Where would you go for Shouldice surgery?

[Watchful]

Say you decide to have your inguinal hernia repaired with a Shouldice surgery, and assume cost isn’t an issue, and travel isn’t an issue. Where would you go among the following?

1) Shouldice Hospital
2) Dr. Sbayi
3) Dr. Yunis
4) Germany (modified Shouldice performed similarly by a number of surgeons there)

I don’t think any of these choices are bad, but what would be your top choice?

The Shouldice Hospital has the most robust track record, so that would be a natural choice. However, they don’t let patients select their surgeon. This means that you could get one of their new surgeons (a couple of which are part time I believe), or you could get a trainee under supervision. A more minor issue is staying 4 nights in a shared room.

The aspect that adds complexity to this is that #3 and #4 perform a modified Shouldice where they don’t cut the cremaster and nerve, and they use prolene rather than steel. Also, some of them use 2 rows of permanent sutures and 2 resorbable instead of 4 permanent.

[Jack2021]

Dr Towfigh also offers a Shouldice repair, following the traditional method I believe, having recently watched her Hernia Talk with Dr Yunis from a couple of years ago, so another potential option for the US list. Please correct me if I’m wrong @drtowfigh.

If I decided to have a Shouldice repair and cost wasn’t an issue, I think I’d currently err towards Dr Joachim Conze in Germany and he uses 4 rows of permanent sutures. I thought Dr Andreas Koch came across well in the Hernia Talk with Dr Towfigh, so if he’d do 4 permanent rows instead of 2 perm/2 resorbable, then he seems a strong option too.

I’m based in the UK, so the distance may bias me somewhat, though I’d also prefer not to have the cremaster and nerves cut, ideally.

[Watchful]

Thanks, Jack2021. He’s a good choice.

I personally don’t feel all that strongly about the cremaster and nerve. They chopped hundreds of thousands of those over the decades at the Shouldice Hospital. If this had bad repercussions with any meaningful frequency, there would a lot of people out there complaining about related problems, but I don’t see that. I’d rather not have them cut if there isn’t much benefit, but it’s probably not as big of a deal as it seems initially.

My main issue with them is the surgeon selection problem. If I could select one of their best, I would choose to go there, and just accept the other aspects of doing that.

[Watchful]

By the way, Good Intentions made the observation (on the vanished thread) that the procedure has been so refined at the Shouldice Hospital that deviating from it is likely to degrade the results. If the risk of recurrence goes down when cutting the cremaster and nerve (tighter repair, better visibility), and there isn’t any meaningful harm, then that would actually be the better procedure. Avoiding another surgery is pretty high up on my list of priorities!

[Good intentions]

It really is a shame that Dr. Sea’s Topic is gone. All of these details were discussed in that Topic. It makes you wonder what causes things to get lost and how much effort a person should put in to participating here. How can a whole multipage thread just disappear, without a trace? It’s like the Secret Service text messages. Very strange.

Anyway, didn’t you say that you had an indirect hernia? The Shouldice repair seems kind of invasive for a small indirect hernia. The point that Dr. Kang made in the missing thread.

Also a shame that a professional’s efforts would be disappeared. Most of us on the forum are just internet “experts”, surfing around the web, reading, trying to understand. Dr. Kang contributed his thoughts to Mr. Sea’s thread as a bona fide experienced professional. And they just disappeared. How can that happen?

[Jack2021]

I agree and hopefully @drtowfigh will be able to have it reinstated.

I checked my history as well and it also said oops, this page is no longer available.

It was such an interesting and valuable thread, so fingers crossed it reappears soon.

If it helps @drtowfigh, Mr Sea started the thread with a write up of his experience with Dr Sbayi.

[Watchful]

Good Intentions,

Yes, it was very disturbing that the thread was nuked. There were very good contributions from a number of participants here, including illuminating posts from Dr. Kang as you mentioned.

I have a medium size indirect hernia. I’m not overweight or old. The Kang repair sounds best in theory, but I’m reluctant to do that because of the lack of a long-term track record – I’m concerned about recurrence. Desarda is another option, but I don’t have the time to research it and think about it too much. I really need to have my hernia fixed ASAP. This leaves Shouldice. Unfortunately, the Shouldice Hospital has its quirks, and there are multiple flavors of Shouldice, so even narrowing things down to the Shouldice procedure still leaves you with some difficult decision making…

[Jack2021]

Re your point about not being able to select a surgeon at the Shouldice Hospital, Watchful, it would be interesting to know what the hospital’s response would be to an enquiry from a paying patient explaining that they’re travelling a long distance and would like to be treated by either a specific surgeon, or say one of a selection of two or three, if you knew all have great reviews.

