MarkT

More on your concerns…and follow-up improvements!

“Likely, the most important limitation of this study is the incom- plete story of postoperative long-term complications. The main marker of success in hernia operations is classically low recurrences rates, even though low rates of chronic pain and higher-quality life outcomes are recently…[Read more]

Yes, there is a bit more info on that.

“Reoperations after Shouldice repair and open mesh repair presented markers for higher surgical difficulty (longer operative time, higher identification of heavy scarring, less nerve identification, and higher frequency of intra-operative consultation) when compared with other techniques (Table 3).…[Read more]

The article terminology is not imprecise…they distinguished between primary repairs of Shouldice, open tissue, and open mesh.

Shouldice very rarely uses mesh for primary inguinal hernia repairs (less than 0.1% of all cases, and almost never for primary indirect). When they do use mesh it is almost always for recurrent hernias, incisional…[Read more]

That makes sense – while they noted no difference in short-term outcomes between low- and high-complexity recurrence repairs, they suggest that may be at least in part to their allocating the more complex cases to senior surgeons, the in-op consult option for juniors, etc…however, that skill/experience is not available everywhere, so if an…[Read more]

I couldn’t edit my prev post – if you are able to see a larger summary than just the typical abstract (as some journals offer that), then my apologies for referring to just the abstract.

I was already logged in so that I could access the full study, so I didn’t see whatever someone sees in front of the paywall.

@mark – glad to hear your tissue repair went well and has held up for 2.5 years and counting, with no ill effects. I had similar experiences, but a long time ago at Shouldice, and I too am glad that I did not proceed with a lap mesh repair from the general surgeon to whom my family doc initially referred me.

You might consider starting a new…[Read more]

Watchful, I agree – I am glad to see that not only are they using data and evidence-based decision making to potentially shift their ideology and approach, but that their own surgeons remain actively engaged in the research.

With so many surgeries performed at Shouldice Hospital, there is a wealth of data and experience that should continue to…[Read more]

@pinto – I’m not sure what is being conflated in the study?

How are tissue and mesh being lumped together under ‘open’ if the categories they used in this study to classify primary repairs included ‘Shouldice’, ‘open mesh’, and ‘open tissue’?

I’m well aware of what an abstract it…and what it is not. My advice stands: If an abstract suggests…[Read more]

Keep in mind an abstract provides only a *tiny* amount of *some* key information that is essentially meant to allow a reader to determine if an article is likely to be relevant for their interests/purposes (i.e., if they should read the whole study).

It is quite inappropriate to make assumptions about (never mind critique), a study from the…[Read more]

Shouldice has been around for 70 years…try again.

There is no way to answer that question from this study, unfortunately…I would suspect there is tremendous variation between cases.

The 460 cases came from hernia specialists at St. Michael’s Hospital in Toronto, Shouldice Hospital, and other clinics in the U.S., Canada, Germany, and Romania.

The reasons for removal among the 460 total…[Read more]

“Studies were done that did not produce expected results. So weaknesses were found in the studies. It is a common problem, cognitive bias. Starting with a hope or goal disguised as a hypothesis.”

While this no doubt occurs, I think it is very important to understand the methodological components and contexts of the studies being discussed before…[Read more]

The study claims that there were no complaints of reduced sensation in the scrotum or inner thigh as a result of dividing the nerve, which they did in all cases where it was normally located.

Again, given that this seems to have relied on patient complaints rather than confirmed via comprehensive long-term follow-up, it is tough to say whether…[Read more]

He defined it as post-op pain that persists after three months.

Because it is a retrospective study, it is looking back on data that had already been collected (vs. a prospective study that purposefully collects specific data to evaluate certain outcomes).

It *could* be a subtle difference, if they employed a proactive follow-up protocol with…[Read more]

Slight clarification to above…it covers 953 hernias in 874 patients.

Statistically significant predictors of inguinodynia were younger age (54 vs. 61yr old), smoker at time of operation, history of prior contralateral repair, and postoperative complication.

Cumulative post-op problems were 11.9% (urinary retention, post-op pain that is not…[Read more]

For what it’s worth, the first link covers 953 of his repairs between 2005 and 2015…patients were 99% male, same avg age and confidence interval.

I pulled that article too…he used general anaesthesia in vast majority…99% were open, with lap reserved for bilateral, recurrence, or both. Worth noting their reporting system captures a pile of…[Read more]

He does not define inguinodynia in his letter.

He is does not disclose what % of his repairs were mesh or tissue, though my suspicion would be that the majority of them are mesh, given that he cites an avg patient age of 60.4 ± 1.4 years.

To expand on that, he says that he does Shouldice on younger patients with an indirect hernia and also…[Read more]

It’s a letter to the editor from S. Huerta, Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern Medical Center

– Best estimate of incidence of inguinodynia is 10%, but widely ranges between institutions (0-64%).
– Has done 1805 open (tissue and mesh) inguinal repairs in his practice since 2005, which is in a…[Read more]

I would still strongly consider dynamic MRI done in the U.S.

Dr. Kang says MRI is not necessary for his purpose…but remember that his purpose is to diagnose inguinal hernias. What if you don’t have a hernia?

I believe that the advantage of MRI is not only it’s demonstrated benefit in diagnosing hidden/occult hernias, but also the information…[Read more]

It is absolutely possible to have an hernia without a bulge. A hernia may also not be palpable upon physical examination. These are typically called occult or ‘hidden’ hernias.

There has been discussion about them here, and Dr. Towfigh and her colleagues have published papers about them with regard to…[Read more]