The Shouldice Method: an expert’s consensus

[David M]

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

[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]

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?

[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.

[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 2 years, 4 months ago by  dave11.

[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 2 years, 4 months ago by  Watchful.

[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 2 years, 3 months ago by  Jtk2.

[Jtk2]

Dressings were applied.

• This reply was modified 2 years, 3 months ago by  Jtk2.

[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.

[Jtk2]

No

[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.

[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.

[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!

[Wim]

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