[Medial]

Hi @Thunder Rose

How are you doing now, 5 years after the surgery? It was very informative, looks like you’ve developed an advanced understanding of the procedure. If you are still around, I’d appreciate some additional comments to help me and others optimize the surgery plan the way you approached it

Overall on question 7, it seems you wanted the canonical 4-layer Shouldice repair with the suturing done the same way as in the Shouldice hospital (except no wire), is that correct? Is there any reason why you would insist on that instead of letting the surgeon choose whatever modification he was most proficient with? Would it be for the reason of achieving their published low recurrence rates, or did you have evidence of more post-op pain or tightness if done differently?

On your specific questions 8 and 9 below (lines 1-2 and 3-4): any reason you are getting so specific on the suturing detail? I can’t visualize the nuances you are talking about, and I have not watched surgery videos. I assume there are other options possible in terms of how to run those suture lines on those specific tissue flaps, but you were very specific about it. May I ask why? Did you research evidence that suturing it differently from how you wanted it could produce inferior results, in terms of either the strength, or more importantly, the post-op pain or tightness?

Similar question on your #11: are there other options besides an oblique incision, and what’s the difference in the outcome?

On your #4: I understand about not wanting the steel wire. Any other reason on insisting specifically on Prolene instead of letting the surgeon choose between Prolene, Silk, or Polybutester?

Your original questions below. I would also welcome comments from @drtowfigh or others who did advanced research on this like @Watchful , @dave11 and some others….

4. What type of suture material would you use for the reconstruction portion of the Shouldice repair?

— I wanted Prolene. I believe this is the material used for Shouldice repairs by Towfigh, Muschaweck, Yunis, and Wiese. My understanding is that Brown uses silk, Sbayi and Shouldice Hospital use stainless steel 32 or 34 gauge, and Grischkan uses Polybutester.

7. For the reconstruction portion of your Shouldice repair, how many lines of sutures do you run over the posterior wall of the inguinal canal? Are you running 4 lines formed by two sutures as in the Shouldice repair described in Glassow (1973: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941165/pdf/canmedaj01661-0043.pdf) and Bendavid (1997: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952996/) or are you running two lines formed by one suture on the posterior wall as in various modified 2-layer Shouldice repairs?

— Answer I wanted: 4 lines formed by two sutures.

8. For your first two lines on the posterior wall, which structures are being sutured? Do you double-breast the transversalis fascia, or is the remaining flap of transversalis fascia not included in the second line?

— Answer I wanted: that the transversalis fascia is sutured first to the back side of the superior wall (conjoint tendon) and then to the inferior wall at the inguinal ligament. The terminology varies by surgeon so it can be hard to parse.

9. If you’re placing a 3rd and 4th line on the posterior wall, which structures are sutured? (Only in general terms. I realize that the structures on the superior wall vary over the length. I am most interested here in the inferior wall as I find it curious that in Bendavid’s reconstruction (cited above) his third and fourth line are to the external oblique aponeurosis just above the inguinal ligament while Glassow and other descriptions I’ve encountered suture to the inguinal ligament itself.)

— Answer I wanted: confirmation that the 3rd and 4th lines are part of the reconstruction and that the surgeon understood the question.

10. For the closing of the external oblique aponeurosis on the anterior wall do you use an absorbable suture?

— Answer I wanted: confirmation that they’re not going to add a Desarda repair on top! I wanted to know that this would be an absorbable suture. Answer I got was short term vicryl.

11. What type of incision do you make? What type of skin closure?

— I wanted an oblique incision and running subcuticular skin closure.

• This reply was modified 1 day, 17 hours ago by  Medial.

ncbi.nlm.nih.gov

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[Medial]

Hi @dave11

I’m also interested to know about the 2-layer Shouldice, I cannot locate the description. You said you’ve done a lot of research on this. Does it use the first 2 layers / 2 sutures of Shouldice? What’s the benefit, is it less tight than the original, and less post-op pain?

What type of hernia did you have – direct or indirect? Did the doctor recommend this repair for your hernia type?

[Medial]

On his website Dr Grischkan describes the standard 4 layer Shouldice. Is the 2 layer variant basically the same as Bassini repair? Was your hernia direct or indirect? How are you doing now, and did the absorbable sutures do the job with no recurrence for you?

• This reply was modified 1 day, 13 hours ago by  Medial.