MarkT
Forum Replies Created
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Your #1 priority should be to find a hernia SPECIALIST…i.e., someone who has done, and continues to do, a large volume of repairs each year…not a general surgeon or urologist who only does a handful in comparison. This is true regardless of the type of repair you chose.
You are talking about your health…it is worth investing in. I would absolutely go to a ‘so-called hernia surgery centre’ before I went to a urologist or general surgeon…neither of those would even be a consideration for me, *especially* if they are refusing to provide quotes, lying about repair numbers, etc. Those types of behaviours are not indicative of ‘quality care’.
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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).
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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.
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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?
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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
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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:
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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!
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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/ -
Thanks for clarifying. 22 months if requiring GA is quite unfortunate…I guess they are basically saying ‘go somewhere else, if it is more urgent and you need GA’.
Five months for the usual repair with IV sedation and local is not *too* bad, all things considered (i.e., pandemic backlog) as it has historically been a few weeks to a few months anyway, depending on volumes…but it could be a consideration for those considering ‘watchful waiting’. It might be worth booking a date now, then rescheduling or cancelling later if you want to continue waiting for whatever reason (I still tend to not agree with watchful waiting, but I understand that everyone’s situations and priorities are different).
I really wish there were a dozen Shouldice Hospitals, perhaps with some practical changes (like eliminating the requirement of a multi-day stay and not being able to choose your surgeon). It is ridiculous that options are comparatively limited for those seeking tissue repairs by similarly expert-level, high-volume surgeons.
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SN, you are correct that Shouldice typically will only operate if the hernia is palpable upon physical exam (there does not need to be a visible bulge, but they have to be able to feel it).
Not sure if crossing the border is a big inconvenience, but Shouldice is having an examination clinic in Vancouver, BC in case that is of interest:
Shouldice Hospital is returning to Vancouver!
Hernia Examination Clinic September 26, 27, 28 & 29
For further information call 1-844-712-1362 -
I should add that while I see merit in this line of research, I also *highly* doubt that it is the case that pre-existing mental health issues are directly and solely responsible for CPIP in any significant number of patients.
While there are no doubt at least some ‘it’s all in the head’ cases, it seems FAR more likely that having pre-existing mental health issues might result in a ‘worse experience’ when there is CPIP…that is, that causality would go in the other direction: that CPIP worsens existing issues. It also seems FAR more likely that CPIP causes issues for many people who previously did not have them. This is why the research needs to be done though.
Regardless of the direction and direct/indirect causality, the advocacy for more comprehensive pre-surgery assessment seems useful. Establishing whether someone has pre-existing mental health issues can inform the pre-surgery consultations (what to expect, the risks, etc.), post-surgical therapy options, and even the decision on whether to operate in the first place or wait (perhaps trying to address or mitigate the mental health issues first).
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Unfortunately, abstracts are very abbreviated and often insufficient. They are meant to give researchers enough of an idea to determine if that study is relevant to their specific interests and is worth reading…they are not meant to provide enough information to critique it.
Despite the admittedly not-so-well-written abstract, I don’t see any confusion of cause and effect…in the body and conclusion of the study, they specifically state that causality in either direction has not been established (and it is not their purpose to establish it, which is not possible to do in a retrospective study of this nature anyway).
The first sentence notes that many patients with CPIP have mental health issues…and the purpose of the study is to determine the prevelance of mental health problems in patients with CPIP. Before you can explore causality or address a problem, even if you have a hypothesis about it, you need to establish prevalence…because if studies suggest little to no prevalence of mental health issues in patients with CPIP, then there would be little point in investing further resources to address a problem that apparently does not exist.
The intro states “Although psychological disturbances, like depressed mood and poor emotional health, have been associated with CPIP [7], the prevalence of these diagnoses in this population is unknown. A better understanding of the prevalence of psychological disorders in patients with CPIP may enable surgeons to optimize patient assessments and treatment approaches. Using the data from our groin pain clinic, we aimed to describe the prevalence of psychological distress, pre-existing psychological disorders, and other psychosocial issues in a group of patients with CPIP.”
