[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.

[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.

[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…

[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!

[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]

Yes, it’s possible for pain to develop later with mesh.

Did your friends have open surgery or laparoscopic?

[Watchful]

Right, why evaporate such an informative and active thread which had a lot of deep dive posts and good paper references? An unfortunate loss.

• This reply was modified 2 years, 4 months ago by  Watchful.

[Watchful]

Right, some doctors are indeed aware of the cognitive impact of general anesthesia, but many are not. In general, this is not widely known.

I had no idea about it until it happened to my Mom. It happened to her twice – she had two surgeries with general anesthesia, with a serious cognitive impact after each surgery. When that happened, I did some reading about it, and found out that this is a known problem, just not talked about much for some reason. I read that doctors started noticing this happening to their parents – it has the most noticeable impact in older people who have less cognitive reserve. Supposedly, some general anesthetics are known to cause less cognitive damage than others, but I don’t know all the pros and cons. It’s best to avoid general anesthesia if at all possible.

[Watchful]

One thing I always wonder about with these studies is what about anesthesia complications? This procedure is under general anesthesia. 0% issues? My mom had complications from general anesthesia: delirium, a jump in cognitive decline. I know this is not specific to this surgery, but still should be mentioned if there were relevant complications.

[Watchful]

For me, the surprising thing there was that “no participants reported severe or disabling symptoms”, although it’s hard to know how to interpret that without a definition of “severe or disabling”.

I think 8% with pain, 7% with mesh sensation, and 2% with movement limitation is pretty bad for those who fall into those groups, and those are not very small percentages.

[Watchful]

My preference is also tissue repair. To be fair, though, chronic pain can happen with tissue repair as well. I don’t know if there are reliable statistics comparing the incidence and severity. My impression from what I’ve read is that it’s worse with mesh, but I’m not sure. One thing that’s pretty clear is that when things go wrong with mesh, corrective surgeries are more problematic.

[Watchful]

Seems like with this type of anesthesia some don’t wake up during the surgery, some are awake for at least part of it not feeling anything, and some are awake during the procedure feeling stuff. At least based on reports from Shouldice Hospital patients.

One confusing thing about local with sedation is if you don’t feel pain, or if you feel it but don’t remember it later. These are not the same thing…

[Watchful]

I’ve been wondering about that too. There are quite a few reviews of the Shouldice Hospital where people complain about feeling significant pain and other sensations during the surgery. It seems like local anesthesia with sedation isn’t an exact science…

[Watchful]

Dan – My understanding is that the Shouldice Hospital doesn’t operate on these small “occult” hernias because they don’t believe surgery is warranted for those. I don’t know if this is valid or not, but that’s their view, which I’m guessing is based on their experience.

The big concern for many of us considering that place is primarily that you don’t get to select your surgeon. Out of the dozen or so surgeons there, there are 2 or 3 who have a significant number of bad reviews. Also, they do have trainees who operate under supervision. The other issues you mentioned are a factor as well, but not as significant.

The Dr. Kang approach is indeed very appealing for indirect hernias. A tissue repair that works extremely well according to his numbers, while requiring a much less extensive surgery than the Shouldice procedure.

[Watchful]

@worldpeace: Thanks for the detailed response. I understand your thinking, but I think my choice would be local anesthesia and Shouldice. The thing that bothers me a bit with Dr. Yunis is that even though he’s willing to do that, he prefers to do general anesthesia and Desarda (your procedure). I feel a little hesitant as a patient to nudge the surgeon to do something that isn’t his first choice. I don’t know why it’s not his first choice – maybe because it’s more complex and time consuming, or maybe he feels that it’s not the best in his hands, or maybe something else. I didn’t ask him for his reasons. There are reports of him doing it successfully (e.g. Thunder Rose), so I’m probably overthinking this.

Alternatives for that procedure are Dr. Sbayi or the Shouldice Hospital. I’m also considering Dr. Kang in South Korea who seems to be doing a modified Marcy with local anesthesia.

• This reply was modified 2 years, 9 months ago by  Watchful.

[Watchful]

I hope all goes well, and you recover quickly. Seems like the least bad procedure available. I may follow you soon.

[Watchful]

Mike M… Sounds like you’re going to have it done by Dr. Kang. Let us know how it goes. I think a number of people here are thinking about doing the same thing, including me.

[Watchful]

Is there surgery that isn’t major? The body didn’t evolve in a way that’s friendly to repairs by surgeons, unfortunately.

The 4 days isn’t the major issue there. The major one is not being able to choose the surgeon. Then there’s the removal of the cremaster and cutting of the genital nerve branch.

In general, the Shouldice procedure seems a bit excessive for an indirect inguinal hernia, which is the reason surgeons are trying simpler, less radical approaches, such as Kang (modified Marcy, I guess) and Desarda. Based on my interaction with the few US tissue repair surgeons who offer Shouldice, they offer it a bit reluctantly, and try to steer you away from it. That bothers me a bit. The only exception is Dr. Sbayi.

[Watchful]

It’s based on what they say – I actually asked them. You can’t do much more than that for verification of what you’re going to get, other than maybe go to the Shouldice Hospital, but that has its issues too. Maybe you can be more certain that you will get the exact procedure, but how well it’s performed depends on the surgeon you end up getting, there’s the cremaster/nerve issue, old-school closure of the incision with metal clips, and who wants to stay there for 4 days…

[Watchful]

This Goretex mesh surgery is pretty far from Shouldice. I was referring to the modification by Yunis, Reinhorn, Towfigh, etc. They adhere to the original (other than the steel sutures) There’s no mesh, and they leave the cremaster and its nerve.