MarkT

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    • #32561
      MarkT
      Participant

      Just FYI, this is a different paper than what was discussed in the now-deleted Mr. Sea thread. This one is by Shouldice docs…the other one was by Lorenz and others (including two Shouldice docs):

      https://pubmed.ncbi.nlm.nih.gov/33502639/

      I summarized a lot of it in that deleted thread, so I’m disappointed to see that all gone…but in addition to describing a standardized Shouldice repair it too surveyed a group of docs, including Lorenz, Koch, and Conze, plus two Shouldice docs, and others from Canada and Europe.

      Amongst the 12 docs surveyed, the only item that didn’t result in a good consensus was when cremaster resection should be included…five said always, five said sometimes, and two said never.

      Some of the other questions:

      No one was married to ‘only wire’ sutures with nine saying ‘wire or non-resorbable’, while three believed long-term resorbable were ok. I’ve heard it said that continuing to use wire is essentially a financial decision…big spools of stainless steel wire are apparently cheaper than prolene. AFAIK, there has been no evidence that wire is ‘bad’ and ought not to be used though.

      Nine advocated for “always four continuous suture lines” (including some of the docs who routinely perform fewer), while two said “always three or more” and one said “always two or more”.

      In response to which tissues exactly, nine said “exact original protocol always”, three said “small modifications allowed” and zero said “modifications allowed”, which suggests the importance of fidelity to the orignal protocol, while recognizing that some cases may warrant minor deviation (perhaps that is linked with the many responses of ‘sometimes’ for cremaster resection, for example).

    • #32510
      MarkT
      Participant

      Actually, now that I read more, that 2012 sale fell through (and it was indeed just for the clinic). Interesting to note is that it would have been to the same U.S.-based company (Centric Health) that in a roundabout way acquired Don Mills Surgical Centre. Shouldice remains privately held, but I’m not sure who the actual ownership group is beyond “Shouldice Hospital Ltd.”, with E.B. Shouldice listed as the board chair.

      There are many options for hernia repair here, but not specialty clinics focusing only on hernias, unfortunately. The standard referral from family docs is to a general lap surgeon either at a clinic or public hospital, almost all of whom do mesh repairs.

      There is a very old case study from 1983 that was revised in 2003, that might be worth a read: (https://coloradohealth.org/sites/default/files/documents/2017-01/ShouldiceHospitalLimited.pdf)
      apparently in the past they contemplated expanding the facility or opening other facilities to meet demand, but AFAIK nothing came of any of that…and I know they used to have a consultation/follow-up clinic closer to downtown Toronto that closed many years ago.

      I agree that a lot of the demand for Shouldice might have less to do with tissue vs. mesh and more to do with it being a specialty centre…and after 70 yrs, there is volume simply from word of mouth and reputation (it was an extended family member in the healthcare system who suggested Shouldice to me).

      I don’t know what the numbers are today, but they do get a lot of patients from across Canada, the U.S., and even international. In one of my admission cohorts, there were at least two from the U.S., one from the U.K., and one from South America.

      • This reply was modified 1 week, 4 days ago by MarkT.
    • #32508
      MarkT
      Participant

      I believe Ontario had seven private hospitals grandfathered in, with three currently in operation. In addition to Shouldice, there is Don Mills Surgical Centre. I’m not sure what the third is, but AFAIK it is similarly a facility of limited scope.

      The Ontario gov’t is looking to expand the public-private partnerships with private facilities billing the public system for procedures and physician fees, similar to Shouldice.

      The talk is that by controlling funding, they could limit the extent to which talent is ‘poached’, prevent the private system doing ‘too many’ surgeries or operating entirely as it sees fit while still billing the public system, etc.. Whether that is truly the case remains a big question.

      In Quebec, there is already a big private healthcare system that includes family medicine, sports medicine, physio, orthopaedics, gyno, GI, imaging, and non-emergency surgical units (including hernia repair). A lot of that is fully private though, so you pay out of pocket or obtain private insurance, while some family physician services are still covered by the public system and those docs can still refer out to specialists in the public system.

