The Shouldice Method: an expert’s consensus

[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.

[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

[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.

[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]

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.

[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]

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.

[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, 7 months ago by  Watchful.

[William Bryant]

Are you on any bph medication Jkt2?

[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.

[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]

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]

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]

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).

[William Bryant]

Hello Bob, which surgeon did your surgery?

[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.

https://herniatalk.com/forums/topic/open-no-mesh-inguinal-surgery-is-this-normal/

https://www.sages.org/video/pantaloon-hernias/

Open no mesh inguinal surgery. Is this normal?

[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?

[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?

[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.

[Good intentions]

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

https://herniatalk.com/forums/topic/indirect-hernia-no-mesh-repair-by-dr-koch/

Indirect Hernia no-mesh repair by Dr. Koch