Medial
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You have a great description of the Shouldice layers, David . I have some trouble fully visualizing layers 3-4 of how the cojoined tendon gets approximated to the inguinal ligament, but I get the overall idea: by doing so it distributes the tension away from layers 1-2 of the TF.
So, the article you are quoting thinks that the Bassini does not suture it the same way and therefore results in more tension, was that the point you are making? There are two variations of Bassini: the original one repairs the TF and also sutures the conjoined tendon to inguinal ligament – I don’t know the detail, but it does it differently from Shouldice, in less layers I assume, and therefore with more tension. The modified Bassini does even less that that, I think it does not even open the TF.
Further questions that I have and cannot find good answers:
– What about the 2-layer Shouldice? Does it only double-breast the TF with layers 1-2 and stops there, or does it also do some limited suturing on the cojoined tendon and inguinal ligament? I’ve read that it’s basically the same as the original Bassini, but like you, I’m confused on the differences.
– What about using absorbable sutures for layers 3-4 of Shouldice, as some German doctors do? How well does it hold after the sutures are gone?
As usual inviting @drtowfigh to comment. I know she favors Bassini over Shouldice when there is not enough tissue.
And Dr Sbayi makes an additional relaxing incision on some other muscle (rectus abdominus?) to further relieve the tension. From my simplistic view, it’s yet more tissue cutting, as if the 4 layers was not enough, just contributing to the opinion that the full Shouldice could be an overkill.
Ultimately, I want to know if there is a sweet spot among all these options: strong enough, not too tight, not too much tension, yet minimal enough.
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What does @drkang @junginkim thinks about the tension issue in Bassini discussed above, since Dr Kang uses a similar method for direct hernia?
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I can see parallels between Dr Muschaweck’s approach and Dr Kang’s repair: repair limited to the weak areas only, no cutting into healthy tissue, smallest possible incisions.
There is one thing that struck me during her interview, and not in a good way. She said she’s done 29,000 repairs and later said she did not have a single case of chronic pain. How is that statistically possible? Is it precisely because she aways cuts the GBGF nerve? It would be more realistic if she had 1-2 in a thousand, but absolute zero just sounds hard to believe.
I found this description of her method by another doctor in the US:
https://www.anthonyechomd.com/blog/how-is-the-muschaweck-repair-different
One thing I didn’t like: he stated the GBGF nerve is always cut in her procedure. That goes against the principle of the least impact. I would prefer that it’s preserved as much as possible. I think most other surgeons no longer routinely cut nerves during tissue-based repairs.
anthonyechomd.com
How is the Muschaweck repair different?: Anthony Echo, MD: Plastic Surgeon
There are several different types of non-mesh repair techniques for sports hernias or inguinal hernias. The technique that I perform routinely is the Muschaweck
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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.
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This reply was modified 1 month, 1 week ago by Medial.
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This reply was modified 1 month, 1 week ago by
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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?
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@Watchful did you mean to say 5-6 centimeters incision at the Shouldice Hospital? That would be consistent with what others surgeons do. 5-6in sounds way too much.
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Hi @drtowfigh . I know this is an old post and the poster is no longer active, but this ultrasound report caught my attention as significant for understanding the risk of various tissue repairs.
Does it mean the scar tissue (“oedematous hypoechoic scar tissue in the subcutaneous tissues”) is from the incision wound?
Is this a normal/common or an abnormal situation to have the incision scar tissue (as opposed to the deeper scar tissue around the sutures of the defect repair) to grow downwards into the nerves?
Just trying to understand which surgery factors (e.g. the size or location of the incision) can contribute to this situation.
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@drkang @junginkim what do you think about disadvantages of a smaller incision? Less visibility, increased risk?
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I realized I should have mentioned @drkang @junginkim in my reply since the topic should be relevant to Dr Kang as well…
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Hi again @Thunder Rose , I agree with you on the major concern about removing healthy EOA tissue. It’s unclear what kind of tension it creates on the front side, and how it could disrupt the very important external oblique muscle in the long run. But, it seems like there are very few complaints so far about muscle issues after the Desarda, I think I’ve seen maybe 1 post with some longer term discomfort so far. So it’s there is a lot of uncertainty here unfortunately…
But I don’t understand why you are singling out
the Desarda repair for manipulating the cord. Isn’t the same manipulation happening with the Shouldice as well? They also have to pull the cord apart and do
the extensive stitching repair on the posterior wall “while holding the contents
on top” as you say. But I have not
watched the actual surgery videos. Have you
observed significantly more manipulation of the cord with Desarda compared to
Shouldice?… -
Thank you very much for all your answers, @KC
Could you please tell me a little more about the risks to the structures inside the inguinal canal during your procedure.Are you saying above that there is less risk to the spermatic cord in your procedure compared to the standard Marcy?
What about the cremaster muscle? Do you have to incise it to perform the procedure? Do you preserve it and not cut away any cremaster tissue?
And what about the major nerves? Is the genital branch of the genitofemoral nerve mobilized and manipulated? What about the ilioinguinal and iliohypogastric nerves, are they out of the way in this procedure?
Apologies for many questions. I’ve only read the abstract because I cannot access the full text behind the paywall. Thank you again for coming to this forum to educate us on this important technique.
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Hello @Thunder Rose what do you mean when you say that a shorter incision can cause more bruising/bleeding/trauma? I can understand how a shorter incision can limit visibility and access and increase the risk of a missed nerve or injury to structures. Is that what you mean? Other than that, as long as it does not cause the surgeon any difficulties, I can’t think of any disadvantages of having a smaller incision, only the benefits. Maybe @drtowfigh can weigh in as well.
@Thunder Rose
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And now it’s been 5 years… it would be indeed fascinating to find out which surgery a mesh surgeon would choose himself… except, if he does not choose mesh, will we ever find out? 🙂
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Hey Mike M
Thank you for the explanations. But I think what you are saying about Marcy vs. Kang is not clear. Based on what I’ve read about Dr Kang’s method this should be a better answer:
- For indirect hernias: it’s just a Marcy-type repair or Dr Kang’s variant of it. There is no reconstruction of the posterior wall.
- For direct hernias: it’s a Macy repair + wall reconstruction using a Bassini-type repair (aka Shouldice layers 1-2).
Let me know if you disagree.
Dr Kang’s method sounds amazing. It’s the most minimal and conservative approach of them all. Your description and benefits of Dr Kang’s method are also very well written. In fact, it’s written so smoothly and positively that I agree with Dr Towfigh it does sound promotional.
My main concern: While I’ve seen Dr Kang’s numbers on recurrence, I don’t see published figures about the chronic pain rates. Did I miss it? Most people care about long term pain outcomes as much as (or even more than) about a recovery or recurrence. Seems like an assumption is made that the repair is so minimal the long-term pain should not be a concern, but it’s still an assumption. It’s never a 0%, so it needs to be addressed directly. Just like Shouldice hospital publishes its data on pain, Gibbeum hospital should do the same. If Gibbeum hospital can show similar low chronic pain rates, that would be really amazing.
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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?
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This reply was modified 1 month, 1 week ago by Medial.
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This reply was modified 1 month, 1 week ago by