Have you tried that to see what they say?

The other point to consider, as noted by one of the posters on the disappeared Mr Sea thread (apologies, I forgot who it was), is that Dr Netto from the Shouldice Hospital stated that their current stats for chronic pain may be significantly higher than stated at perhaps 5%+ and they need to look into this further, or something along those lines.

If correct, could their long term pain rates be linked to cutting the cremaster and nerves? The problem here is that we don’t have a long term study of chronic pain and recurrence of the original Shouldice vs the modified Shouldice (i.e. the version that doesn’t cut the cremaster and nerves and has 4 lines of permanent sutures) and we may never get one, certainly not in time for those of us currently watchful waiting.

I’ve not heard the actual quote from Dr Netto, but if it’s true that their pain stats aren’t accurate, why aren’t they accurate and does it therefore also raise some doubt about their stated recurrence stats too?

[Watchful]

Jack2021,

Yes, I tried it. I was told that I could request specific surgeons, but they couldn’t promise anything.

On the nuked thread, I posted a link to a 1991 paper from Germany that said that there’s a lower recurrence rate when cutting the cremaster, but higher pain. Still, it concluded that cutting the cremaster is an essential part of the Shouldice repair:

Cremaster Paper

There was an independent source of information about recurrence at the Shouldice Hospital. There was a study from insurance in Canada, and it was consistent with the results claimed by the hospital. I don’t have the link readily available, but I can find it.

I don’t really doubt their historic recurrence numbers. Assuming they’ve been keeping up the level of quality work there, their repairs should be solid on that front (at least if you get one of their best surgeons). Chronic pain is a bit of an unknown, but not sure what it really is for other Shouldice surgeons either.

[Good intentions]

I found the video with Dr. Netto discussing chronic pain. I think that you have to listen to everything he says about it to understand what he means. He said that they did not know and guesses at “maybe 5″%”. He also talks about the type of pain, describing it as pain that does not require pain meds. Overall, he seems to be just saying that chronic pain from the Shouldice procedure deserves more study. He has an accent so you have to listen carefully, plus his microphone was cutting out.

It’s at about 19:00. I timestamped the Share so it should start there.

[Good intentions]

Dr. Netto and Dr. Szasz also had some comments about the Lorenz et al paper that was referenced in the missing Dr. Sea thread. It doesn’t look he has published anything since his Towfigh interview.

It is pay-per-view and a comment so there is no abstract.

https://link.springer.com/article/10.1007/s10029-021-02455-z

[Jack2021]

Hi Watchful,

Reassuring that the Shouldice hospital will listen to patient requests for specific surgeons, albeit without promising. I guess you’d have to be politely assertive on arrival that you’d only see whoever you’d enquired about. A longer the list of acceptable surgeons would hopefully raise the odds of getting one.

Thanks for reposting that link, I’d forgotten about that!

Also reassuring to hear about the Canada insurance study re accuracy of recurrence rates, as long as it was fully independent.

It seems to me that unless there’s an increased appetite within the sector to champion and independently monitor long-term hernia outcomes with the different tissue repairs and their modified versions and for individual surgeon results too, to account for varying degrees of skill and expertise, we’ll have to accept what’s most believably evidenced currently and hope we make the right choice.

As some of the doctors I’ve spoken to have told me, they can’t always guarantee their rates of pain and recurrence, because former patients aren’t always contactable, particularly over the long-term and if someone has a bad outcome, they may go to a different doctor, so the original surgeon never finds out that there was an issue. These unknowns may well be factored into success rates for many surgeons who keep their own records.

[Jack2021]

Great links to the video and comment Good intentions, thanks.

Here’s a link to the comment – https://www.deepdyve.com/lp/springer-journal/shouldice-hospital-comments-on-shouldice-standard-2020-review-of-JkkEjJj2yQ?key=springer

[Good intentions]

Thank you for that link to the Comment. It’s funny how you can find more if you look, I didn’t look hard enough.

