MarkT
Forum Replies Created
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Haven’t we already done this thread, Chuck?
Shouldice has been around for 75+ years…I had my first flawless ‘sushi roll’ repair with ‘guitar string’ there in the very early 90s.
Such characterizations are embarrassingly shallow and irresponsible, much like many of your other posts.
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Although I don’t agree with everything they have to say, one forum member went to Dr. Yunis for a Shouldice repair with positive result, per the thread below.
You absolutely want to go to a high-volume specialist (which he is)…I’m just not sure what volume of THAT repair he does, which could influence a decision. I would consult with him regardless if I were in your shoes and that close by.
https://herniatalk.com/forums/topic/13-questions-to-ask-before-inguinal-hernia-shouldice-repair/
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It would be nice to get more information on ‘tension’ because there seems to be a multivariate spectrum of how it manifests (short vs. long-term, unnoticeable vs. problematic, etc.).
At the low end, there is clearly normal, temporary, non-problematic tension associated with a tissue repair that is either unnoticeable or that resolves over the short-term. This would describe my case, as I had (and continue to have) absolutely *zero* noticeable ‘tension’ following unremarkable recoveries from either of my Shouldice repairs many years ago.
At the high end, it seems we can get to chronic, problematic tension, perhaps due to issues associated with a large hernia (as Dr. Towfigh stated above), maybe also due to poor/insufficient tissue quality regardless of hernia size? Perhaps even just a poorly performed repair? In addition to ensuring a tissue repair is suitable for a particular case, is this perhaps yet another reason to avoid getting a tissue repair (especially a more complex one like Shouldice) from a non-expert surgeon?
Shouldice Hospital generally describes tension is normal and that it resolves, so I wonder at what point tension is too high, tissue quality is so poor or strained, etc. that such adaptation is simply not possible?
From Shouldice Hospital’s website:
“…The reality is that tension is not the enemy of hernia repair as it exists naturally throughout the abdominal wall. All hernia repairs by their nature involve realigning tension within the abdominal wall by repairing the tear or weakness in the muscle. The key is what happens to that tension over time.
Natural tissue techniques can put immediate, but minimal, tension on the muscles and surrounding tissues as they are drawn to repair the hernia, but this mild discomfort subsides quickly as the tissues stretch and compensate in the natural healing process through muscular adaptation so well described by physiologists and seen in weight lifters. Thereafter, only the strengthened natural tissue abdominal wall remains…”
https://www.shouldice.com/hernias-explained/ (click on sub-heading of ‘The Myth of ‘Tension’ in Hernia Repair’ – this is just an excerpt of what is written there).
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Dr. Kang, I wonder if you might have more nuanced data at some point?
Since you accept all patients regardless of their health status, hernia characteristics, etc., I wonder if your overall statistics are being ‘dragged down’ by outcomes from the very difficult/complex cases…i.e., could it be that the recurrence and chronic pain rates are significantly lower for the average ‘normal’ patient?
Perhaps it might be worthwhile to supplement the overall statistics with subgroup analysis to see whether outcomes differ among primary hernia repairs, recurrence repairs, and very unusual/complex cases…whether they differ for patients based on health status…etc.
Some research suggests that much longer follow-up periods are necessary to accurately estimate recurrence and chronic pain rates, so hopefully such data will follow in the coming years.
It is great that you are taking the time to collect this data, thank you!
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That last line is very unclear.
“While I am still below my aspirational 0.5% complication rate for inguinal hernia repairs, and thankfully I could operatively clean up my own mess, I could have done better.
If 0.5% is his ‘aspirational’ complication rate, then (by definition) he has not achieved that rate, so what does he mean that he is ‘below’ it? Or does he actually mean ‘below’ in a non-quantitative sense (i.e., that he has not yet reached that low rate)?
In any case, we would need to know what his follow-up protocol is to really judge his (or anyone’s) figures. It is wrong to assume he is ‘lying’…he may simply not have reliable data (or maybe he does and he really is *that* good…we just need more info to judge).
We already have good reason to believe that that most studies looking at long-term outcomes have inadequate follow-up periods (never mind patient attrition issues) to accurately estimate chronic pain and recurrence rates. One study posted here suggested that a significant proportion of such problems occur well beyond most study cut-off dates.