      I wouldn’t necessarily worry about the construction impacting Shouldice operations. We build skyscrapers on tiny footprints in busy downtown cores without everything shuttering around them. While relocation is possible, and has been talked about since the initial sale back in 2012, I can’t imagine it would shut down. It has never been a big money maker. It was sold for ‘only’ 14 million in 2012, so ownership’s ROI expectations are presumably reflective of that?

    • #32486
      MarkT
      Participant

      I think it will be fine. The grounds are quite nice, but the reality is that very few people made use of them. In the nicer weather (and before covid), patients could go for walks out there on their own or with visitors, but they certainly don’t need acres and acres of land for that.

      What I would actually like to see is some updating of the hospital itself. It’s ‘quaint’, but could definitely use a refresh lol

    • #32476
      MarkT
      Participant

      The lands had already been sold to someone else a while back, with the hospital having a long-term lease (16yrs left acc. to the article). The hospital itself had been sold from the Shouldice family to a healthcare company back in 2012. Here is some earlier news on redevelopment:

      https://www.thestar.com/local-markham/news/council/2021/09/04/5-tower-development-of-shouldice-hospital-lands-in-thornhill-up-for-scrutiny.html

    • #32453
      MarkT
      Participant

      You’re asking for opinions that are going to be rather meaningless…

      How can anyone on this forum (including the surgeons) offer an educated opinion when they don’t know what your mesh and tissue looked like prior to removal, what the removal surgery entailed, what the current state of your tissue looks like, etc?

      Your questions should be directed to Dr. B, as he is the only person who can answer them as they pertain to your unique situation.

    • #32424
      MarkT
      Participant

      I echo the Shouldice Hospital recommendation (I’ve personally had left and right inguinal repairs done there, many years ago, with zero complications both times).

      They do their own open no-mesh repair that has been around for many decades, their experienced surgeons average ~50 repairs per month, and almost all of them are done under local anaesthetic (you would actually have to make a special request to get general anesthetic there). I’ve heard that for foreigners, it can be cheaper than many options in the U.S. too.

      edit: Just read your “I can’t go to Canada and even if I could I would not” response, so…never mind!

      • This reply was modified 2 weeks, 1 day ago by MarkT.
    • #32393
      MarkT
      Participant

      Maybe worth noting just to avoid any confusion…there are two recent consensus-themed papers on the Shouldice repair.

      This one (Mainprize et al., 2022) is by Shouldice docs, while the one we discussed in the now-deleted Mr. Sea thread (Lorenz et al., 2021) included a dozen docs, two of whom where from Shouldice.

      The Shouldice Method: an expert’s consensus
      https://pubmed.ncbi.nlm.nih.gov/35939246/

      Shouldice standard 2020: review of the current literature and results of an international consensus meeting
      https://pubmed.ncbi.nlm.nih.gov/33502639/

    • #32603
      MarkT
      Participant

      I see what you are saying, though we must not make assumptions that there is inherently a problem between provider vs. patient perspectives. There *could* be, but we can’t evaluate whether that is the case unless we know the probabilities associated with various outcomes and the nature of those outcomes.

      A drop in recurrence rate doesn’t just benefit the provider…it obviously benefits patients as well. No one wants to experience a recurrence. Not only is a patient again absorbing all the usual risks associated with hernia repair, but some of those risks may be elevated when repairing a recurrence.

      Where there could be a disconnect in provider vs. patient is if the drop in recurrence and missed hernias is accompanied by an elevated risk of other negative outcomes, and particularly if some of those are severe…but again, ‘it depends’.

      For example, let’s just say the risk of recurrence and missed hernias/weak spots associated with cremaster resection is a 2% reduction…but that is accompanied by a 0.5% increase in the risk of chronic pain. A provider may indeed see that tradeoff as ‘worth it’ in the overall numbers, while an individual patient may not. As you note, that also depends upon the initial risk too.

      It is tempting to conclude that a ‘50% reduction in risk’ of anything sounds *incredible*…but whether that has practical significance depends, in part, on whether the initial risk is high or low. A 50% reduction (or increase) when the initial risk is 10% may be quite significant, while a 50% reduction (or increase) when the initial risk is 0.1% seems less significant (but again, even that depends upon the nature of the outcome, as a 50% drop in risk from 0.1% down to 0.05% when the outcome is ‘death’ is suddenly not so insignificant!)

