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Disadvantages of Shouldice repair?

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  • Disadvantages of Shouldice repair?

    I've been in email communication with a Dr. a few hours away that has experience doing over 600 Shouldice repairs and feels confident that I am a candidate based on low weight. He is quoting a very low recurrence and chronic pain rate (between 1-2%).
    Assuming he could deliver on low chronic pain and low recurrence, the disadvantages that I can think of for this procedure is resection of the cremaster muscle (it's function is not restored after surgery) and just the fact that it is a much more involved, longer, and more difficult surgery than a mesh repair (I would have to assume that more can go wrong based just on viewing a video of this procedure). Also in my personal case I would have a longer travel time after surgery (two hours which includes a ferry).
    Any other disadvantages anyone can think of? Basically there are no other doctors around me that do this procedure, and he is a big proponent of it so he is very positive on it. I am looking for some more reasons to continue on with a laparoscopic mesh repair, or go with this option.

  • #2
    Hi. Is the doctor who does the shouldice repair located at Stoney brook? Ultimately you will have to make a decision on what you feel is the right way to go on this one. I can tell you I had laparoscopic hernia repair with mesh 6 years ago and it ruined my life and I eventually had to have the mesh removed in a long and tough surgery. My mesh had folded upon itself and folded over and become rock hard. It had to be peeled off the bladder and a few patches had to be left on the spermatic cord and other structures. It seems the majority of people do well with mesh but if it goes wrong you really are screwed and are left alone to figure it out. Ultimately I had to travel out of state and pay out of pocket for s lot of this procedure.
    if you decide on getting a mesh repair then I rx going to see a specialist-I'd even rx making the journey to another state if I have to. I'd pick a surgeon who is not only an expert at this procedure but has experience removing it if something should go wrong. Unfortunately there are very few of these surgeons.
    i never experienced the shouldice repair but I can definitely tell you if I could do it all over again I would have gotten a pure tissue repair and avoided mesh. Just my two cents

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    • #3
      I have read a little about your experience on this board and unfortunately you are not the only one I've seen that had to go through that. Your experience is probably what I would fear most: having to go through removal once it has been incorporated in tissue. I don't understand what causes the mesh in some people to fold up and get rock hard and that scares me. Cases like yours really weigh on my mind and are why I haven't done anything for over 4 years.

      I had planned for the last several years to go to Shouldice when the time came (before the Dr. in Stony Brook was an option). But since this summer, I really tried to read all I could from different perspectives. I really wanted to understand why almost all Drs. want to use mesh. I read the HerniaSurge international recommendations, the EHS recommendations, and considered their advice on using mesh. I watched the Shouldice repair a few times, and in a small way I "saw the light". It looks like a complicated surgery just to fix a hernia and there is a lot of blunt dissection and cutting, pretty much down to the floor of the inguinal canal, and then a lot of suturing to recreate it. You lose the cremaster function completely, although one can live without it. Things can and do go wrong in it, and I can see why it would lead to chronic pain also. The results and the tightness of the fascia afterwards are all in the hands of the surgeon. In fact I was sufficiently scared of a Shouldice too. It can make Laparoscopic insertion of mesh look attractive again. It's just a different angle of looking at things.

      Also, I started watching the SAGES seminars on youtube, and Dr. Towfigh and many colleagues make presentations concerning chronic pain and complications in hernia repair, so they are aware of it and some very smart and talented surgeons are always working on improving things. If it was as easy as "just do Shouldice", they would do it. It may be complicated but not beyond their abilities.

      I ended up seeing a couple of Docs, and ended up scheduling mesh surgery in three weeks from now, but I'm not done seeing Docs yet. I still have open questions and often consider cancelling the surgery. I'm still trying to understand from all angles.

