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No-mesh Shouldice Hernia Surgery in Germany / Europe


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  • No-mesh Shouldice Hernia Surgery in Germany / Europe

    I thought it may be helpful to European based forum readers to know there are a few mesh-free Shouldice hernia repair options available in Germany

    Dr Andreas Koch in Germany (unsure of location)

    Dr Ulrike Muschaweck in Munich Germany (sometimes in UK too?)

    If you know of any other European surgeons who are experienced in the Shouldice hernia repair method, or another no-mesh method, feel free to add the to this forum thread.

  • #2
    Hello Chaunce. Great idea to start a topic for this. I think that Dr. Koch is the Holland-based surgeon in this partnership, along with Belgium. Dr. Muschaweck apparently handles the UK and Germany. Ireland is either. And there is a separate "International" link.

    Looks like this person, Nahom Welldeiesus, started the partnership, after his/her own hernia repair in 2015. It's on the About Us page. It looks like the three of them are the business, and both surgeons can be contacted through the Biohernia site.

    Also note that they reference three methods - Shouldice, Desarda, and Muschaweck. And mesh removal.

    Here is an excerpt that I translated from their Holland page, using Google translate. The web site is a bit clunky, it's new of course. Click the "how does it work" from the info link.

    "Kom voor een kennismaking met onze chirurg, Dr. Andreas Koch, langs op één van onze maandelijkse spreekuren."

    "Come for an introduction to our surgeon, Dr. Andreas Koch, along on one of our monthly office hours."


    • #3
      Hi chaunce,
      Dr ralph lorenz in berlin also does the shouldice surgery and is a good friend of dr koch. I funnily asked dr koch if he had a hernia wer would he go too and dr ralph lorenz was the man he said so id definently say have a look. Also berlin is much more convenient as the closes airport to dr koch is easily over 90 mins away and difficult to get to with public transport. Dr Muschaweck has a great setup in munich but her prices can be triple the amount of the other two doctors that i have stated. But do your research carefully and also wanted to ask if you have contacted the shouldice clinic for more information? The clinic will clearly state that the technique is not a shouldice if sutures that are absorbed are used. Good luck


      • #4
        Hello Baris. Can you tell more about your situation? The type of hernia and what made it fail? I saw your other post and replied but it is Unapproved at this time.

        I was very athletic also but had a laparoscopic mesh repair. The mesh was worse than the hernia, it made athletic activity impossible without side effects.

        Any details would be appreciated. Good luck at Shouldice.