From the discussion, after the results: “Psychological testing in our inter-disciplinary groin pain clinic revealed that patients with CPIP may have higher rates of psychological disorders than the general population. We do not know if antecedent psychological disorders placed patients at risk for developing CPIP or vice versa. Nevertheless, a psychological evaluation for patients with CPIP, or referral to a center that can provide this expertise, may be wise before attempting surgical intervention. After psychological assessment in our groin pain clinic, recommendations are made by the psychologist for appropriate next steps in care. These recommendations, based on clinical judgement and the results of the psychological testing, may include pain rehabilitation or additional psychological evaluation and treatment prior to surgical intervention. The psychologist may also conclude that there are no psychological contraindications to surgery.”
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“This study has limitations. It represents the retrospective findings of a single institution and is a small sample size. This study is further limited in that we did not compare the CPIP group to a control group to determine statistical significance of any results evaluated. Additionally, we do not know if the psychological assessments and interventions in this population impacted clinical outcomes. We also do not know if the higher than expected rates of psychological disorders seen in this cohort are due to pre-existing psychological disorders that place these patients at higher risk of developing CPIP, or because patients with CPIP are more likely to develop psychological disorders. Further prospective work needs to be done in this area. Finally, this study represents the findings of a high-volume hernia center, and our results may not be generalizable.In conclusion, an inter-disciplinary groin pain clinic has revealed that patients with CPIP often have complex psychosocial issues, including mental illness, a history of childhood abuse, pain catastrophizing, disability, and a history of substance misuse. A multispecialty approach to CPIP may improve preoperative assessments and identify patients who may benefit from further psychological evaluation and treatment. Future research should also seek to identify the relationship of these psychological disorders with outcomes after the surgical treatment of CPIP.”
Having said all that…I have little doubt that a key idea is that some subset of cases of CPIP are at least partially attributable or worsened due to pre-existing mental health conditions….but the authors wisely avoid making this direct implication and instead stick to what CAN be shown: that patients with CPIP may have higher rates of mental health issues.
The real work will come later…trying to determine whether, what kind, and to what extent, pre-existing mental health issues predict CPIP…and to what extent CPIP predicts subsequent mental health issues in previously ‘healthy’ patients. Establishing causality in either direction will necessitate experimental studies (plural) with appropriate controls. In the meantime, their advocacy for more comprehensive pre-surgical evaluation seems to have merit, simply based on the prevalence findings.
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Many surgeons choose to specialize in one thing (like hernias) because they genuinely want to become ‘experts’ in their job. You have a greater likelihood of a successful surgery with a specialist vs. a generalist (which is not to say that all generalists are ‘inferior’, but it is wise to play it safe and go with a specialist).
As for bad reviews, every surgeon is likely to have complaints of some sort. That is in part due to the fact that no surgery has a 100% success rate, no matter how skilled and experienced the surgeon.
I think it is important to keep in mind that hernia specialists typically perform a large number of repairs per year…so even if they are highly skilled and have a very small complication rate, after many years of operating they will still have quite a few patients out there who have a complaint of some sort…and thus there will be negative reviews to be found.
I don’t want to pry either…but is there a reason that you won’t go to Canada? Shouldice is an excellent option, but there are also very experienced surgeons in Europe (and some in the USA) who offer that repair or other tissue repairs. Dr. Samer Sbayi has unfortunately left Stony Brook in NYC, but I understand that he will soon announce where/when he will be taking patients again…he was trained at Shouldice. It would be nice to know more about why he left and why there is this delay though…
Since you are in the Phillipines, you might also consider Dr. Kang in South Korea. He has developed his own tissue repair and apparently is achieving very good results (http://gibbeum.com/main/main.php) and his costs are relatively low compared to some options in the USA. There is at least one thread on here where someone included a breakdown of their costs to travel and have surgery there.
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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.
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@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.”
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“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!
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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).
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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.
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“Very likely” might not be good enough in your eyes, but in reality that is what we have to work with because we don’t have great data.
Of course there is variation among the Shouldice surgeons…the question is what the *range* of that variation looks like. Since we don’t know, we have to fall back on logical reasoning when thinking about it.
I will point back to what I said earlier…if skill/experience is a primary consideration, then where do you think surgeons are getting better training and more experience with the repair than at Shouldice Hospital? Per the website, all surgeons “regardless of prior experience” are required to assist on 50 repairs before being allowed to perform their own, and then must perform up to 100 more before being allowed to lead a surgical team. Do you think external surgeons are getting the same training and supervision before doing their own Shouldice repairs, never mind performing them with the same regularity?
