[MarkT]

I thought the critique of bio/absorbable was significantly higher risk of recurrence…that they either did not last long enough and/or there was not enough scar tissue to be sufficient to hold a repair once it was gone.

I don’t recall if it was that video with Dr. Heniford, but I’m almost positive that one HerniaTalk guest briefly mentioned a newer absorbable that lasted longer (12+ months?), but I can’t remember what they said about it…either/both that it was not yet widely available and/or was so new that there was not enough time yet to see if it improved outcomes…?

[MarkT]

Some ‘medical glue’ products have been around for a while. For at least 10 years, I know that one avenue has been using it to close up the breastbone following heart surgery.

The potential applications seem endless. Here is one that seems interesting in terms of the flexibility to tailor it for different purposes (even adjusting how long it lasts in the body). It apparently addresses some of the shortfalls of current options and has already gone through animal testing:

https://www.nibib.nih.gov/news-events/newsroom/squirtable-surgical-glue-could-transform-surgeries-and-save-lives

[MarkT]

Not to stray too far from the OP, but it is worth noting that the way the cremaster is treated during some repairs does not mean you will lose the cremaster reflex.

I’ve had right side (30yrs ago) and left side (18yrs ago) inguinal hernia repairs done at Shouldice, and the cremaster reflex is still present.

[MarkT]

Hopefully @drtowfigh can chime in here…but I found a wee bit of info from one of her HerniaTalk videos on umbilical hernias and pregnancy (timestamped at 56:02):

https://youtu.be/Iyauzcas6Jg?t=3362

For women who had an umbilical hernia repair:
– higher risk of recurrence following pregnancy
– if a mesh repair, higher risk of chronic pain in that area during pregnancy
– for women without symptoms, best to wait until done with pregnancies before getting repair

Given that you are not symptom-free and have sufficient pain to have booked surgery, perhaps Dr. Towfigh would have different advice for you.

You might even consider contacting her office, if you need more info ASAP (https://www.beverlyhillsherniacenter.com)

[MarkT]

Another option is stainless steel, which has been used successfully at Shouldice Hospital for decades…and Dr. Sbayi, who worked there for a year, and is now at Stonybrook in New York, uses the same stainless steel too.

[MarkT]

Another caveat with that study:

The Shouldice repairs were not performed by surgeons at the Shouldice Hospital…and the study describes a modified Shouldice technique.

i.e., the outcomes for the ‘Shouldice group’ in the study are unlikely to be representational of outcomes for Shouldice Hospital patients.

• This reply was modified 2 years, 10 months ago by  MarkT.

[MarkT]

Hi Monika,

I’ve had two repairs at Shouldice Hospital for inguinal hernias (right side 30yrs ago, left side 18yrs ago). Both were flawless as far as I can tell, with no post-op complications or long-term chronic pain at all.

Shouldice’s recurrence rate is extremely low and they guarantee their repair for life (fees are waived for a confirmed recurrence).

[MarkT]

Looks like there is some relationship between them, as both are listed here:

https://www.fremontsurgerycenter.com/general-surgery-1

I assume Dr. Brown gave (or sold) the sportshernia.com domain to Dr. Nguyen, who still maintains his own site too (https://lifetimesurgical.com).

[MarkT]

A quick note on study ‘paywalls’…

If you know anyone who attends a university (or has a kid in a university), you can ask them to try and pull a copy of the study through their school library’s online database. It is free for them, takes literally a few minutes to find and download/print, and they can do this from home. Not *all* studies will be accessible by students at any given school.

Alternately, virtually all studies include contact info (email + school/institution) for the authors and a primary contact is often indicated for correspondence (otherwise, contact the first author). More often than not, they will be willing to email you a copy of the study and they are typically happy to learn that someone is interested in their work. They might even point you to some additional resources.

[MarkT]

Granting that there appears to be a fail/complication following the mesh removal and tissue repair at Shouldice, I have a few question (not sure if you are able to answer all of them):

1. How did the current surgeon ‘retroactively’ diagnose that there was no mesh rejection and that it should not have been removed?

2. What alternative explanation did the current surgeon offer for your post-mesh repair pain and instability?

3. Did you have any imaging done at some point before or after the Shouldice surgery?

[MarkT]

I doubt they are unaware of the status quo. Part of the purpose behind publishing research is to advocate for progress or change. This type of instrument and paper were no doubt developed (at least in part) because the status quo is to neglect this facet of patient care.