      In terms of catching hidden/secondary hernias and weak spots, let’s just grant the claim that ~13% of hernia patients present with one, which can be repaired at the same time. Questions I then have:

      1. What proportion of that 13% are caught *specifically* because of the way Shouldice repairs hernias, including cremaster resection?
      2. What proportion would still be caught by a modified Shouldice repair that left the cremaster alone?
      3. How would #2 change if reliable imaging is also included (remembering that imaging does yield some false positives and negatives)?
      3. What proportion of that 13% are likely to be missed with other repair options (with and without imaging)?

      In terms of resection, I would also want to know:

      4. What is the corresponding introduction or increase in risk for other negative outcomes (e.g. chronic pain) because of cremaster resection?
      5. How does that compare with risks associated with other repair options, with or without imaging? (i.e., is the elevated risk with Shouldice *still* higher/same/lower as other options?)

      It’s very complex to tease all of that out. To do so requires carefully designed studies, which are unfortunately difficult, expensive, and time consuming, particularly when there needs to be long-term follow up of large sample sizes.

    • #32597
      MarkT
      Participant

      @gohaiga (Watchful), I would like to see more research on the cremaster.

      The claim is improved visibility to detect secondary hernias and weak spots, which can be addressed at the same time as the main repair…and that the way the cremaster is resected, with the stump included in one of the suture lines, helps reduce the likelihood of recurrence. There seems to be some allusion to it being relevant to detection of sliding hernias too in the 2nd link below, but it is not clear (wasn’t that Pinto’s problem with their initial Kang repair, btw?)

      From the Shouldice site:

      “As part of the Shouldice procedure, we do a thorough search for other hernias, or weaknesses, in the area and repair them as well. This aspect of our technique is unique and not commonly practiced elsewhere, as most natural-tissue techniques (including Desarda), or virtually all open mesh techniques, do not go deep enough into the pre-peritoneal space to allow exploration of the whole area. Research has shown that up to 13% of people with hernias have a second weak spot in their muscles, or a “hidden” hernia. Our skilled surgeons have the expertise to find these hidden threats; in fact, it‘s one of the most important benefits of the Shouldice repair, by avoiding the need for a potential second surgery.”

      From Dr. Bendavid (https://basicmedicalkey.com/the-shouldice-method-of-inguinal-herniorrhaphy/):

      “Resection of the Cremaster
      This important step seems to have been entirely forgotten. Few students have seen it performed, and fewer surgeons practice it. This step was clearly described and emphasized by Bassini, repeated by Catterina, and perpetuated by Shouldice. The resection of the cremaster and lateral retraction of the cord bring into view the posterior inguinal wall in a manner that can best be described as a “revelation.” It becomes impossible, then, to overlook a direct or indirect inguinal hernia. The transversus abdominis aponeurosis (i.e., the posterior inguinal wall) is now in full view. Whenever possible, the cremasteric vessels should be doubly ligated separately from the cremasteric muscle.”

      “Search for Multiple Hernias
      Statistics show that a second, simultaneous, ipsilateral hernia was found, if adequately searched for, in 12.8% of the patients who underwent operation. This search in all instances must rule out an indirect hernia, a direct hernia, a femoral hernia, an interstitial hernia, a prevascular hernia, a Laugier hernia (through the lacunar ligament), a prevesicular hernia (anterior to the bladder), and, lastly, lipomas, which on occasion perforate through the internal oblique and transversus muscles at the deep inguinal ring. The search must be established as a routine.”

      https://basicmedicalkey.com/the-shouldice-method-of-inguinal-herniorrhaphy/

      Now whether that is enough to justify the accompanying risks associated with cremaster resection is another story and remains perhaps the hottest topic of debate with the traditional Shouldice repair.

      It would be expensive and time-consuming to carry out a well-designed study, with a large sample, a sufficiently long follow-up period, and controlling for all potentially relevant variables (notably, surgeon expertise) to compare the traditional protocol with a modified one where the only modification relates to the cremaster not being resected…but one can hope!

