Very Interesting Puzzling Picture from Dr Grischkan’s website.

[David M]

Ok, my hernia is fairly large, probably direct.

So, wanting to avoid mesh as much as possible, but not being an ideal candidate, I’ve wondered about the possibility of somehow strengthening the transversalis double breasting by putting something between the two layers. That way the peritoneum is still touching the transversalis fascia on the posterior side of the mesh(like in the Lichtenstein) and the mesh is also covered on the top by transversalis fascia such that the spermatic chord is also separated from the mesh and not as likely to get stuck to it.

Finally, because the posterior wall of the canal is now double reinforced, layers 3 and 4 of the shouldice are less necessary. This might help with the problem of tension in the Shouldice.

So, does anyone have a clue whether that is what Grischkan is doing with his modified Shouldice in this picture? One can see the second layer of the transversalis fascia is still retracted as the mesh is being sewn in.

The Modified Shouldice Hernia Surgery Technique – WITH MESH [Panel 6]

• This topic was modified 1 month ago by David M.

[William Bryant]

I’d say it’s a hybrid or combination of mesh and Shouldice suture. But you need answers from the forum experts!!!

[drtowfigh]

Dr Grishkan sometimes does a combination Shouldice + Lichtenstein repair.

The picture is inaccurate in that the transversalis fascia should not be open at the stage of mesh onlay placement.

[Watchful]

There’s also the other combo option of open preperitoneal mesh combined with a version of Shouldice. This is what is done at the Shouldice Hospital in rare cases of bad tissue quality (based on what I was told there).

[David M]

Thanks, Dr Towfigh. What is he actually doing, then? The first two layers of the Shouldice topped by the mesh?

[David M]

….so, skipping layers 3 and 4 of the regular Shouldice?

[David M]

I guess he calls it a standard Shouldice:

“The Modified Shouldice Repair allows the surgeon to proceed with a standard Shouldice repair but reinforces the repair with a small latest generation mesh”

A four layer Shouldice plus mesh almost sounds like subtraction by addition, if that’s what he means by standard shouldice.

[Watchful]

Right, what’s the role of the Shouldice part in this case? I guess there could be some types of tissue damage where just mesh isn’t sufficient.

[David M]

This is an earlier review of Grischkan on herniatalk and it’s a devastating review, overall. As far as the 2 vs 4 layer, the poster thought he was getting a 2 layer modified, but the surgeon’s report talks about 4 lines of sutures.

[David M]

Oops, the link…

Grischkan review

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