But, the one reference that we would all like to see, #5, about chronic pain rates, is still behind a “sign up for free trial” wall, just a few lines down from the preview. Oh well. This internet world is a strange place. It might be worth a sign-up for Watchful or others.

“lower post-operative complications (including chronic pain) [5]”

In addition though, another useful item in the Comment article is the email addresses of both Dr. Netto and Dr. Szasz. Maybe somebody could invite them on to the forum, for their views. Or they might respond to a well-written query about chronic pain or other details of the Shouldice procedure.

[Watchful]

Dr. Netto answered questions from a Scottish Parliament Committee in 5/2022 here:

Scottish Parliament

He mentions that their post-op pain figure used to be 1%, but they need to redo their statistics now that the definition of post-op pain changed. He doesn’t mention his 5% guess in this one.

[Good intentions]

That is an excellent find, thank you for that. Everybody should read it, whether they are looking at a Shouldice repair or not. Dr. Netto covers the inguinal hernia repair in whole in his remarks. With some very interesting comments about why mesh is so popular today. Save the link immediately. The battle continues. It’s like a civil war.

I would be very interested to know how, exactly, the Shouldice Hospital uses mesh. Dr. Netto seems to have fallen in to the trap of referring to all types of mesh and ways to use it as “using mesh”. It’s the great confuser of the hernia repair field.

[Mike M]

Full disclosure: I went to Dr. Kang and had a successful Dr. Kang repair.

#1. Dr. Kang – Scenario: You are going to war in your own town and Dr. Kang is like a GPS, laser guided, Smart Bomb with the least amount of collateral damage while still maintaining maximum effectiveness in the targeted area (as it relates to open tissue repair). Dr. Kang doesn’t cherry pick patients and he is not afraid to engage with his audience with full transparency. Dr Kang is well respected by his peers (including Dr. Yunis) and his results so far have been spectacular even if we do not have 20+ years of documented long-term results (many procedures don’t). Keep in mind after 6 months the collagen in that area of the body has healed up to “normal” strength or greater* from what was disclosed in our previous discussions? Dr. Kang also has 20+ years of experience with hernia repairs in general (thousands) and additionally he has extensive experience with intestinal issues (St. Mark’s Hospital London, Gibbium Hospital).

#2. Dr. Grischkan or Dr. Yunis – Shouldice is like carpet bombing imho. Evacuate the area and leave no stone undisturbed. I feel that these two doctors would be the least “invasive” with well documented long term results from both the doctor and their patients.

#3. David Krpata, M.D., Cleveland Clinic – “Uncorrupted” Bassini repair. Probably the closest operation to Dr. Kang’s for Direct Hernias? I believe Cleveland Clinic is currently performing this method when requested to very successful results. I did not have a chance to investigate this further before my Kang repair but some previous posters (with major mesh issues) had great success with that repair at the Cleveland Clinic. He has also been a guest on Dr. Towfigh’s webcast.

Modified vs. unmodified. – It really depends on what your ideology is on medical procedures. I feel there is strong enough evidence from multiple credible sources that diverting from the original procedure in this particular procedure most likely yields better results, specifically as it relates to chronic pain.

There is no doubt that the Shouldice Hospital and other doctors like Dr. Sbayi have had tremendous success despite cutting the Cremaster and nerves.

However, the chronic pain with shouldice has been increasing? in cases, is not well documented, and is expected to be somewhere around 5%+ from the Shouldice Hospital lead surgeon’s own admission? Keep in mind this is from well selected patients with semi-strict criteria.

If I was going to accept a procedure that cuts the cremaster and genital nerve branch I would go ahead and just get mesh.
If we’re getting to that point I feel the risk is similar or possibly even less at that point.

[Good intentions]

When talking about mesh you have to include the solution to the chronic pain problem if it happens. With mesh it’s mesh explantation. I have not seen anything that suggests, realistically, that the pain clinic remedies actually “cure” the problem. They cover it up and create new pharmaceutical based problems. A person could be on pain meds for life. The same with neurectomy. A new risk of new problems.

I like your summary but the discussions of risk almost always end short, in my opinion. You have to consider the long-term.

[drkang]

Hello Watchful,

You seem to be now at a very sensitive point in making your final decision. So, I am very careful about posting new article.
Shouldice surgery is surely a very good repair technique. And I do not intend to influence your decision in any way. I think you’ve worked very hard, and have more information than surgeons, so you’re good enough to make the best decision for yourself.
Nevertheless, I am posting this simple article because I felt the need to answer your doubt about Pinto’s case. You pointed out that Pinto’s recurrent case was omitted in my previous statistics.

