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MarkT,
Thanks for the information from the paper.
This is consistent with what I was told there when I asked what to do if my hernia recurs. As I mentioned before, I was told that lap mesh would most likely be the best choice if this happens.
This is a fairly big change for them. There are other changes as I mentioned before (suture material, cremaster/nerve resection).
It’s good that they are now open to move away from their prior orthodoxy based on evidence, but it makes you wonder what other surprises are coming now that they are re-examining things. For example, I wonder if they’ll start being more reluctant to recommend Shouldice for larger hernias. That is, move closer to the German guidelines.
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Good luck, Oceanic. You made a good choice. Please report how things go.
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Dr. Conze does a lot of Shouldice as well as Lichtenstein. He also does some revisional surgery.
I believe Dr. Kang does only tissue repair now, although he used to do mesh. He has his own techniques. I think you are largely correct in your observation. One comment is that Dr. Conze makes a smaller incision than the Shouldice Hospital.
It’s really a tough decision between the options you mentioned. My personal preference would be Conze because of his large number of good reviews, and the track record of Shouldice. Also, for those with a large hernia or bad tissue quality, Conze would be a better choice because he will not force a tissue repair on cases where it’s not a good fit.
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If your friends had hernia surgery in the 70s or 80s, they were likely kids at the time. I believe inguinal hernias in kids are almost always indirect, and a simple Marcy typically works well on them. My parents should have treated my hernia at that age.
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That incision size is normal at the Shouldice Hospital. They are famous for low-recurrence tissue repair; not for being gentle on the patient…
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Pinto,
I think my surgeon was honest when saying Shouldice would be good for my case before the surgery. I didn’t get the impression he favors mesh at all, just that he doesn’t favor Shouldice either. He viewed both as good options in general, and in my particular case as well. I expected surgeons there to be biased toward Shouldice (viewing it as a superior approach), but he wasn’t, so that surprised me a bit.
The fallback in case of bad tissue quality is mesh. At Shouldice, they reinforce with posterior mesh in these rare cases. Some of the Germans do the same thing, and some do Lichtenstein in such cases. At Shouldice, they apply Shouldice even in some cases where the Germans would use mesh. Tissue quality isn’t the only criterion used by the Germans. They look at hernia size and anatomy as well when making the decision.
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William,
I don’t know where Lorenz had his Shouldice.
You can find reviews for German doctors on jameda.de
Some of them also have reviews on Google under their name or their clinic’s name.
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Pinto,
Yes, we discussed mesh before surgery. After the exam, I asked my surgeon if Shouldice would be a good technique for my particular case. He said yes, it would be a good and maybe one of the top two ways to fix it. I then asked about mesh, and he said they do it only if the tissue quality is very bad. I then asked about the details of the mesh procedure, and he said they were doing posterior mesh (similar to Kugel, I guess), not Lichtenstein. He mentioned something about a Shouldice still being part of it, and the posterior mesh is used as reinforcement.
My tissue quality was adequate, so he didn’t use the mesh reinforcement. It was a long and difficult surgery, but he claimed he was still able to repair the hernia well. So far, I don’t have a recurrence, so that seems correct as things stand now. However, this was achieved at the price of extensive work that caused persistent issues (I hope these still improve.) I did ask after surgery if Lichtenstein would have also been difficult, and he said no. As I mentioned, this is not the mesh procedure they do anyway.
Their philosophy there as far as I can tell is to do whatever it takes to repair inguinal hernias with Shouldice, possibly with posterior mesh reinforcement in rare cases where there’s no choice. The goal is to repair in a way that avoids recurrence, and do it with Shouldice. Minimizing the invasiveness and scope of the repair, and reducing the length and complexity of the procedure aren’t goals there.
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GI,
There was nothing wrong with my diagnosis – a very large, life-long hernia. It was correct and known from the beginning, even if the exact measurements and anatomy weren’t known until I was opened up. The only wrong thing was the type of repair. Mesh (either open or lap) should have been used rather than Shouldice.
You are correct that the problem here was that I went to a place that doesn’t tailor the type of repair, and forces Shouldice even in cases where the surgery would be difficult and with questionable outcomes. Mine didn’t even remotely qualify for Shouldice based on the European guidelines as followed by the German surgeons, so I’m pretty sure they would have used mesh.
Chuck,
You are confusing risk with certainty. They do regularly get chronic pain outcomes at Shouldice, but those are still the exception, not the rule (at least by whatever definition they use for chronic pain, which may not include very minor pain and discomfort).