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Chuck, please stop repeating that Shouldice has very high rates of long-term complications. That is simply FALSE unless you are foolish enough to go to someone who doesn’t know how to do it properly because it is a more complex/nuanced repair.
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I would never base my choice of surgery upon something like ‘size of incision’. Unless someone’s line of work depended upon them looking as flawless as possible when naked, I fail to see why this would be a key consideration.
The incisions are low enough that you never see them with normal clothing, including most swimwear, and they fade greatly with time (mine are barely noticeable, though I suppose that will also depend upon your skin colour).
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Dr. Sbayi is now with Northwell Health at Glen Cove Hospital. There is contact info for him here:
https://www.northwell.edu/find-care/find-a-doctor/surgery/dr-samer-sbayi-md-11513991
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Surely something as relatively benign as suture material changes are not what you had in mind when you claimed that I “unwittingly equated Shouldice 50 yrs. ago with a recent operation, obviously benefitting by decades of medical advancements” – LOL
Prolene sutures were developed in the late 60’s…not a recent medical advancement…and Shouldice’s decision to use stainless, and in recent decades (and its been decades) is hardly based on that idea either as it has negligible (if any?) impact on the repair itself.
My understanding is that Shouldice has continued to use stainless for two reasons: cost (it’s cheaper – Dr. Towfigh said she was even told this by them when she visited) and to a lesser extent because it is essentially ‘inert’ in the body (whereas an extremely small % of people may react to synthetics).
Perhaps a surgeon could speak to this, but I also imagine that they have long since stopped being trained using stainless sutures in most applications and apparently synthetic is considerably easier to use. Some patients also specifically ask for synthetic for whatever reason. It seems natural that Shouldice would transition to having both at some point.
I have no reason to ‘disagree’ with anyone’s decision to use whichever one they want…both have proven to be highly effective. Some surgeons there switched over 20+ years ago. I believe today it comes down to surgeon and patient preference.
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Does it resolve if you sleep on your side and, if so, on either side or only one…or do you just always sleep on your back?
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“Was it Mike T who unwittingly equated Shouldice 50 yrs. ago with a recent operation, obviously benefitting by decades of medical advancements”
I don’t know if there is a Mike T here (?) or if that referred to me…but keep in mind that “decades of medical advancements” would not seem to apply much to Shouldice Hospital, if you understand their model. In the lap mesh space, it certainly would though!
I’ve also never brought up my experiences there (30yrs and ~20yrs ago) to ‘equate’ them with recent surgeries, but rather to speak to my experiences at the time, my outcomes (flawless in all respects, to the present day), and what someone might generally expect after a Shouldice repair in terms of a ‘standard’ recovery, to ease their concerns over the unknown.
I think you are quite right to highlight things like cultural differences, which may impact both surgeons and patients, particularly patients’ expectations and reports. Such differences are very important to keep in mind when surveying attitudes, behaviours, experiences, etc. across cultural groups.
Watchful, your experience with your surgeon before and after, and your outcomes thus far, makes me wonder about a few things relating to diagnostic and surgical expertise and practise, the pros/cons of specialists dedicated to one repair type vs. offering multiple options, and how healthcare models (e.g. billing practises) might factor into all of that….I’ll make a separate thread as I ponder it some more, as I think it could be an interesting discussion.
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I appreciate your post, Pinto.
They really do seemed to have maintained their regimen over the years. I didn’t find any of it problematic, to be honest. I don’t recall the wakeup being 5:30am, but it’s been a while…they did have scheduled ‘morning exercise (stretching), meal times, walking as much as possible, etc., but much of it was ‘strongly encouraged’ rather than ‘forced’.
I’m also not a 100% staunch defender of the way they have done (and continue to do) things. I don’t think it is ‘necessary’ to have the multi-day stay, for example, and I agree with concerns over not choosing your surgeon (though apparently requests can be accommodated). Overall, I do like their overall ‘specialist centre’ model in comparison to the ‘standard’ within the public healthcare system.
I believe I posted my thoughts on that surgeon’s blog post some time ago. Most importantly, I find that she fails to focus upon what is ultimately most important: the quality of the repair and the patient perspective. I think there is some problematic personal (and irrelevant) bias, undertones of bitterness/jealousy, and some ignorance. In one reply to a comment, she admits she had never heard of the Desarda repair, for example, and she fails to acknowledge that there is research that does suggest ‘repetition’ supports developing expertise.
