[Watchful]

I think what some people don’t like about Desarda is that a flap is cut from an unrelated muscle (external oblique aponeurosis) and used in the repair. However, tissue is cut in the Shouldice procedure as well – flaps from the transversalis fascia. It involves pretty extensive dissection. Also, the cremaster and its nerve in men (in the unmodified procedure), and the round ligament in women.

I’m also considering Dr. Yunis among others. He seems very capable and has a few Shouldice success stories here. On the other hand, he does primarily mesh, and relatively few Shouldice and Desarda. My impression has been that he actually prefers Desarda to Shouldice due to its relative simplicity.

I’m surprised that there are no reports here of surgeries with Dr. Sbayi who has done more Shouldice procedures.

[Watchful]

Hi Thunder Rose,

The information in your thread has been very helpful. It looks like you got a great result from your surgery with Dr. Yunis – a good repair without issues. I wish more people reported their experience and results here.

One question is why you wanted to avoid steel sutures. I think you mentioned somewhere that you were afraid that they would break. Was there a reason to expect this, or to be concerned about this? The suture material is one of those aspects of the surgery where it’s not clear if the Shouldice Hospital is doing things just because of historical reasons (why mess with a winning formula?), or whether it’s indeed the best way of doing things. I think in terms of sensitivity or allergies, there are rare cases of Prolene reactions, and there are rare cases of reactions to metals in steel. I don’t know if one is better than the other, if steel elicits less inflammatory response, etc.

[Watchful]

Thanks for reporting your results, Dr. Kang. No cases of chronic debilitating pain out of 10,000 tissue repair surgeries is amazingly good.

May I ask how many cases of recurrence have you seen out of these 10,000?

[Watchful]

Exactly. Chronic pain happens with tissue repair as well, and there are plenty of ways this can happen with the Shouldice procedure.

A surgeon at Shouldice Hospital (Dr. Netto) who works in the trenches is a good professional source. I would take what he says seriously.

[Watchful]

The Shouldice Hospital does the largest number of these procedures. Their surgeon is saying that the incidence of chronic pain that they see is higher than they thought it would be. This prompted them to perform a study, and he estimates it to show about 5%. I would take that seriously. He said that their official number is still 1%, but that’s for debilitating constant pain. For chronic pain in general, the number is higher. Higher than they expected, and they are studying it. He thinks 5%. Please watch the video.

[Watchful]

Right, but chronic pain is real with Shouldice as well, including at the Shouldice Hospital. Watch Dr. Towfigh’s video with Dr. Netto from the Shouldice Hospital. He said they were surprised by a higher percentage of chronic pain than they thought, and were studying it. He was expecting the study to show about 5%.

[Watchful]

The Shouldice Hospital is a bit of crapshoot, unfortunately. This can be seen in on-line reviews and some blog posts. Overall, most of the reviews are good, but there are quite a few bad ones, including some seriously bad issues. A few surgeon names appear again and again in bad reviews, and those surgeons are still there.

Regarding cutting the cremaster muscle and its nerve… It is indeed true that thousands of these procedures are done a year, so it can’t be that bad to do this. However, this doesn’t mean that there aren’t occasional complications from this (low-hanging testicle, spasms, pain, etc.) which may not be necessary – is the potential benefit really worth the potential trouble? Hard to say, and surgeons who are not trained at Shouldice don’t like to do this. It does add even more complication and anatomical changes to a procedure that already has a lot of that.

Also, if we apply here the argument of “many procedures are done, and there isn’t a widespread outcry about results”, then we can equally apply it to mesh. Hundreds of thousands of those are done a year in the US, and if this was truly a bad procedure, we would see a lot more bad cases. The reality is that there is a small percentage of issues with both Shouldice and mesh, but the vast majority turn out fine. There don’t seem to be definitive studies on what is better, so there is uncertainty on that aspect, but we have to keep things in proportion when thinking about what to choose, and look at things realistically for both procedures. I personally lean toward Shouldice vs mesh for my case, but I’m not sure that this is the “right” decision. I would in all likelihood be ok either way. Maybe the worst case with mesh is worse than the worst case with Shouldice, so that could be a valid argument even when the risk is very remote.

[Watchful]

Right, but the question is what is the probability of bad mesh complications in the hands of a top hernia surgeon? Is it meaningful, or is it extremely miniscule?

You mentioned size of defect. I don’t think the Shouldice Hospital limits itself to small or medium size hernias.

[Watchful]

Chuck – That is maddening – sorry to hear that.

I’m leaning toward tissue repair. You mentioned Desarda, and that one is interesting. Simpler than Shouldice. Cutting a strip of a healthy muscle (external oblique aponeurosis) and using it over the weak area may sound a bit scary, but it looks like it works well. I haven’t seen any repercussions mentioned for the slicing of that muscle, but that doesn’t mean that there aren’t any. Some nerves occasionally do need to be cut during the Desarda procedure, so it’s not always nerve-sparing (neither is Shouldice).