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Pinto,
There was no mention initially that the statistic was just for the latest (post-Pinto) among his 50 (!) versions of the indirect procedure. This came out when I asked how come you weren’t counted. Once my Korean colleague studied the Korean on-line reviews and found the reports of recurrence, I moved on. I was particularly affected by the one reported by my colleague where a patient with a recurrence said that he encountered two other patients with a recurrence at the hospital on his surgery day. All this doesn’t prove that his recurrence rate is or was too high, but it was enough to raise doubt in me, particularly since recurrence is indeed the big concern with a Marcy-type repair in adults.
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GI,
Even my surgeon at Shouldice told me that the technique that’s least likely to cause chronic pain is lap mesh. He said even that procedure can cause it unfortunately, but the incidence is lower than with Shouldice and open mesh. He was pretty direct about the chronic pain issue saying that they encounter new bad cases on a weekly basis among their patients, and it’s sometimes debilitating. He told me all that before the surgery in response to my questions on this topic.
I decided to go ahead with it anyway since this wasn’t a surprise to me. The thing that got me was that I had a pretty huge hernia. There was no mention of that as being a problem before the surgery even though the surgeon examined me, and I asked him if this would be a good procedure for my case. After the surgery, it was mentioned as a reason for the difficult and long surgery. Also, he told me he still managed to fix the hernia well in spite of its large size. I then asked him if mesh would have been difficult as well, and he said no. I have no recurrence so far, so that’s good, but the surgery caused way too much trauma to the area, and persisting issues.
It goes even further than that… I chatted with him quite a bit after surgery about the tissue repair vs mesh choice that I made, coming there for it, etc. There was zero indication that he thought this was a better approach than others, which surprised me. He viewed it as one of the modalities that could be used, and that’s pretty much as far as it went – no particular enthusiasm for it vs others. This wasn’t even just in the context of my case, but part of a general discussion.
When I asked what to do if there was a recurrence, he said that this was unlikely to happen, but lap mesh would likely be the best choice.
I really think they should follow some guidelines on hernia size and maybe other anatomical aspects, just like they do with the weight. They obsess a lot about the weight, and not at all about the hernia size. The Germans do factor the hernia size into their decision, with a hernia defect size limit. The Germans also do a careful ultrasound as part of the process of figuring out the best treatment for the particular anatomy. They can also make the decision that mesh is more appropriate during surgery, which Shouldice does only in extreme cases. You probably don’t want Shouldice to do mesh on you actually because they don’t get much experience with it…
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Chuck,
Not sure if you’re aware that Kugel is actually more invasive than Lichtenstein. That doesn’t mean that it’s not better, but it’s not obvious. I haven’t encountered much data about it, but I didn’t really focus on it.
You’re engaging in selective belief/disbelief based on your particular results with your lap mesh procedure.
In the case of Kang, I don’t recall that he even provided any chronic pain and discomfort results. He provided some of his recurrence stats (without counting Pinto which raised the question of who else he may not have counted) – that’s all I remember.
As I mentioned before, I think the lap mesh procedure is scary, and I don’t like general anesthesia, so I’m not a fan of it personally, but these are personal biases. I think that objectively and generally speaking, it has been shown to be the least bad approach all things considered. That doesn’t mean that it’s best for every type of case, or that you won’t get bad results in some cases.
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Hen egg size is nothing. My indirect hernia was somewhere between zucchini and eggplant size. Not a brilliant idea to do tissue repair for that in my experience.
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Chuck,
I’m not sure what is meant by “tightness”. I do get some dull pain and a feeling of pressure in some situations. I guess this feeling of pressure could be called tightness, but it feels more like it’s caused by the injury to the area and scar tissue from all the dissection rather than tightness of the repair.
I’m not sure what to make of the Mike M one year post-Kang update because he mentions a difficult surgery, initial severe pain and discomfort for 48 hours, and then improvement over time. It sounded like he didn’t suffer from severe symptoms after the first 48 hours, but it’s not clear how long he continued to have at least some symptoms of pain and discomfort.
I don’t know what tissue repairs your friends had. My dad also had a no-name tissue repair of an inguinal hernia, and it recurred eventually. He said his scar was small, and his recovery was very fast. As we know, Dr. Felix also recurred after his unknown tissue repairs. Even the Shouldice procedure had pretty high recurrence rates in most places outside the Shouldice Hospital back in the day.
I agree with ajm22 – you are looking for some ideal solution which doesn’t exist in reality. Pick a very experienced surgeon with excellent results as far as you can ascertain, but realize that it’s still a crapshoot.
Yes, Conze would still be my first choice for open repair. I don’t think Shouldice is a problematic procedure if done right, and on the right patients, but these are pretty big “ifs”. Conze seems to do it right, and he tries to avoid doing it on cases where it’s not a good fit (unlike the practice at the Shouldice Hospital). In those cases, he uses open mesh, and he is really good and very experienced at that as well based on my research.