It is true that this is not *all* about the patients though…there is benefit for the surgeons too, in being able to better manage patient expectations. That type of dual-benefit is necessary to demonstrate if there is any hope for buy-in by stakeholders. If the benefit is 100% for patients, and otherwise just represents an additional cost or burden on the system, then it will go nowhere.

I’m equally pessimistic as to how responsive the overall healthcare system will be. Sadly, there probably needs to be a ‘bottom line’ benefit for something like this to gain traction. I know an orthopaedic surgeon who started using his own survey instrument to better understand his patients and track outcomes, but that was entirely his own initiative, due to his own motivation.

Getting back to the hernia community, I find it *appalling* that the problems of mesh remain what they are. I’m also dismayed to see that tissue repair is the exception, rather than the norm, in terms of training and practise, given these problems. More than anything though, I find it highly unacceptable that much better data is not kept and shared that would better inform (and hold accountable) everyone involved…from medical device suppliers to surgeons to patients. How is it that we don’t have a much more clear idea of who those ‘15%’ are in terms of patient characteristics, the nature of their problems, how those problems have been addressed, their long-term outcomes, who operated on them (specialist vs. generalist), etc? I know one complicating variable is privacy vs. info sharing…but that can’t be an insurmountable hurdle.

[MarkT]

I would say it is focusing on psychology *in addition to* physical results.

This is advocating for brief psychological engagement with individual patients, ideally by the actual surgeon (“Although the POPS could be delegated to another member of the surgeon’s team, we strongly suggest the surgeon engage the patient”).

It is not a comprehensive psyc eval and many surgeons already do something similar…this proposes a more consistent process and instrument rather than the ad hoc method that currently exists (if it does at all).

This might *seem* naive or asking a lot…but it shouldn’t be. There should be no reason that a surgeon (or at least a member of the surgical team) can’t spend 15 minutes at some point with EVERY patient before they operate on them (barring emergency surgery, of course) to address their beliefs, concerns, understanding, and expectations in a more streamlined, consistent manner. A surgeon can only perform so many procedures in a day…how onerous could such a practise possibly be?

I don’t interpret this as a ‘lowering expectations’ exercise at all. Understanding and addressing a patient’s prior beliefs, concerns, and expectations, etc. and paying attention to the psychological component of a condition, surgery, and recovery, is a good thing. We should get behind this type of initiative, IMHO.

[MarkT]

Hi Peter,

I agree with Pinto that it could be helpful to engage with the people responding, although simply sharing your experience is certainly fine too.

I understand from your posts that regaining normal functioning, never mind a return to your previous athletic-level functioning, is not possible…I can only imagine how that must feel.

You have mentioned reconstruction and I’m curious to know what the proposed outcome might be from that. There is obviously a massive gap between ‘professional dancer’ and ‘unable to carry things down the stairs’, so what would reconstruction potentially mean for you in terms of improving upon the status quo?

I hope you don’t mind me mentioning this (and you don’t need to answer), but I do wonder if you have explored any mental health support too. This is nothing short of a life-changing traumatic experience and one that remains ongoing. Seeking some support as you navigate your options and move forward could be of great benefit.

[MarkT]

It is worth bearing in mind that the Shouldice repair has a long history behind it…50+ years and hundreds of thousands of total repairs.

Do we have any evidence, even anecdotally, that the way the cremaster is treated carries a relatively high level of risk for negative outcomes? And that this risk is not offset or more than offset by the benefits of treating it they way they do? Wouldn’t we have many thousands of Shouldice patients with low or non-functioning cremaster reflex (or other negative outcomes) that would have identified this aspect of the repair as a key concern?

Of course I would rather see data than hypothesize in this manner. My point is not that the cremaster dissection is a ‘trivial’ concern…I just question whether it should be a *key* concern or barrier when making a decision on repair type.

[MarkT]

Watchful, I don’t have notes, so I can’t confirm with certainty, but dissection of the cremaster is apparently standard procedure at Shouldice Hospital, so I can’t imagine that mine wasn’t touched in two repairs by different surgeons? I suppose I could try to get notes though…I was actually there very recently and completely forgot to ask about cremaster, since that keeps coming up here as a concern (I don’t really know why) by people contemplating repair options.

Zero complications or chronic pain after both repairs and no restriction whatsoever on lifestyle (weights, swimming, yoga, etc) since then.