        • #5
          Hi good intentions.
          id start right from the begining.
          after doing my research these times last year i decided to opt for the desarda technique and spoke to moham desarda.
          i had tbilateral inguinal hernias.
          i found dr koch on the desarda website and decided to get in touch.
          at the time i went directly through bio hernia who were extremely helpful and great at organising everything.
          when i arrived and was assesed a day before surgery i asked the dr if he can please peform the desarda. He told me that he will check once he opens me up whats best and that desarda is mainly for skinny people and not suitable for my size (6ft 3 was 105kg). He stated that if the shouldice was to be used he will not cut the cremester muscle like they do in shouldice clinic as he finds it pointless having testicles dangling.
          on the day of surgery 16/08/2017 after i recovered from the general anasthesia we had a brief chat and thats were inwas told the shouldice technique was used with absorbable sutures. I felt great after two days of intense pain i was fine and greatful my bowels were working properly for the first time in a couple years. 5 days later i returned to london.
          About 10 weeks into my recovery i felt as if my surgery areas were weaking so i took a flight back to germany to be seen. He told me there and then that nothing is wrong and told me to continue strengthening it.
          Come end of november i contacted the doctor again and told him that my left side has a bulge coming through and my right side feels very weak and bulgy. I took a flight out there agian. He said there was no hernia and what i felt was blood rushing down to my legs. After having a discussion and talk he told me that he will reoperate both. He reoperated 14/12/2017 and told me that the left side had a little hole and therefore he just went over it with a small permanent suture. On the right side he told me that he used a german mesh called dyna mesh which has big pores and is soft. He said he used that because the posterior wall was weak.
          After surgery i was in a lot of pain for the next few days and had local ansthesia 3 times before i returned to london. Nothing felt right . Nor my right or left side. I was told to be patient and wait as it was recovering and there was a lot of scar tissue he removed. My complaints never stopped since. My left side reoccured as soon as i had my first bowel movement in london. The right side lasted a few months however it felt so uncomfortable and as if my body was hanging stuck to something. I continued waiting in discomfort until about the 6th month as i was told not to do anything for 12 weeks.
          I started running once supposedly better and it was constant pain. I kicked a ball gently and straight away my right side felt like someone had cut me with a knife. From then onwards my right side got worse and worse and within a week t was bed bound everytime i tried doing sports
          In early june or late may 2018 the doctor was in london and i kindly asked if he can reasses me and see wether the hernias reoccured. He looked for a few seconds and told me once again that its not a bulge its blood running through my veins and the pain is caused on the right side by the scar tissue readjusting and reforming due to there being a mesh. I was very frustrated as i knew he knew that i had both hernias as kt was the same bulge that was there in the first place which he assesed and said surgery was needed back in 2017. Out of frustration and desperation i contacted the shouldice clinic. I told them of the situation and spoke to the chief surgeons assistant.
          She said he was dissapointed a shouldice technique was used using absorbable sutures. The clinic told me this dosnt represent the success rate of the technique as a main area was altered with by using sutures that are absorbed.
          she also told me that the main part of the technique is actually having the cremester muscle cut as this reduces the chances of reoccurence.
          They were even more shocked at the fact that the surgeon decided to reoperate after only a few months. The chief surgeon said that at the shouldice clinic there is a one year wait for re surgery as it roughly takes this long for the muscles to heal and be at a good enough level to be restitched. They said my second surgery was a pointless attempt as failure was the only option due to being so fresh from previous surgery.
          A lot of surgeons on their website or when u speak to them directly, will state they are shouldice trained when this is not the case. The clinic told me that they only allow doctors to observe for a few days whilst surgery is being taken place and that no training is given.
          after speaking to the clinic and pleading for help the surgeon decided to operate on me at the end of this year or otherwise i had to wait till may 2019.
          when they found out i was 105kg and that i was that weight when i had the first surgery, they wernt too happy. They booked me in and told me that i must come in at 89 kg for them to operate on me as this will allow the surgery to have a higher success rate. Its been 6 weeks since i first conctacted shouldice and today i am 91kg.
          There has been a huge difference in the way i feel since ive lost the weight. The side with no mesh is literally pain free but just a bit restrictive however the right side is more painful and have sharpen pains since the weight loss. I generally feel a lot better since the loss and maybe thats due to also recovering.
          ive had a very bad time over the last few years especially last year and its put me through a lot, mentally, pyhsically and financially.
          The proffesionalism of the shouldice clinic is what has impressed me the most. A leading hernia mesh removal surgeon dr kevin pietersen if im correct, states on his website if he were to have any issues in realtion to a hernia he will go to the shouldice clinic. And touching on mesh removal, the shouldice clinc do not do mesh removal unless there is a reoccurence of the hernia.
          The diet plans ive been given and the level of care even before ive stepped into the clinic has given me hope and the feeling maybe this time id end this misery and be able to live a normal life.
          My surgery is sceduled for the end of november and sadly or funnily, however it may seem, i am looking forward to the next surgery day just with the hope that i might be able to one day make a full recovery.


          • #6
            Thank you for posting that Baris. It sounds like you've been through the wringer.

            It's a shame that these professionals can't get together and discuss the pros and cons of what they do without criticizing the other methods, and guarding their own. All of the methods seem to have horror stories attached, and all seem to have inherent flaws. But they all seem to have some positive stories too. If they could just share the knowledge with a combined effort to determine the best method for the individual patient, everyone would be better off.

            Here is a link to a thread I started about good mesh stories. The last one I posted, #30, is one of those positive stories. Keep it and the surgeon he used in mind if the Shouldice technique doesn't stick. It's a mesh-based procedure but the person had very good results. I wish we knew why. I'm not promoting mesh by any means, just offering a "known-good" repair's surgeon. Good luck.



            • #7
              Baris Thank you for the update and for sharing your experience, this is important data to know and it will undoubtedly help other patients in decision making. I'm sorry to hear that your initial procedures failed and I wish you the best in your future re-do surgery, and please keep us updated on you progress and how that goes.