However, if I knew mesh was the way to go in my case, I would seriously consider lap mesh instead of open. You and a couple others here had a bad experience with it, but it seems to have better results overall based on studies.
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Lichtenstein isn’t so great. Remember the hard bacon pictures of removed open mesh with adhered nerves posted by Dr. Brown? He was doing many of these removals, and said that this was the procedure that caused him to lose the most sleep.
As I mentioned a couple of times before, one of the general surgeons with whom I consulted needed a nurectomy after a Lichtenstein procedure he had for his own hernia. Now he normally cuts the ilioinguinal nerve in his patients (just like VA surgeon from the Hernia journal letter).
With inguinal hernia surgery, all you can do is pick your poison, and who will give it to you. It does turn out ok in most cases regardless of the choice of technique, but at least some level of chronic issues is too common for comfort.
Lap mesh does seem scary, but surprisingly it actually has the best results overall in most studies that I’ve seen – faster recovery, lower rates of chronic pain, and similar recurrence rates. The risk of causing nerve issues is higher with open mesh and tissue repairs than lap mesh.
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Hi Pinto,
GI and I are on the same page, so nothing really to debate. I also think that mesh is over-used, and there are cases where tissue repair is an excellent solution, and avoids the added risks of mesh.
There are cases where mesh is the best option. I don’t think GI disagrees with that. It looks like mine was one of those. Unfortunately, I wasn’t aware of that when I was planning the surgery. Actually, I should say that Shouldice wasn’t a good way to treat mine. Maybe Desarda would have been ok – I don’t know. I doubt the Kang method would have been good for a very large indirect hernia with deep anatomy like mine, but he says he does large hernias, so maybe I’m wrong – I don’t know what he does for someone who has an indirect hernia with a very large defect.
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Tissue repair does appear to be the better approach all things considered for a primary repair, but there are all kinds of caveats. You need to be a good candidate for this repair, and there are a bunch of factors that play a part in that. In some cases, mesh is the better solution. Also, there are very few surgeons to choose from for tissue repair.
The difference in recurrence rates between tissue repair and mesh is higher than 1% based on the studies that I’ve seen. Shouldice performed at the Shouldice Hospital is really the only tissue repair study that I’ve seen with a very large number of patients where the recurrence rates were similar between tissue repair and mesh. Many surgeons don’t really believe those numbers, saying that no other center has been able to reproduce these results in their practice, but the results were verified by data from Canadian insurance, so I tend to trust them. These were pretty old numbers. I don’t know where things stand today.
Dr. Brown believed that tissue repair doesn’t cause chronic pain and discomfort, but that’s not the case. Chronic pain is a significant issue with tissue repair as well as with mesh. It’s hard to know the exact chronic pain numbers for different types of mesh procedures, and tissue repair procedures, but it is known that tissue repair has a significant incidence of chronic pain and discomfort. There are a number of people on this forum with that problem after tissue repair (including me), studies show this problem, and most tissue repair surgeons (including the Shouldice Hospital) admit that this is an issue.
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I really wonder about the “not higher rates of complications when compared with other techniques” statement at the end of the Results section of the abstract. They say the difficulty of the recurrent hernia surgery is higher with Shouldice, but not the complications rate.
Do they actually substantiate that in the paper in some way? Seems like a difficult thing to figure out.
Based on my experience, they don’t actively follow up with their patients. No one ever contacted me after my surgery. I guess maybe they contacted their recurrent hernia patients (mine was primary). Even if they got that information somehow, not sure how they figured out what the complications rate would be with other techniques for repairing recurrent hernias after Shouldice and open mesh repairs.
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One reason I mentioned the size of the hernia as a criterion is that this paper uses the length and difficulty of the surgery as a motivation for re-thinking the use of Shouldice to repair recurrent hernias (after Shouldice or open mesh). The choice is between a particularly difficult Shouldice repair, and a normal lap mesh repair.
The same logic would apply to large hernias, at least based on my experience, and based on the German guidelines. The Shouldice surgery on my large hernia was twice the normal duration, and it was difficult even for my highly experienced surgeon. As I mentioned before, when I asked him if Lichtenstein would have been difficult as well, he said no. Now, the difficulty of the surgery shouldn’t be the only criterion, of course, but if that’s enough to prompt a re-think, then it seems that a re-think of Shouldice for large hernias would be reasonable as well.
You mentioned Dr. Kang – how he can be confident with applying his tissue repairs in all these cases that other tissue repair experts are struggling with is a mystery to me, and one of the reasons I never felt comfortable with going there.
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This doesn’t sound so great. Having symptoms for months after surgery, and still feeling something there after a year (even if minor) isn’t great. Not bad, but not the most desired result. We need to remember that you didn’t even have a large hernia.