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This study (among others) is one of the things that convinced me to go there.

One thing that bothered me with this study is that it didn’t look like they compensated for BMI (weight) in any way. The Shouldice Hospital treats only people of normal weight, and rejects those who are overweight or obese, while other providers treat them all. It is known that weight contributes to recurrence.

Regardless, these recurrence results for the Shouldice Hospital as shown in this study were definitely very impressive. As you mentioned, things have changed since then, so it’s possible that the results would be different now. The surgeons are mostly different. Also, they’ve been tweaking the original procedure, and stopped adhering religiously to some of the original details, which is something that surprised me when I was there. It’s not clear what the effects might be. Things have probably changed with other providers, possibly leading to better results than what they had back then.

The weakness in the studies of the Shouldice Hospital has always been the lack of the study of chronic pain. Their record on recurrence was really good, but what about chronic pain? Based on reviews, that seems more problematic. Virtually no one complains about recurrence, but quite a few complain about chronic pain. Like I mentioned before, they are currently studying it, but they’re doing it wrong from a logistical perspective in my opinion.

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Apropos your comment about open mesh on another thread (27 good cases you know, etc.) I happened to have coffee with an old colleague and friend of mine yesterday, and I mentioned my hernia surgery. He then told me that he had an open mesh surgery 20 years ago for an inguinal hernia, and he still gets occasional pain. He said it’s rare, but he still gets it from time to time.

He never told me about this pain before, even though I’ve known him for almost 20 years now. He did tell me about the surgery at some point, but not the pain. People really don’t like talking about these issues, and it may only come out in a conversation where you share your own experience, or probe a bit more.

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Chuck,

Studies of Shouldice surgeries performed outside the Shouldice Hospital in the old days showed significantly higher recurrence rates than at the Shouldice Hospital, and this includes German studies. However, those studies didn’t focus necessarily on the top surgeons.

I don’t know of any current data on recurrence rates at the Shouldice Hospital, and I don’t think you are correct in stating that they follow up. If you go there with a recurrence, they will know about it, but I don’t believe they actively follow up, and no one followed up with me so far. If I had a recurrence, they wouldn’t know about it unless I went back to their clinic complaining about it.

The situation with the Germans is similar. They don’t chase former patients and ask them about recurrence, chronic pain, etc. If a patient comes back with a complaint, they will register it in their database, but otherwise they wouldn’t know, and it wouldn’t be registered or counted in their statistics.

I did ask Conze this question about the validity of the statistics. He said that patients typically lose trust in the surgeon if they get a bad result (recurrence, chronic pain), and at that point they often don’t bother going back to the original surgeon. He was talking about the situation in Germany specifically. He said this means that he doesn’t really have the most accurate picture of his results. His results are very good based on the data he has, but that may be an incomplete picture.

Having said all that, I can tell you my subjective assessment which may be wrong or delusional, and it’s not something I can substantiate. I don’t think recurrence is a big concern even these days if you go to one of the highly experienced surgeons at the Shouldice Hospital. I don’t think it’s a big concern with the top German surgeons that we’re talking about either, but I’m a bit less confident about that. With chronic pain, my impression is flipped. A bit more likely at the Shouldice Hospital than with the German surgeons. Again, all this is just my hunch after all my research, discussions with surgeons and patients, and reading reviews, nothing very solid.

Something to bear in mind in this context, is that the Germans are a lot more selective in the cases where they perform tissue repair. Not as picky as the Shouldice Hospital on the weight front, but more selective in other areas such as hernia size, anatomy, and tissue quality. This means that the statistics on the results would be hard to compare even if we had them.

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It’s a “mechanical” problem which tends to get worse with time due to physics and tissue degradation. I don’t think the mind has anything to do with the actual problem or its progression, just maybe in perceptions. Keeping your weight low and avoiding strain are likely to help. A truss helps in some cases, but didn’t in my case, and it’s a pain to use.

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Indeed, Voeller going to Shouldice was shocking.

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Thanks for the kind words, David M. I was thorough in talking to a variety of surgeons, but I didn’t have an accurate picture of my hernia because of a grossly inaccurate ultrasound. If I had known how bad it was, I wouldn’t have pursued tissue repair. I was aware enough to avoid tissue repair on a hernia of this magnitude. No one knew, though. The only way for me to find out would have been to go to an expert in hernia imaging, and I don’t know of any in the US. Maybe Dr. Towfigh could have arranged that, but she didn’t want to pursue tissue repair in my case, so there was no opportunity for that. For mesh, it didn’t really matter.

ajm222, William – I have chronic pain and discomfort. It’s not severe, and it’s not debilitating, but it’s definitely annoying and disturbing occasionally. I’ll write more around my 6-month anniversary. There has been an improvement, but it has been extremely slow and gradual. I do expect things to improve further with time, but I’m not sure by how much.

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Chuck,

I had a phone consultation before going to the Shouldice Hospital. It was with a different surgeon – not the one who did my surgery. There was another consultation the day before surgery (in person with my surgeon).