I have changed the surgical method dozens of times since I started non-mesh tissue repair in 2012. Just like a child growing up, Kang repair took on its present form as it grew up.
The reason the last statistics were for patients 7 to 32 months after surgery was because there was an important change in our indirect hernia repair method in December 2019, 32 months ago. Before then, all indirect hernias were repaired with absorbable 2-0 Vicryl. But from December 2019, I used permanent 2-0 Prolene in some patients, because I suddenly had a thought that an absorbable suture material might be the cause of recurrence.
At the beginning, Prolene was used only in patients with sliding hernia, recurrent hernia, large incarcerated scrotal hernia, or in patients with large internal ring or severe ascites etc. And for patients with average risk, I continued to use an absorbacle Vicryl. As a result, there was no recurrence in 401 high risk patients who used Prolene, but among 1405 patients who used Vicryl, recurrence occurred intermittently, and 12 patients have relapsed so far. So, since September of last year, we have repaired all indirect hernias with permanent 2-0 Prolene.
My previous statistic of no recurrence with 738 patients 7-32 months after indirect hernia repairs, were only about those with the permanent Prolenes.

Pinto, who underwent the first operation in August 2019 for left sliding hernia, was excluded from the previous statistic because he had surgery with Vicryl at the time. But Pinto’s reoperation was done using Prolene in March of this year.
Thank you all, and thank you Mike M!

[Watchful]

Does anyone here know of anyone who had surgery for an indirect hernia with Dr. Kang? The only case I heard of is Pinto. He posted that he had an indirect sliding hernia, and his hernia recurred pretty much right away after surgery by Dr. Kang. A second operation by Dr. Kang has been successful so far. I know we have successful direct hernia experiences, but what about indirect? Those are two completely different procedures with Dr. Kang.

[Watchful]

I posted at the same time you did, Dr. Kang, and hadn’t seen your post. This helps me understand what happened there. I certainly need to decide soon. I’m in bed right now trying to get my hernia back in!

[William Bryant]

https://herniatalk.com/members/linzee-1018/

linzee had an indirect hernia repaired by Dr Kang. It has held up for many years.
And, afaik, is still perfect.

Linsay, according to Dr Kangs site, can also be contacted direct by email for further discussion.

Hope this helps Watchful

[William Bryant]

That’s weird linzee link states “no activity”.

Unless I’m doing something wrong.

[William Bryant]

Here’s some of what Linzee/lindsay wrote
It can bee seen it was an indirect hernia repair by Dr Kang

7th January, 2019
My name is Lindsay, Australian, age in early 60’s. My contribution is for anyone with an inguinal hernia that is considering travelling for a mesh-free repair. I relate how I reviewed my options when in this position, ended choosing a Kang repair, and my experiences in following this through in Korea. My experience was very positive.
..
Background
I had an indirect inguinal hernia for >10 years, which deteriorated quickly and needed to be fixed. My quickest option was a local mesh repair, which in my case was to be larger than average in scope, entailing an open operation and general anesthetic.
..
I did some internet searches and noticed concerns with hernia mesh repairs. These included unpredictable adverse responses to mesh in some patients, and that significant pain was not uncommon after the repair. I also found reports that large hernias carry a higher than average possibility of recurrence, and higher probability of problems with mesh pain. From this, I sought only mesh-free repairs, but found only one clinic advertising this option in Australia.
..
Non-mesh inguinal hernia repair options
I found “HerniaTalk” to be a good place to learn about non-mesh inguinal hernia repairs, and where they might be available. I encountered recent information mostly on Shouldice, Desarda and Kang repairs. I found a recent presentation by Dr. Kang that provided a very useful overview to inguinal hernia repair approaches – https://www.youtube.com/watch?v=kzOyeRYysj4 . Hence, the Kang repair for indirect inguinal hernia appeared to me to be most suited to my situation. This repair is available at Gipum Hospital in Seoul.
..
The strengths I saw in a Kang Repair

[Watchful]

Thanks for looking up Lindsay’s case, William – this helps. It’s a good sign that he moved on – he must be happy with his repair.