              I believe the Shouldice clinic uses ultra-thin stainless steel sutures, which are presumably very strong and maybe that's another reason why they have such great success at the Shouldice hospital in Toronto. Just theorizing here but maybe the absorbable sutures used in your first repair dissolved before the muscles had a chance to fully regrow to one another.

              Out of curiosity, what is the general weight-loss diet that Shouldice recommends to their patients? Low carbohydrate?


              • #8
                Hi chaunce,
                yes maybe tgat was the case but would it be right to state uve learnt the tecnique in canada and do the same thing but change a main area to it in terms of sututres?? That just becomes a new technique in my eyes and maybe if yhat was discussed prior to surgery that would of been much more ideal in enabling me to make the best desicion. The diet is a very low carb one and specifically states that it is temporary due to the sudden changes and reduction in calories consumed. I just believe its super healthy and i can manage it forever if i really needed too and a lot of previous shouldice patients have stated that they actually do continue with the main concepts of the diet. Id certainly say i feel much better.


                • #9
                  Hi good intentions,
                  in terms of mesh i am not against it. I understand that it is needed in some cases especially with elder patients with direct hernias. What frustrates me most is the fact that i had two indirect hernias which with the shouldice technique mesh is pretty much never needed as stated by the chief surgeon. I have images of the hernias whilst in surgery and the space the fat has come out of is very small. And maybe that explains why im in so much pain.
                  In terms of mesh i wouldnt be able to say but for no mesh surgeries i really do believe losing weight especially fat will enable a better repair and also recovery.


                  • #10
                    Originally posted by Chaunce1234 View Post
                    Dr Andreas Koch in Germany (unsure of location)
                    He is based in Cottbus, east Germany.


                    • #11
                      It's quite worrisome and depressive reading Baris such bad experience in Germany.

                      People who search for Dr. Koch want a non-mesh repair and most of them are thinking about Desarda, but I think Desarda is the repair least done by him.

                      Anyway, I thought that he could tell before surgery which repair would be most suitable in his opinion, either by examination, or requesting any exams.

                      Deciding on the operating room for a mesh or non-mesh or Desarda or "modified" Shouldice doesn't look nice.

                      After reading this I think that one can get the surgery one wants only if they go to specialized clinics like Desarda's in India, Shouldice in Canada, or Dr. Kang in Korea.

                      When searching for surgeons I found one in Germany that could do some 8 repair types with training in lots of Clinics throughout the world. I discarded him right away because only a superman could be enough proficient in so many repairs... Any normal surgeon would do any of them once in a while and hardly would be that proficient.

                      I really hope Baris is finally in good condition with his repair in Shouldice after so many bad experiences and spending so much money with all those experiences.

                      All this makes me think twice as my hernia is only esthetic, everything working fine and zero pain. Even if esthetic is quite important too and makes me miss a lot the time I had my groin area in perfect condition and didn't know I lucky I was.


                      • #12
                        I found an article by 3 German surgeons who did Desarda repairs in Rostock:

                        "Inguinal Hernia Repair According to Desarda - Implementation of a Mesh-Free Method in a German University Hospital" (2015)

                        The article is written in German and requires subscription. It's a 2-page article and first page can be read as preview in Thieme's site.

                        Authors are
                        Phillip M, Förster S and Klar E. I could only locate Dr. Ernst Klar who is Director at the center where repairs took place.

                        I don't know how many patients were operated and results (abstract in English at Pubmed doesn't disclose that).

                        All information in center's page in Rostock is in German, so it seems they're not looking for foreign patients, but this can be an additional contact in Germany for people wishing to have a Desarda repair:

                        Prof. Dr. Ernst Klar
                        Abteilung für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie
                        Universitätsmedizin Rostock

                        In clinic's site there's contact information for Prof. Dr. Klar (Secretaries Anja Meschke and Frau Stein).

                        If anyone can find info on the other 2 authors, please share here.

                        Rostock is in Northern Germany and I could find a single flight there. It's operated by Lufthansa and travels Hamburg-Rostock in about 1 hour.
                        Universitätsmedizin Rostock. Spitzenmedizin für die Region. Forschung für den Menschen.