You can submit a questionnaire on their web site. If you get approved, you can ask for a phone consultation. I doubt that they will approve you because you don’t have a bulge. Their philosophy is that if you don’t have a bulge, then you either don’t have a hernia, or you have a hernia that isn’t bad-enough to justify surgery. Unless things changed there in this regard (I don’t think so), the Shouldice Hospital is irrelevant to your current situation.

Conze didn’t examine me in person. He does a thorough exam including an ultrasound before surgery. I doubt he would have done Shouldice in my case, but I don’t know for sure. My hernia was way bigger than the German guidelines for Shouldice, but I didn’t know that at the time because my ultrasound was grossly inaccurate. Your situation is different, though.

I wonder about the same thing you’re wondering about with Kang. I don’t have the answer.

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Conze started focusing solely on hernias about a decade ago, but he had been doing hernias among other surgeries long before that since the beginning of his career. His training was with Schumpelick who was a godfather of hernia in Germany.

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They are both very good, and both would be good choices, but I would prefer Conze. Wiese is higher volume, but Conze is very experienced as well. Since Conze is more expensive and lower volume, he can be more careful and spend more time on each case.

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She mentioned on a number of occasions that she prefers Marcy (instead of mesh) on small indirect hernias in skinny women.

I actually consulted with her in person. She was willing to do mesh (either Lichtenstein or lap), but not tissue repair (Shouldice) in my case. I think it was a reasonable call, and most likely the right call in hindsight since Shouldice turned out to be a difficult surgery in my case. She didn’t predict that it would be difficult, but she thought that the risk of recurrence would be too high. Maybe I should say that she reached the right conclusion, just possibly for the wrong reason. We’ll see – hopefully there will be no recurrence. She thought that mesh would not cause trouble in my case, so she saw no reason to go with tissue repair with its higher risk of recurrence.

I had a really good impression of her – she’s thorough, spends enough time (an hour), and writes proper notes (unlike all the other surgeons that I saw). Clearly, very experienced and careful. If I hadn’t been fixated on tissue repair, I would have most likely gone with her for the surgery.

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My hernia actually got significantly worse when I started doing core exercises. I can’t tell for sure if it was correlated or just a coincidence, but I think it was related. That worsening actually pushed me toward surgery. I could live with my hernia before that worsening, but not after. I would recommend being very careful with core exercises with a hernia based on my experience.

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Thanks, William – I think there will indeed be further improvement. That’s the reason I don’t like writing updates on the pain and discomfort which are too frequent. Once it gets to the “chronic” stage, you need to give it a lot of time to assess how things evolve.

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Avoiding general anesthesia was one of the reasons I preferred to avoid lap and robotic mesh.

Lichtenstein is typically done under local anesthesia with sedation, so that would have been the same as Shouldice. From that perspective, Lichtenstein would have actually been a bit better because it’s a shorter surgery, so less time under sedation.

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Pinto,

Yes, it’s possible to measure the size of the defect as well as the hernia sac with an ultrasound. You can even get an indication of the tissue quality. Neither the technician nor the radiologist in my case had any specialization in hernia, and it didn’t seem like they knew what they were doing. The technician kept going back and forth to the radiologist in the back room to ask questions, they did only a lying-down ultrasound, etc.

The bottom line is that the measurements were very inaccurate. My actual defect size was more than twice what was specified on the ultrasound, and my actual hernia sac was about 40% larger. The defect size as measured on the ultrasound was still within the German guidelines for Shouldice, but the defect in reality was double the max in the guidelines. My internal ring was like a hula hoop 😉

Conze told me that he can get all the information he needs from the ultrasound he performs to make a decision about the procedure, and surprises during surgery are very rare. It’s a special competency that you don’t get from a generic technician and radiologist. He said they are not trained to do that.

At the Shouldice Hospital, they perform the Shouldice procedure even on very large hernias. I don’t think anyone else does that currently (not 100% sure). Who knows what it entails to do this procedure on such hernias, but based on my experience it’s a long and difficult surgery with a difficult recovery. Mine was large, but not one of those “giant” hernias with a loss of domain or anything like that. My surgeon told me that they do see hernias of this size on a weekly basis, so mine wasn’t all that rare.

Unfortunately, in addition to the large size, my anatomy was also very deep, which evidently makes this surgery even more difficult. Not sure if that’s something that can be seen in an ultrasound or other imaging. I didn’t know that this is a factor before my surgery, and I never saw it mentioned in any papers, so I didn’t know to ask any surgeons about this. If I remember correctly, Mike M mentioned that he had a deep anatomy, which made his surgery with Kang more challenging.

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You would have to ask her, but here’s my impression for what it’s worth.

She has a lot of experience with mesh problems and revisional surgery. This enabled her to develop a profile of people who are more likely or less likely to develop problems from mesh. Things like sex, age, body type. Similarly, she has experience with tissue repair, and tissue repair going wrong. Based on her experience, her assessment in my case was that I should be more worried about the risk of recurrence with tissue repair than the risk of trouble from mesh.

The size of my hernia played a part among other factors in her rejection of tissue repair in my case. I wasn’t 100% sure about one thing, though. It wasn’t clear to me how much her concern about Shouldice in my case had to do with what she thought the results might be in her hands specifically. She did say that some other surgeons would do it, but she wouldn’t, and it wasn’t clear to me how to interpret that. Did she mean that others might be able to do it better, or did she mean that others might be less conscientious or less concerned about recurrence? This wasn’t clear.