I used to think that treating inguinal hernias was straightforward, so I didn’t bother researching it much all those years while watchful waiting. I thought I would just go to a good general surgeon and get it done when the time comes.

When the time finally came, I went to a general surgeon, and he told me that he himself had had an inguinal hernia which was repaired with open mesh, and he had chronic pain after that, and needed a neurectomy. Also, he told me that he routinely cuts the ilioinguinal nerve while performing the procedure. At that point, I realized that I knew nothing, and this was absolutely not a trivial thing.

I then went to a laparoscopic hernia surgeon, and he said he was 80% sure he could do it that way in my case, but there was a 20% chance that he would have to abort the procedure, and convert to open. At that point, I started being even more concerned.

The next step was to research mesh because those were mesh procedures, and this freaked me out even more. Meanwhile, my hernia symptoms kept getting worse. The next phase was researching tissue repairs, and looking into the very few places that offer it. I’m still shocked that treating this simple condition has so many pitfalls, and you need to travel far and maybe even to a different country to get it treated in the least bad way.

Anyway, I’m at the tail end of the research part, and it’s time for action. I really wish my hernia hadn’t become so symptomatic over the last year. It was minimally symptomatic for many years. That’s what aging does to you, I guess. Your existing issues get worse, and new ones pop up to make things even more interesting.

• This reply was modified 1 year, 2 months ago by Watchful.

[William Bryant]

I’ve sent a message Watchful.

I get all your saying… Similar to my experience.

But I also have other issues too!!!

That said think hernia is probably worst.

[Mike M]

One very important distinction between Shouldice and Dr. Kang’s indirect hernia repair is with Shouldice there is not just “cutting”. Shouldice also includes the *removal* of a “significant” portion of the cremaster muscle (30%-50%) to get a “tight” repair around the inguinal ring. This is what I was told by several Shouldice surgeons mentioned in this thread. The only surgeon that I found doing Shouldice which avoids removing cremaster tissue is Dr. Yunis.

“Dr. Kang’s indirect repair: “창고 속의 facility를 수리하기 위해서는 창고문을 열고 들어가야 하듯이 cremaster muscle fiber를 split open 하고 속의 구조물을 수술한 후 다시 창고 문을 닫는 것과 같다고 생각하시면 됩니다.
To repair the facilities in the warehouse, you can think of it as if you had to open the warehouse door and enter it, split open the master muscle fiber, operate on the structure inside, and close the warehouse door again.”

So there is some injury (which is to be expected) with that indirect hernia repair but it is superficial? which skeletal muscle can easily resolve with minimal risk to full function. No removal of cremaster muscle tissue with Dr. Kang’s indirect hernia repair.

Removing 30-50% of your cremaster muscle doesn’t appear to cause loss of function in most Shouldice patients? but I would still consider removing muscle a larger risk then carefully cutting and closing muscle back up.

[Watchful]

Mike M,

There was a recent thread with extensive discussion of this, but it disappeared.

The original Shouldice technique as practiced at the Shouldice Hospital and Dr. Sbayi completely cuts the cremaster, and leaves two stumps. One stump is used in the reconstruction of the inner ring to make the repair more resilient to indirect hernia recurrence. Search for “cremaster” in this paper to understand what is done:

Shouldice Paper

This paper also explains how the procedure avoids a dangling testicle.

The cutting of the cremaster is mentioned as an essential part of the repair in a number of papers. It makes it possible to visualize the area better and find hidden hernias, get a better reconstruction of the inner ring, and it’s shown to reduce the recurrence rate. I found one paper (cited earlier) which mentions more pain when this is done, but still concludes that it’s an essential part of the repair. Outside the Shouldice Hospital and Dr. Sbayi, this part of the procedure isn’t widely performed. An obvious question is why deviate from a proven technique which has been performed on hundreds of thousands of men with seemingly excellent results overall. Well, at least in terms of recurrence. I think the chronic pain results are less clear.

The other thing to keep in mind about the Shouldice procedure is that it’s a 4-layer repair which reduces tension by spreading the load. Again, geared toward reducing the risk of recurrence.

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

[JamesDoncaster]

You can get the catched version of Mr. Sea’s post here

https://webcache.googleusercontent.com/search?q=cache:6etqZguVm0YJ:https://herniatalk.com/forums/topic/shouldice-repair-dr-sbayi-stony-brook-ny/+&cd=1&hl=en&ct=clnk&gl=us&client=firefox-b-1-d

[William Bryant]

Brilliant, thanks James. That’s something at least.

