchful]

Really sorry to hear that, Bob. It’s very strange that both your testicles are painful. How would the surgery affect the testicle on the other side? Different nerves, blood supply, etc.

Do you know if your surgeon resected your cremaster completely?

I was leaning toward having a Shouldice procedure done, but I’m getting cold feet after reading too many patient reports of chronic pain and discomfort. It must be a small minority, but still larger than I expected.

[William Bryant]

There are quite a few instances of chronic pain on their reviews. Suppose it’s true that has to be weighed up against the number of operations and then it’s probably only a small minority. But thats true of most pute tissue surgeons. It’s such a dilemma and major decision. No wonder I go round in circles.

[Good intentions]

Just posting to show the other end of the spectrum from the pain reports from the thousands of Shouldice procedures. Here is a material, described in the paper linked below, with a perfect record. No recurrences and no pain. 31 patients.

It is definitely tough to ignore the concrete, Individual stories of pain. They have impact, for sure. But if you ignore the odds, the probability of problems, then really you’re susceptible to the person or corporation with the best sales/marketing pitch. The most convincing story. Or the most hopeful story. I ignored the odds and hoped that my professional surgeon friend knew more than I was seeing in the literature. But it turns out that he was just hoping also.

https://www.sciencedirect.com/science/article/pii/S2405857218300196

[Watchful]

Looking at many studies, I get the impression that chronic pain rates for open mesh and tissue repairs are roughly the same, and higher in both cases than what I feel comfortable with. Some studies show better results for TEP mesh, although that doesn’t seem all that conclusive.

Clearly, these surgeries are something to be avoided other than for some pretty bad hernias. I think many people are not aware of this. I know I wasn’t. Also, surgeons don’t recommend watchful waiting as much and as often as they should.

I’ve had my hernia for many decades, and a number of surgeons told me over the years that I should really have it fixed. That seems to be true now, but definitely wasn’t necessary back then, and I’m very glad I didn’t listen. I didn’t even know the relatively poor outcomes of these surgeries, and surgeons certainly weren’t divulging that. At some point, surgeons started listing a bunch of bad post-surgery scenarios in their notes, but weren’t talking about those during the consultation.

The first time I realized that this surgery wasn’t a trivial matter was when a surgeon mentioned to me that he had chronic pain after his hernia was repaired with a Lichtenstein procedure, and he needed a neurectomy. In his mind, though, this wasn’t something to be concerned about if the ilioinguinal nerve is cut as a prophylactic measure during surgery, and that’s what he started doing with his patients.

Some surgeons I talked to insist to they have essentially zero cases of chronic pain, or maybe they had one or two in their entire career. I don’t really know what to think of that. Maybe they have a different definition of pain, or maybe they’re in denial, or not being truthful, or maybe some surgeons are really that awesome. In some cases, I find reviews from patients of these surgeons complaining about chronic pain, so I don’t know how that can be consistent with the claims of no chronic pain.

[Author]

Posts