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I agree, but there isn’t much point really because mesh took over the world. There’s little to no tissue repair offered for adults in most countries. Some in Canada as long as the Shouldice Hospital survives, a few old-timer surgeons in Germany, very little in the US, Kang in S. Korea.

In a decade or two, the transition to a lost art will likely complete.

Meanwhile, I think the Germans (Conze, Lorenz, Wiese, Koch) have the best handle on assessing patients and tailoring an open surgery for them based on tissue repair or mesh. This is the reason I’ve been recommending that path here for a long time.

I picked a different path (Shouldice Hospital), which turned out to be a mistake for my particular case, but I think it’s very reasonable for those with a run-of-the-mill hernia and anatomy. It’s not always clear if that’s the situation, though, so the Germans are a safer bet because they attempt to diagnose and tailor.

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Indeed, all cases aren’t equal. Weight can be a factor, and so can the size of the hernia, the tissue quality, and the particular anatomy of the individual. Certain tissue repairs (like Shouldice or Desarda) may not be a good fit for some individuals.

The problem is that if you go to Shouldice (and you aren’t overweight), you will get that repair regardless of the difficulty of the surgery in your case (as long as your tissues aren’t disintegrating). A difficult and long surgery is more likely to cause chronic pain and other complications.

If you go to Tomas, you will get Desarda. If you go to a mesh surgeon, you’ll get mesh. There are extremely few surgeons who can tailor the repair, and most of them don’t have a lot of tissue repair volume. I think a few German surgeons are the exception, but even they have their limitations. For example, the ones with a lot of tissue repair experience don’t do lap or robotic mesh, just open mesh.

Things are further complicated by the fact that the surgeon may not be able to tell in advance what the best approach would be in your particular case, and this may become evident only after they cut you open.

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I don’t think he knows, or anyone knows – there is no definitive answer to the chronic pain risk question. The point is that it is a significant problem even with tissue repair (namely Shouldice in this case). It is telling that he thinks the risk is lower with lap mesh regardless of whether that’s really established or not. It was clear from his reaction to my questions about this that chronic pain was an issue that was weighing on him, and he was sad to see such cases appear weekly, with some of them being debilitating.

I’m sure that by “new” he meant patients who didn’t already report chronic pain before. I don’t know how they define chronic. It’s probably 3 or more months post surgery. He told me that most of those cases improve significantly by one year, so that was one positive observation.

As I mentioned in another response (to MarkT), they are currently trying to quantify the chronic pain issue, but I don’t think they’re doing it well.

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GI,

I didn’t say anything about equivalence. Actually, I said that tissue repair appears to be a better approach (for primary repair) all things considered IF you are a good candidate and you can get the right surgeon.

Dr. Brown used to make claims about no chronic pain with tissue repair, and this is clearly wrong. We have such cases on this forum, and all the tissue repair surgeons that I asked (other than Dr. Brown) said that they do indeed have chronic pain cases. At Shouldice, I was told they see new chronic pain cases among their patients on a weekly basis. Dr. Lorenz said up to 3% of his tissue repair patients get chronic pain. Dr. Conze said he had a few such cases, but they were rare. Dr. Yunis said he had a few such cases among his Shouldice patients (I think he had done a bit over 100 by then). I didn’t ask Dr. Sbayi and Dr. Wiese about this, so I don’t know what their experience was.

I felt “holier than the pope” at Shouldice, because it seemed like I believed in the merits of this procedure more than my surgeon. In my consultation before the surgery, he said Shouldice is one of the two best procedures for my case, and maybe the best, so not the strongest endorsement. That’s also when he mentioned (in response to my question) that they were seeing new chronic pain cases among their patients on a weekly basis, and that lap mesh has the lowest rates of chronic pain, but it’s still a problem even with that.

When I came back for a follow-up, I had a long discussion with him. That’s when I asked about whether Lichtenstein would have been difficult too in my case, and he said no. Also, that’s when he said lap mesh would most likely be the best option in case of recurrence (as in the paper you posted), which shocked me a bit. I described the mesh options that I had explored, and mentioned that I felt that tissue repair would be better, and it’s worth going all the way there because they know how to do Shouldice right. He looked at me funny, and said that other modalities would have been ok. I felt like a bit of a sucker quite frankly because I got the strong impression from all of this that they currently view tissue repair (specifically Shouldice) as a very good, but not really superior option overall. Just one good option among a number of good options. Like I said, I was holier than the pope on tissue repair.

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Thanks, MarkT. The lack of study of chronic pain and discomfort has always been a weakness there. Recurrence and other complications have been the focus.

As I mentioned before, they are currently doing a study of pain. I think they’re doing it wrong, though. In order to participate, the patient has to fill out many pages of forms. I started doing it, but gave up, and others I asked didn’t bother at all. They really should have a way that’s less onerous for the patients. Also, they should follow up with patients regardless of whether they bothered to fill out all those forms before and during admission.