Can I just ask are you in UK? I’m going on the Doncaster bit

[Mike M]

@Watchful It sounds like the procedure (as described) in that link is a removal (in that section) and what is left is “repurposed” ?

“All cremasteric structures—muscle, vessels, and genitofemoral nerve—are taken.” 1168 E.B. Shouldice / Surg Clin N Am 83 (2003) 1163–1187

“To ensure no difficulties of this nature, the distal end of the divided cremasteric structure is secured during the closure to the newly formed external ring or subcutaneous tissue. The proximal end plays a role in the repair, being incorporated into the forming of the new internal ring.”

I still don’t understand how there wouldn’t be a high chance of cremaster function loss (as well as permanent low hanging testicle) when removing and/or repurposing a large part of that muscle. I do not see anything else in this process that would restore cremaster function to what it was prior to the surgery. Obviously with so many successful cases and reports of full cremaster function it can be done and function normally it is just not explained how?

It could be that 50-70% remaining cremaster is enough to not impact function?

[Good intentions]

Don’t overlook the scrotum. The body often has redundancy (e.g two testicles). Here’s a couple of references and one that I pulled from the Wikipedia entry about the cremaster muscle.

https://www.verywellhealth.com/scrotum-anatomy-4782407

https://en.wikipedia.org/wiki/Cremaster_muscle

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1979762/pdf/brmedj03205-0028.pdf

[Watchful]

@Mike M
It is a removal in that section.
One stump of the ligated cremaster is used in the internal ring repair.
The other stump is “included into the external ring or subcutaneous tissue to prevent any possibility of the testis becoming dependent.” This prevents a dangling testicle.
I’m not an expert on this, but I don’t see how whatever remains of the cremaster could possibly function after this. Recall that the nerve is cut as well. This means that the testicle will not be moving up and down anymore as far as I can tell.

The loss of cremasteric function is not something that I would care about all that much personally. Still, the removal of a muscle/nerve and the loss of function seem like something to be avoided unless they are essential. There is disagreement among surgeons about that. Some remove it (Shouldice Hospital, Dr. Sbayi), some “shave” it (thin it down and don’t remove the nerve), and some only open and close it. A very confusing situation for patients trying to decide where to go for a Shouldice procedure.

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

[Watchful]

@good-intentions

The only other muscle there is the dartos muscle, and it is innervated by the same nerve that’s cut (the genital branch).

Maybe the muscles on the intact side have some residual effect on the operated side.

[Good intentions]

I would study more about the actual function of the cremaster muscle. My shallow reading is that it serves a dual function. One is the rapid protective retraction of the testicle in cases of danger. The other is the temperature regulation function. Which is also a function of the scrotum. The scrotum might also pull the testicles up, rather than just going along for the ride. Somebody has probably studied this.

So it might be that all that is lost is the speed at which the testicle moves. Not the actual range of movement up and down.

Sometimes when I see these concerns I also wonder about boxers versus briefs. Brief wearers spend most of their day with the testicles high. Boxer wearers not so much.

[Watchful]

Maybe. I don’t know if the scrotum itself can contract without muscles doing the work.

[JamesDoncaster]

@bryan I live in the USA … on a street called “Doncaster”.

[William Bryant]

I guess it all depends on what low hanging means, with age the testicles hang lower anyway according to Google.

But the review from a former patient claimed his was by his knee and he could no longer wear jeans etc… And it was uncomfortable.

That may have been over exaggeration but it raises the question, an inch, 6 inch hang. What’s the maximum?

And being highly sensitive would the drag create any dull ache.

Bringing it down a level, testicles can retract on orgasm, would it affect that or ejaculation for example?

Ages ago I read that the retraction soon after repair can damage repair, another reason for cutting it was claimed.

[William Bryant]

Thanks James!

We have Doncaster here. I’m fact I’m going to Dodsworth Hall in Doncaster soon. Old victorian era grand house, sight seeing.

Take mind of hernia for few hours

[William Bryant]

* bringing it down a level = no pun intended

[MarkT]

I would go to Shouldice first…then probably Dr. Sbayi…then I would do more homework on the U.S. and European options.

Shouldice has the history and track record. Even the ‘new’ surgeons there are going to very quickly gain more experience with the repair than virtually any external surgeon whose practise is not primarily focused on that repair…and they will have been trained ‘from the source’.