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      • #4
        Hey i totally hear where you are coming from. That's one of the reasons i rx if you do go the mesh route do it with a hernia specialist. They have not only a better understanding of the anatomical area but an understanding of what the best type of mesh to be used for the specific patient. For example not only was the mesh used in me having a lot of issues with other people (bard 3D maxx-please avoid this at all costs as it has a tendency to fold over Bc of its design). The surgeon who removed my mesh felt not only was that type of mesh not the best for thin people like myself he also felt that he surgeon tried to fit to big of a mesh into to little of a space.
        some thoughts I have about open repair vs laparoscopic pros and cons.
        open repair is not as close to vital organs so doesn't pose as much risk if something should happen to the mesh. However, if something should go wrong with the mesh and it needs to be removed I feel it is a more invasive procedure and a higher chance one or all of the inguinal nerves have to be cut or aggrebated. It is will also take a little longer to heal.
        laprascooic there will be less recover time and less pain in the groin area but there will be three incisions in your stomach for the instruments and the camera and you will be filled up with gas to inflate the stomach and of course general anesthesia. And that can be an uncomfortable process during recovery. Lapro als puts the mesh closer to vital organs such as the bladder etc.
        however i also feel from my experience and from corresponding with others that it may well be easier to remove the mesh should it need to be.
        my biggest discomfort from my removal was the incisions and gas used for the surgery. I had very little "traditional pain" pain from the removal which I thought was remarkable especially since it had to be peeled off my bladder amongst other things
        Don't get me wrong recovery hasn't been a cakewalk and their is discomfort that I am going through but people I talk to who have mesh removed openly seem to be in a lot of pain in the early months of the removal.
        some more thoughts. Shouldice repair isn't the only type of pure tissue repair. There is the desarda and bassini repair. But you will have to travel-these seem like less invasive repairs these the shouldice and many don't use permanent sutures but absorbable ones. There is dr. Tomas in Florida that does the desarda repair, dr. Peterson that does some version of a pure tissue repair and dr. William brown that does a modified bassini approach. Worth looking into if you haven't already. Of course you will most likely have to travel and pay out of pocket.
        I think it also depends on how big your hernia is. If it is small, I really think you should consider anoute tissue repair and may not have to go with the shouldice if it looks a little to invasive etc.
        there is a dr. Kang from South Korea on another thread I've been on-no mesh repairs and he only does pure tissue relairs and again supports is results are very good. Maybe you can ask him his views on the different tissue repairs pros and cons. He has been great in responding to me
        ans finally dr. Towfigh has mentioned that she is now doing a laparoscopic pure tissue repair for select patients. Man this seems promising and with looking into.
        i totally understand your hesitancy and I think you are wise in researching this and weighing the pros and cons of each type of surgery. But on the other hand you don't want your hernia to get larger as your options may dwindle.
        whateber decision you make the best thing you can do is select the best and qualified surgeon
        for the type of repair you go with. This will dramatically increase a successful repair.
        hope this helps

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        • #5
          Also in response to your point why do so many surgeons use mesh-I believe it is for a Minnetonka of reasons.
          1) I believe mesh was and is promoted to lower recurrence rates. This is debatable but that is what they believe.
          2) mesh covers up all the weak spots in the ground where hernias can occur so it protects
          you from other hernias-direct indirect and femoral no matter which one you are going in for.
          3) most surgeons also use mesh Bc that is what they are trained in how to do.

          however the downside to mesh is that it is a foreign body in your system and can cause a boat load of trouble. Chronic pain has gone up with mesh even if recurrences have maybe slightly gone down-again debatable.
          if it doesn't go wrong you are in a big world of hurt with very difficult decision of what to do.
          my biggest problem isn't with mesh itself but the fact that it has become so prevelant that it is very difficult to find alternatives. When I got my repair I wasn't give a choice-i just trusted what my surgeon told me. At the very least surgeons should receive equal training in mesh and non mesh repairs so the patient can make an informed choice. However the pure tissue repair seems on its way to becoming extinct and that in my opinion is just flat out wrong. There isn't ever just one way to do something

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          • #6
            thanks for the advice. I have read so many bad stories of that 3D Max mesh, I hope it has been pulled from sale. One thing I hate about this is the constant changes they make for marketing purposes to add unnecessary gadgets and gizmos like multiple layer "systems", plugs, shaped or rigid mesh, expansion springs, etc. None of this was ever for patient benefit.
            The lack of suture options is frustrating. Shouldice hospital is one of the last bastions of high volume suture repair left, that is amazing to me. If not for them, there may have been no high volume data left that could demonstrate that a suture can be effective in the right hands. It makes me feel like I must be crazy for considering a mesh-free repair.

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            • #7
              Totally agree on your points. And the fact that the mesh companies don't have to any clinical trials and can push it through the FDA through a special process is even more disturbing. I'm the perfect model for all the arguments-I have an open placed mesh on my right side that has been pretty good, I have had obviously the mesh removed from my left side which has ruined a part of my life and I had a small umbilical hernia that was seen up during the initial left side laparoscopic repair and I don't or never feel a thing. Never would of know that pure tissue repair was even done.

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              • #8
                Meant to say sewn up

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