Where would you go for Shouldice surgery?

[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.

[Good intentions]

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

https://www.shouldice.com/remote-clinic

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

[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.

https://herniatalk.com/forums/topic/laparoscopic-non-mesh-hernia-repair-todd-ponsky/

Laparoscopic non-mesh hernia repair – Todd Ponsky

[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, 8 months ago by  Watchful.

[William Bryant]

What are the other worse possibilities Mark?

[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]

* bringing it down a level = no pun intended

[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]

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.

[JamesDoncaster]

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

[Watchful]

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

[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]

@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.

[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, 8 months ago by  Watchful.

[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

[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?

[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

[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

[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, 8 months ago by  Watchful.

[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: “?? ?? facility? ???? ???? ???? ?? ???? ??? cremaster muscle fiber? split open ?? ?? ???? ??? ? ?? ?? ?? ?? ?? ??? ????? ???.
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.