                        • #13
                          I'm sorry you had this bad experience Baris. I know it's of no comfort to you, but it needs to be said that not every operation has the same outcome. We are all unique, and there are many variables that influence the outcome. I think that's also what makes surgical studies difficult, because you have so many things to consider and measures to compare across, the results easily become diluted and incomprehensible or inconclusive.

                          Did you say you had triple hernias? Two indirect hernias? Scrotal even? What was the third one?

                          I had my surgery at the hands of Dr. Koch about 1 month ago now, and I can assure you I am 99% recovered, I have fully restored function in my groin, I have no pain or discomfort. Frankly I can't believe it ended up being this good. If I knew I would have had it operated on years ago. But I only had one, indirect hernia on the right side. I had it for about 8 years, and if I had not repaired it I think it would have gone down to the scrotum which would have complicated things. So the lesson I learned is that as soon as you recognize that you have a hernia you need to start doing your research and making plans for repair. It should not be postponed. The trouble with postponing is that you start stacking problems one on top of the other. This is true for all ailments, not just hernias. Problems are meant to be dealt with, the sooner the better.

                          Dare to ask questions! I knew exactly what type of inguinal hernia I had (indirect), why I had it (congenital), and what type of repair would be done, and I even knew what type of sutures and gauge would be used. I was told all these things by Dr. Koch. But I got many of these details by simply asking him, it's not something he will tell you unless you ask. Most people will find this level of detail boring or even frightening, and while my experience with ordinary general surgeons who don't specialize in hernia surgery don't even tell you what type of mesh they will use, Dr. Koch is ready to answer all your questions.

                          Yes, Dr. Koch uses a modified Shouldice repair. But I knew that before I even came to Germany. Because I knew what the so called "original" or genuine Shouldice entailed, because I did my research beforehand. Using steel wire for suturing? Are we still living in the 18th century? I am glad that Dr. Koch uses a combination of absorbable and non-absorbable synthetic sutures. And why would he cut the cremaster muscle unless he needs to? Just because the Shouldice clinic dictates so? Because the inventor of the technique – Dr. Earle Shouldice – who lived in the 20th century used a steel wire and used to cut the cremaster muscle? The technique used should be fluid, not a static teaching from the previous century, just so you can say that you are staying in touch with the tradition.

                          What I liked the most about Dr. Koch is that he is approachable, he listens and adapts to your specific needs. There is nothing worse than blindly following the teachings of an old school just for the sake of preserving the tradition. Be water! As Bruce Lee would have put it. Formless! Shapeless! Dr. Koch uses the same principle. Could it be that Dr. Koch is the Bruce Lee of hernia surgeries?

                          All the major and minor hernia repair techniques are improvements or modifications of one or the other. You have McVay, Desarda, Shouldice, Bassini... I don't recall now what order these came in, but I am pretty sure the "original Shouldice" borrows from some other technique, and that's alright, that's how it should be. Borrow freely what you find useful. That's the only way to a better way. How does that old saying go... all artists borrow, the best ones steal?

                          Losing fat prior to surgery is always a good idea, if you can manage, regardless of type of repair or even type of surgery being done. I started doing strength training and conditioning 2 months prior to my surgery.

                          As I recall I got 10 big wound dressings in my goodie bag. On day 2 after the surgery I could hardly get out of the bed on my own and stand up straight. I walked like a robot. I did not have much pain, but I was feeling very stiff and my abdominal muscles were tense and I even had episodes of twitching. That's because it was sutured in. Dr. Koch told me that this is normal and that the muscle needs to remodel itself, and so it did. I estimate that for each day that went by I was feeling 9% better. So right about day 10 I was nearly 100% recovered and I was feeling like myself again. I thought to myself this is amazing... Dr. Koch has accurately assessed how many wound dressings I would need. From that point on I saw nothing but improvements.