So while there certainly is variation amongst Shouldice surgeons, that variation is likely to be fairly small after a rather brief period of time…and it is also likely that range still occupies a higher level of the skill/experience spectrum such that even the ‘low performers’ at Shouldice are likely to be comparable (if not better than) the majority of external surgeons who have performed fewer Shouldice repairs and with lower frequency. Of course we can’t KNOW this…but logically speaking, that is a reasonable belief absent evidence to the contrary (evidence we essentially can’t get).
Reviews, blogs, etc. are helpful, but they are neither representational nor verifiable. IMHO, they are mostly useful to identify potential red flags. For example, if you see multiple instances of the same criticism, then you might want to dig a little deeper or ask certain questions. But if you are basing your assessment of a surgeon largely on reviews and blogs, then you are fooling yourself into believing that you have anything close to a clear picture. Further, if you try to compare surgeons on that limited, non-representational, unveriable information, then you *at least* need to adjust the raw number of ‘bad reviews’ to account for differences in how many repairs each surgeon has done, how long they have been practising, etc.
How the cremaster is treated not terribly relevant to the debate on whether it is problematic to not choose your surgeon at Shouldice…it is more relevant when deciding whether to go to Shouldice in the first place.
Observers being allowed is also not relevant to the concern over not choosing a surgeon there…and is even not likely too relevant overall when you consider that hospitals routinely allow residents and other observers (and for much ‘higher stakes’ surgeries than inguinal hernia repairs). If it was such a potential hinderance to surgical teams, it would not be allowed…and Shouldice, as a private hospital that is not affiliated with a university, would presumably have even less obligation/motivation to allow observers if it were a problem. If you want to reach for a possible effect on allowing observers, you could also just as easily frame it as a positive…that a surgeon might be more careful as they want to ‘impress’ or at least not mess up in front of others.
The unknown chronic pain numbers are neither relevant to not choosing your surgeon at Shouldice nor a unique concern to Shouldice…what other surgeons have independently verified, long-term follow-up of their patients to nail down a firm number?
Having said all that, would I rather be able to choose at Shouldice, even absent good data to inform that choice? Sure…even limited, unreliable, non-representatioal information on blogs, forums, reviews, etc. is (hopefully) better than nothing…but my point was merely that not being able to choose at Shouldice is likely not *as big* a deal as it might seem on the surface…because of the training and experience that all surgeons will quickly gain there (compared to the training and volume/frequency of most external surgeons offering the repair).
To the broader question of choosing Shouldice at all, I share some of your concerns and there are things I would like to see changed/improved or be better studied. The multi-day stay is surely not critical for all patients and most other surgeons treat is as day surgery or an overnight stay…more study on the pros/cons of cremaster resection (and perhaps giving patients the option to choose how it is treated)…whether the ‘narrow’ patient profile is too narrow and should be expanded…and some updating of the hospital itself to match more modern facilities. I am also intrigred by Dr. Kang’s tissue repairs, particularly that he treats indirect and direct hernias differently and does not have such a narrow patient profile, and I hope they become better studied.
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It is a worry, but IMHO it should not be as big a worry as it seems on the surface.
Why do we want to choose our surgeon? Because we know that surgeon skill/experience with any repair is an important factor in patient outcomes. How does a surgeon gain a high level of skill/experience? With proper training in the repair and by performing a large number of them with regularity.
Where is there likely to be better training in the Shouldice repair, and where is a surgeon likely to be performing more repairs with higher frequency, than at Shouldice Hospital?
Ask any surgeon you are considering how many Shouldice repairs they have performed to date and how many/how often they perform them today and then compare that to the numbers for even a ‘new’ or part-time Shouldice surgeon. I bet the answers will surprise you.
I don’t mean to imply that there are not excellent options for a Shouldice repair outside the Shouldice Hospital…or that there is not variation in outcomes between Shouldice Hospital surgeons (no doubt some are better than others)…but you are very likely getting a certain ‘high’ standard of skill/experience at Shouldice, regardless of which surgeon you get. That may not eliminate the concern at not choosing your surgeon, but that additional context should reduce it a great deal, IMHO.
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@ajm222 – where are you getting those timelines???
The consulation clinic used to be walk-in, but I see it is appt now (no referral req)…and surgery typically was anywhere from 1 to a few months out. I can imagine the backlog of cases from the pandemic has affected that…but 2-3 months for consult and 2-3 years for surgery…are you sure about that???