I wouldn’t be ‘happy’ to go through it in detail again…but I would be willing to do so if anyone wants to discuss it, because I think this blog post is that problematic (despite raising some valid system-related points too).
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@jengiz1 – Dr. Jonathan Yunis is close, in Sarasota.
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@jamesm
Do yourself a favour and speak to people who rely on evidence, not anecdote…I’ll leave it at that. Consult with @drtowfigh and she can likely also refer you to someone closer if you prefer not to travel.
If you are a young, slim, healthy male with a small hernia, you are indeed likely an excellent candidate for a tissue repair.
I’m biased towards the Shouldice repair and had each side repaired at Shouldice Hospital in Toronto (30 and 20 years ago, respectively) with flawless outcomes both times. I think you will be hard-pressed to get a ‘better’ Shouldice repair elsewhere because their full-time surgeons average ~700 of them per year. Even new and part-time surgeons there will average far more of them than surgeons elsewhere who are not focused on that repair.
There are comparably skilled high-volume surgeons offering it in Europe, but you have some U.S.-based options too, including:
– Dr. Sbayi in NY (trained in the repair at Shouldice – https://www.northwell.edu/find-care/find-a-doctor/surgery/dr-samer-sbayi-md-11513991)
– Dr. Towfigh in CA (https://beverlyhillsherniacenter.com)
– Dr. Yunis in FL (https://www.centerforherniarepair.com/jonathan-yunis-md/).Regardless of who you choose and which repair, your best chance of an excellent outcome is with a specialist who performs a high number of THAT repair…especially with a more complex/nuanced repair like Shouldice, which is highly effective in the hands of an expert. I would not get a Shouldice repair from someone who only does a handful per year, by comparison. Good luck!
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From the wording, I think the multi-year data (from 2296 patients) only concerns recurrences, while the pain data (from 302 patients) is limited to patients at 1yr post-op?
Yes, I think they would justifiably be called chronic pain sufferers after 1yr. While the study defines chronic pain as “pain persisting for more than 3 months, affecting everyday activities”, I’ve seen timeframes of up to 6 months suggested elsewhere. The 1yr mark seems suitably liberal to avoid most cases of ‘slow healing’ or things like that?
I agree with Watchful that the concluding statement of ‘1.7% chronic pain’ is accurate by the study’s definition of chronic pain, but it seems problematic from a patient point of view (again, as Watchful highlights, this criticism has nothing to do with Dr. Kang…it has to do with the chronic pain definition).
When a patient thinks about chronic pain, I’m sure that means they would like to know the likelihood of experiencing *any* degree of long-term non-ignorable pain following a surgery. Of course it is highly relevant to distinguish between pain that would and would not interfere with daily activities, and treatment options may vary between them, but it seems inappropriate to simply exclude ‘non-interfering’ pain from the definition of chronic pain. It’s still pain and it’s still chronic.
I agree that we need longer-term data though. While it is plausible that some small % of patients’ pain may fade or resolve even beyond that 1yr mark, there is apparently a significant likelihood for new cases of pain to manifest beyond that time frame (and beyond the 3-4yr mark for recurrences), according to other research. It would therefore be likely that the chronic pain and recurrence rates are understated with these follow-up times, so hopefully more data will follow. Dr. Kang indeed deserves praise for collecting this data as it is extremely helpful.
Capturing this nuance in measuring chronic pain is important. We can imagine a situation where an overall pain rate is in line with what other studies are finding, but that the degree (severity) of that pain differs. E.g., if a surgeon or repair type was associated with the rate of enduring pain, but that pain was mostly of a much lower severity, then that would still be a very good accomplishment.
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Oh, just read Dr. Kang’s post…
It’s nice that a rather small % have problematic pain, but that more than 16% have ‘pain that not possible to ignore’ is indeed concerning and not all that different from what other studies are finding.
It will be interesting to see longer term data since his timeframes are inherently short.
In his potential defence, more nuanced data could be extremely helpful. He really should break that down by patient/hernia characteristics since he doesn’t turn anyone away. Maybe a certain subgroup of patients have disproportionately high pain rates that are dragging down his overall stats and misrepresenting what the average patient can expect…?