Dr. Sbayi was at Shouldice for a year, where he learned the repair and performed many hundreds of them…and he has performed many hundreds since then. AFAIK, he remains quite faithful to the method too. In North America, that is about as close to “Shouldice, but outside of Shouldice” as you are going to get.

For any other option, I would want to know where that surgeon learned the repair, how many they have done to date, the volume/frequency they still do, what they modify (if anything), and hopefully some patient outcome data including how they track it.

While it is almost certain that it is not necessary to average 50 repairs a month to become sufficiently proficient so as to provide the best chance at an ‘optimal’ outcome, we also don’t really know what level of volume/frequency is necessary to achieve comparable results. At minimum, I would want someone who has done a lot of them and who continues to do a lot of them…a relative handful per year is not going to cut it, IMHO.

I’m still amazed at how much discussion revolves around the cremaster…I just don’t get it…in fact, I think it is almost a ridiculous focal point when there are many other risks associated with the surgery to which no one is devoting nearly as much discussion…some of which are more likely to occue and/or are much more debilitating.

Do yourselves a favour and contact Shouldice…ask for a list of risks and their approximate likelihoods…ask about cremaster function and why loss of reflex or descended testicle is very uncommon despite the resection…I suspect many of you will probably stop obsessing about the cremaster if you do so 😉

[William Bryant]

What are the other worse possibilities Mark?

[Watchful]

@markt – thanks.

The loss of the cremaster reflex with this procedure is a certainty, not a risk. It’s mentioned in the German paper that I cited earlier in this thread. You can also search for cremaster in the following document which is in English and cites that paper:

New Clinical Concepts in Inguinal Hernia

“Tons and Schumpelick reported the cremaster reflex to be absent in all patients after division of the genital branch”

Whether that actually matters or not is a different question. In the same paragraph:

“Clinical implications of an absent cremaster reflex are unclear.”

Beyond that, there’s a higher pain rate when performing this part of the procedure according to that German paper. However, they still conclude that it is essential to do it. I read in another paper that there’s a higher risk of a hydrocele as well when doing this. Anyway, these are risks, but the loss of the cremaster reflex is a certainty.

I’m more concerned about other things with the Shouldice Hospital. I think if you get one of their best surgeons, it’s right at the top as long as you’re ok with cutting the cremaster/nerve. When Dr. Burul was asked where he would go if he needed the operation, he said one of the best surgeons at the Shouldice Hospital. If you read the link I posted above from the Scottish Parliament, you’ll notice that Dr. Netto mentions that some of their surgeons are part time. If you look them up, a couple of the new ones appear to also work elsewhere doing other types of surgeries.

Their reviews are mostly good, but I would say a bit mixed. Some surgeons get more bad reviews than others. Quite a few reports of chronic pain. Some infections. A significant number mentioning issues related to the level of sedation and local anesthesia – being conscious and in pain during the procedure, etc. Maybe it’s just the statistical reality of doing a large number of procedures.

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

[Good intentions]

If I had an indirect hernia I’d talk to Dr. Ponsky. He seems very rational and very well-informed. Even though he is primarily a pediatrics surgeon, he also works on older adults. He might be open to repairing an adult hernia via his laparoscopic procedure.

You might be find that his method makes the most sense and you can move on from considering the Shouldice repair.

Laparoscopic non-mesh hernia repair – Todd Ponsky

[Good intentions]

Also just saw this on the Shouldice site. Visiting Vancouver n late September.

September 2022 – Vancouver Clinics

Shouldice Hospital is returning to Vancouver!
Hernia Examination Clinic September 26, 27, 28 & 29
For further information call 1-844-712-1362

[Watchful]

@good-intentions

Yes, that’s an interesting approach for indirect hernias. Much less problematic than mesh or tissue repair when it works. However, I think I passed the age where it would apply.

It’s laparoscopic high ligation of the hernia sac which should work fine if the internal ring tightens by itself after the hernia sac is removed. That is actually what normally happens up to a certain age – not sure what it is, but I’m pretty sure I passed it. My understanding is that at some point a muscle defect develops there if you don’t treat the hernia earlier in life, and then you need either mesh or tissue repair to avoid a high recurrence rate.

Still, I will contact him to hear the latest on this.

[Author]

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