Long story made short, I severely overstretched abs/groin/thighs this past September and thought I had a new hernia or recurrence…but multiple doc visits, ultrasound and CT, and a very recent visit to Shouldice for exam by two different docs, has yielded no evidence of a hernia. Shouldice doc believes it to be adductor insertion strain that keeps getting aggravated before properly healing, so I’m treating it as such for now.

I am hoping to get an MRI at some point to confirm a diagnosis of some kind, but the backlog following the pandemic means waiting until at least April for an appt…

[MarkT]

Hi Monika,

Fair point…travel can be an obstacle for many people. I can say that Shouldice does get a lot of international patients. When I was there, there were a few from the U.S., U.K., and S.America.

Regardless of what repair method you choose, surgeon experience/frequency is an important variable, and this is particularly true of the Shouldice repair, which is described as relatively complex. I would be quite reluctant to have that repair performed outside of the Shouldice Hospital unless I was certain that a surgeon had a LOT of experience with that repair and performed it fairly frequently.

[MarkT]

Hi William,

Neither of those have been major concerns for me, to be honest.

Shouldice has a reputation and track record to protect…they aren’t going to allow an unprepared surgeon to ruin that. Per their site, their training includes a surgeon assisting on 50 repairs before they are allowed to perform one themselves (under supervision) and then they perform up to 100 repairs (under supervision) before they are allowed to lead a surgical team.

I am not sure why there is so much discussion/concern regarding the way Shouldice treats the cremaster. While I honestly can’t speak to associated risks, keep in mind that *hundreds of thousands* of repairs have been carried out at the Shouldice Hospital over many decades. If significant risks and negative outcomes are associated with the way the cremaster is treated, we would surely have heard of it by now in the research literature and/or via patient reports. Anecdotally, my cremaster reflex has been unaffected by both surgeries.

Dr. Bendavid, a surgeon and researcher from Shouldicde who has since passed, wrote:

“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.” (https://basicmedicalkey.com/the-shouldice-method-of-inguinal-herniorrhaphy)

I’ve read that patients will sometimes have more than one hernia present…so, in addition to claims of reduced recurrence, perhaps this is also a tool to help ensure than no other hernia or area of weakness is missed? Many surgeons will state whether they touch it or not, but I have yet to read anyone claiming that it “ought not” to be touched or any evidence regarding negative outcomes.

It is ALWAYS good to ask questions…but I would not let those two points deter you from considering Shouldice.

[MarkT]

Hi William – I’ve actually been to Shouldice twice for inguinal hernia repairs. I had one side done 30yrs ago, the other about 18, I think. I really have nothing negative to report, as I had no post-op complications, no long term pain, and no impact on lifestyle/exercise/etc. ever since.

I have recommended Shouldice to many people over the years and I will almost certainly go back, if this does prove to be a hernia. I am clearly not an expert, but I have yet to see compelling arguments to NOT go with their repair (or some version of it), providing that it is determined to be a suitable option (I know going to Shouldice may be a less straightforward decision for non-Canadians).

btw, Valsalva maneuver can be found online…for the purposes here, it is kind of like straining for a bowel movement, which can help ID abdominal wall hernias during imaging. Dr. Towfigh mentions it in her HerniaTalk vid on imaging from Aug. 2021 that is on youtube and posted in another thread.

[MarkT]

12 weeks is their current wait time for surgery…you can walk-in for a consult same-day, depending on how busy they are. Without a palpable hernia, I’m pretty sure they do not operate…but wondering if they do if you have imaging evidence. You can submit a medical questionnaire on their site and a surgeon will review it, potentially asking for more info, so I may go that route to see if MRI would do it (again, assuming it does prove to be a hernia).

Hopefully it does not progress much and I can arrange an MRI at some point soon.

[MarkT]

Thanks, I appreciate your response. It is anxiety provoking for sure, though it was indeed a relief for the initial ER visit to reduce the likelihood of an emergency problem.

It has actually been about 8 weeks now and the symptoms, despite no palpable hernia, leave me pessimistic that it is ‘only’ a strain…although that would be a welcome diagnosis (relatively speaking)! At this point, I just want a definitive diagnosis either way, so I will try to get the MRI done soon.

I know some are ‘lucky’ and have had virtually pain-free hernias (even for years!), but my past experiences have been that it simply grew more and more uncomfortable in the short-term. Right now, it seems that Shouldice is booking ~12 weeks out, so I would rather not ‘wait and see’ for too long.