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I didn’t say chronic pain was anecdotal…I said people have skewed perceptions of reality, largely as a result of spending too much time on forums, FB groups, etc. with non-representative samples of problem cases.
A 15% complication rate is indeed too high for comfort…but that is not what patients of most high-volume specialists realize, it almost surely is lower for ‘normal’ cases (smaller hernias, no comborbities, etc.), and it still invalidates some of the ridiculous statements around here of ‘so much chronic pain with Shouldice’, that ‘almost everyone who gets a tissue repair has problems’, that there are ‘no good options out there’, that all mesh should be ‘banned’, etc.
There are people coming to this forum for legit information, not hysteria and lies.
What has Dr. Kang recently posted, btw? I have not seen it.
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Is there good evidence that a larger incision is associated with greater complication rates, particularly long-term?
Personally, I’d be FAR more concerned with the surgeon, repair quality, evidence regarding long-term outcomes, etc. vs. incision size.
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Someone else understands! I have been saying this for a while.
I think a number of people here have skewed perceptions of risk/complication prevalence because they spend so much time reading about problem cases online which represent a significant minority of cases, especially from high-volume hernia specialists.
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In our discussion I granted you that while pointing out that you unwittingly were equating “old” Shouldice with the “new” Kang—that I believe were your two surgeries, the former decades ago and the relatively recent one. Apparently you didn’t realize that your thread came off as comparing Kang with Shouldice—a new with the old.
Both of my surgeries were a long time ago…30 years on one side, 20 years on the other. I have no idea why anyone would interpret any of my experience posts as a comparison between Shouldice and Kang in terms of ‘old’ vs. ‘new’…?
I well recognized that you wanted to help people with your experiences—-again, I granted that. What you don’t recognize are nuances that are emitted—intentionally or not—in one’s communications. How you couched your thread and presented it appeared to have other purposes. Even if you didn’t intend it, readers could glean it so.
Please expand on this part…I’m typically very careful about the words I choose when I write, specifically to avoid any confusion or where ‘nuance’ can cloud my intentions. I suspect someone readers might be making assumptions here or reading beyond the words I wrote if such ‘nuance’ is being interpreted. I’d appreciate an example though.
Another point you make rather naively: “keep in mind that “decades of medical advancements” would not seem to apply much to Shouldice Hospital, if you understand their model.”
Right there you conceded Shouldice decades later is not absolutely the same as before (by saying “apply much”). Subtle enhancements can make a great deal of difference for surgery outcomes. Surely there were major personnel changes in the hospital decades hence. What you don’t recognize is the difference between model and application.
“Naively”? Again, I choose my words carefully…”much” is to grant that OF COURSE it would not be the case that EVERYTHING is EXACTLY the same as it was 70 years ago. They have used different sedation medications. They allow for different suture material. There have surely been some subtle changes, but these things are not inherently relevant to the repair itself such that my repairs many years ago are rendered incomparable to someone receiving a repair today.
Models are one thing; applications, another. That’s just about technique. Then there are materials! At least some Shouldice surgeons changed from steel thread suturing to polyester! You kindly credited me, in that earlier thread, for helping you recognize that the occasional twinge you feel is likely from the steel suturing. On principle alone there is no way you can discount decades of medical advancements. So incredibly shortsighted your argument. Thus it was necessary, as is now, to caution your apples-to-oranges writing—if not your thinking.
I think you are confusing me with someone else…? First, I do not feel the occasional twinge from either of my surgeries. I’ve said in many threads that I have no lingering effects from either of my hernias or repairs…ZERO. What I have said is that in the very short term (a few months) afterwards, I recalled getting the occasional twinge (which was a normal part of the healing process).
I think it is a HUGE assumption for anyone to claim that a post-op ‘twinges’ would be due to the stainless sutures. I don’t believe I have ever granted that was the case or even a possibility, but if you have a thread suggesting otherwise, please link it.
I’m still waiting for examples of “decades of medical advancements”. If you think some of the surgeons choosing to use Prolene over stainless steel amounts to that, then I’d say a better choice of words is in order…because that certainly does not have a relevant impact in comparing my surgeries years ago with someone going there today.