There’s some perception that Shouldice is superior to Desarda, but I’m not sure what’s behind that. Maybe just the long history of experience with Shouldice, while Desarda is relatively new. In the papers that I’ve seen, results seem to be similar, just with faster recovery for Desarda. Seems like a good alternative – I haven’t really seen anyone raising a clear objection to it other than the shorter history.

[Watchful]

Are you planning to do just a Shouldice procedure there or Shouldice+GoreTex mesh?

I think the procedure that minimizes the cutting of tissues and risks to nerves is actually laparoscopic TEP mesh, although it has the disadvantage of requiring general anesthesia. Shouldice involves a lot of manipulation of your tissues as you can appreciate by reading the steps of this surgical procedure. My wife sometimes calls it “doing a Picasso on you”.

I’m personally not a fan of either procedure, but there isn’t really a great solution. This is why watchful waiting is the way to handle it as long as the hernia doesn’t progress beyond a certain stage. Once that’s not an option any longer, you basically have to pick your poison.

I would lean toward the original Shouldice (maybe with the modification of not cutting the cremaster and the genital nerve branch). The main reason is that it seems that when mesh causes trouble it’s more serious trouble than when Shouldice causes trouble. However, if mesh complication rates are miniscule in the hands of a top surgeon, then I’m not sure that this is the right thing to focus on.

I have no experience with the surgeon you mentioned – sorry.

[Watchful]

You may be able to ask your doctor for allergy tests for the metals in stainless steel and for prolene.

[Watchful]

My understanding is that cutting the cremaster reduces the bulk of the spermatic cord, and this enables a tighter repair. Also, there are benefits in better visualization and access for the area. I read that they also use the end of it to shape a new inguinal ring.

It is a somewhat controversial part of the procedure, and not all surgeons do it, but it has been shown to reduce hernia recurrence in some studies. Not sure what all the downsides are – it does indeed seem a bit drastic to cut this muscle and nerve.

If even the experts disagree on this, not sure what hope there is for us patients to sort it out.

[Watchful]

Prolene mesh and sutures can cause reactions. Stainless steel supposedly less so, but not sure by how much (allergies to metals do exist). Regardless, my understanding is that those adverse reactions are rare in both cases, so I don’t think I have a strong preference for one versus the other.

The advantage in cutting the cremaster muscle and genital nerve branch is somewhat lower hernia recurrence rates according to the Shouldice Hospital.

[Watchful]

That’s a reasonable concern, at least in theory – thanks. Whether it happens in practice or not, who knows… Since the advantages of steel when compared to Prolene aren’t clear either, I can see why going with Prolene can seem more reasonable.

On the other hand, there’s all this fear of foreign body reaction with Prolene mesh, and I’m not sure why the same wouldn’t happen with Prolene stitches. The amount isn’t the same, of course, but there’s still a significant amount of material even with the stitches.

[Watchful]

Hi Dr. Kang,

Thanks for providing the numbers. These are extremely good results – congratulations on such a stellar record.

I think in terms of recurrence, the results claimed by the Shouldice Hospital are in the same ballpark as yours. There is some difference in terms of pain, though. Dr. Netto (from Shouldice) was mentioning 1% chronic debilitating pain, and an estimate of 5% for chronic pain in general. Your results are effectively no chronic debilitating pain, and you didn’t mention the result for chronic pain in general.

Is there something in particular in your procedure (when compared to Shouldice) that makes it better in terms of chronic pain?

[Watchful]

I’m surprised Dr. Sbayi wanted general anesthesia. Was this because of anything specific to your case? He normally uses local+sedation. Dr. Yunis actually prefers general, but will do local if you insist.

[Watchful]

So, where does all this lead? Both mesh and tissue repair cause chronic pain in some cases, and both suffer from recurrence in some cases. Different studies show different results, and there is no clarity on which type of procedure is better in terms of chronic pain and recurrence.

The information I got from doctors that I asked is to expect similar results in the hands of top surgeons. In other words, the surgeon matters more than whether the procedure is mesh or tissue repair. Similarly, even Dr. Netto from the Shouldice Hospital said that the difference in outcomes between Shouldice and mesh is in the statistical noise.

The problem is that it’s much more difficult to find a top tissue repair surgeon than a top mesh surgeon. On the other hand, when mesh goes bad, it can go REALLY bad (requiring complex removal), while with tissue repair bad outcomes don’t quite reach that level.

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

[Watchful]

Why not steel sutures?

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It is both motor and sensory. The motor part is for the cremaster and dartos muscles. The sensory part is for some areas of the skin of the scrotum. It shouldn’t affect sexual function. Also, scrotal sensation supposedly comes back eventually.

[Watchful]

That’s my understanding too regarding your own tissue growing and paticipating in holding the load. This is not specific to Prolene stitches, though – the same happens with steel, and also with a mesh.