    • #32467
      MarkT
      Participant

      Yes, 100% normal…zero problems.

      The first one was 30yrs ago, the other side was done about 18yrs ago. I’ve never noticed anything while playing tennis, doing yoga, swimming, weight lifting, walking/running, etc.

      If I remember correctly, after the first one I would occasionally get a twinge of pain, but that was entirely gone in a relatively short period of time afterwards (a month? it’s been a long time, so I can’t be sure).

    • #32460
      MarkT
      Participant

      Chuck, chronic pain numbers may be underreported across the board, not just at Shouldice. Historically there has been inadequate long-term follow up, chronic pain definitions and measures have varied, and some patients may go elsewhere when they have a problem rather than returning to their original surgeon, further complicating getting accurate numbers.

      I’m not here to “pump Shouldice” and I’m not ignoring anything…but I do believe that when done by expert surgeons it is one of the best options out there, especially as a 1st option instead of mesh. Since I had two flawless repairs done there myself, so I can also offer some insight into the experience. I’m also going to respond when you post junk about it (or other repairs), because you don’t accurately communicate research results or put them into proper context.

      You need to remember that no one has a 0% chronic pain rate…and HUNDREDS OF THOUSANDS of repairs have been done at Shouldice over the years…so *of course* you will find people with chronic pain who went to Shouldice and *of course* you are going to find other surgeons who have treated Shouldice patients. You seem to think that means something bad, when statistically that is *expected*. =

      Dr. Belyansky, Dr. Towfigh, Dr. Kang, etc. will all have patients with problems too because they don’t have a 0% rate either (didn’t someone here experience a post-op complication after a Kang repair?). You won’t see nearly as many ‘bad reviews’ because they have not done HUNDREDS OF THOUSANDS of repairs at their clinics.

      There are still good choices for us here, but even the best choices are not risk-free and they likely all have underreported some post-op complications…and when *so* many hernia repairs are done each year in total, even ‘small’ recurrence and pain rates mean that there will still be a lot of people out there who experience problems.

    • #32430
      MarkT
      Participant

      Where in Canada, @virginiacreepers ?

      Shouldice Hospital is a private hernia-only hospital specializing in no-mesh repair, but the surgery is still fully covered by your provincial healthcare plan (even if you don’t reside in Ontario).

      Semi-private rooms are available for an additional fee…although those may be covered if you have supplementary insurance through an employer or private plan.

      See the FAQ here for details and you can always call them to confirm: https://www.shouldice.com/faqs/

      I would highly recommend you check them out, particularly if you prefer to avoid a mesh repair (which is very likely what you will be getting if you are going elsewhere in Canada).

    • #32398
      MarkT
      Participant

      I would like to see more study and discussion on Desarda too.

      I was quite disappointed to read this on the site of Drs. Tomas and Brick: (https://ufirstrejuvenation.com/no-mesh-hernia-and-surgery-center/no-mesh-hernia-surgery-inguinal-umbilical-hernia-surgery-desarda-technique/)

      “The Shouldice inguinal hernia repair method has been around for many years and has good results, however they use stainless steel wire. Having stainless steel wire is as bad as having mesh in your groin.”

      Really? I would love to see their evidence for that claim.

    • #32386
      MarkT
      Participant

      Watchful, cherry picking results and making broad claims like ‘lots of chronic pain with Shouldice’ is irresponsible…I don’t know how else to put it. If you want to defend that sort of behaviour on this site, that’s on you.

      Do you want me to start acting that way? Here we go…I hope you will defend my irresponsible behaviour the same way. Here’s my ridiculous context-free one-sentence statement: TEP recurrence rate is really high, over 25%.

      Now, should I be more responsible and include in my post the ONE study where that figure came from? Should I point out that the study has a very small sample size? That all of the data came from surgeries at one institution? That while the study is recent, the data is relatively old and even the authors note that things have changed since then? That’s not even getting into the finer methodological points….or do I get to just run around and say that TEP has over a 25% recurrence rate like how Chuck is characterizing chronic pain with Shouldice, and his various other ridiculous statements?

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