                          Right around the end of week 3 I reactivated my gym membership and started doing some light cardio workouts. After week 4 I started doing some weight lifting. I could not wait to start hitting that gym again, and I am dead serious about exercising now. I have never exercised this much in my whole life. I exercise 5 times a week with 2 days off during weekend. I am nearing the end of week 7 now and I am doing squats and pull ups, something I could never do before. I have never been a fat guy. I used to compete in athletics for a local club, I did that for 7 years, I trained karate for 3 years, I gave tennis a shot, among other things. I am what you would you might call a normal guy, just a little bit over the "normal" limit if you look at the BMI or waistline. My hernia is/was mainly congenital, but having a sedentary job did not make things better for me and frankly I believe that's largely what contributed to my hernia (loss of supportive lean muscle).

                          There are a lot of things to be said about the surgery, but I have nothing but only positive things to say about my experience with Dr. Koch.

                          I can highly recommend Dr. Koch to anyone looking for...

                          1. A surgeon who listens and tailors the surgery to your wishes and needs.
                          2. A highly skilled hernia surgeon with special training in Shouldice repair.
                          3. Well educated and informed surgeon who keeps in touch with the literature and the hernia field.
                          4. A surgeon within Europe that does mesh-free hernia repairs.
                          Last edited by John Fortem; 06-30-2019, 12:17 PM.


                          • #14
                            Ah yes! I got it now. Dr. Shouldice was influenced by Dr. Bassini. Here is an excerpt from a book called Textbook of Hernia, published by Springer in 2017, where Dr. Koch is a contributing author. I believe he penned the part about tailored approach and history of hernia repairs. Here we go...

                            "The ancient history of inguinal hernia is remarkable with many creative but mostly futile approaches to its treatment. One illustrated and informative resource for the work and workers of that era are the early chapters in Hernia Healers by Stoppa et al. [14,15].

                            The modern era of inguinal hernia repair began with the works of Bassini [16]. He recognized that the transversalis fascia was the Achilles tendon of the groin, the layer through which hernias develop. He proffered that to correctly repairan inguinal hernia the groin must be dissected layer by layer knowledgably and carefully from the skin into the preperitoneal space. Only then could the muscles, fascial elements, vessels, nerves and vassal structures be identified and preserved. His reconstruction began with the posterior wall opened. After checking for a femoral hernia,he dissected the peritoneal sac to its true neck and ligated it there. He then used a three-layered interrupted suture repair to reconstruct the canal’s posterior wall. His deepest suture line included the lateral edge ofthe rectus muscle, the internal oblique muscle, the tranversus abdominus muscle, and the medial edge of the transversalis fascia. He approximated that four-layer composite to the lateral edge of the transversalis fascia and the inguinal ligament. He replaced the spermatic cord in its normal position and sutured the external oblique aponeurosis to comfortably re-create the obliquity of the canal and the external inguinal ring. In his earlier operations, starting in 1844, Bassini insisted his patients be awakened enough from anaesthesiato perform straining motions to prove that his repair was sound. Bassini’s results for inguinal hernia repair was astounding compared to the poor results of other surgeons of his time. With 90 % personal follow-up of 262 casesover 4 years, his failure rate was less than 3 %. He eventually reported this in a paper entitled, Nuovo metodo operativo per la cura dell’ernia inguinale. While some have noted that Bassini never specifically wrote about the importance of opening the posterior wall, illustrations by his devoted pupil, Catterina, clearly showed that he did open it and that he had described doing so in his own paper, Bassini’s operation for the radical cure of inguinal hernia [17].

                            Bassini’s true repair was altered and became known as the Modified Bassini Repair/North American Bassini Repair as was its impressive results. Many North American surgeons, influenced by Andrews, did not appreciate the importance of completely reconstructing the canal’s posterior wall. Most simply ligated the peritoneal sac and pulled the transversus arch to the inguinal ligament, frequently under enough tension that a relaxing incision was needed. The short-and long-term result of the Modified Bassini repair was not good. Most failures could be traced to the inability of tissues pulled together under tension to withstand normal intraabdominal forces associated with ordinary bodily functions.

                            In the early part of the twentieth century severalother suturing techniques were used to approximate the internal oblique and transversus abdominus muscle, with or without the medial flap of the external oblique, to the shelving edge of the inguinal ligament. The “Darn” technique was popular in the UK, Europe and the Far East [18]. Continuous single or double strands of nylon or silk suture that bridged the canal created a mesh-like structure. This technique never gained much interest with American surgeons.

                            E.E. Shouldice, a Canadian surgeon, revitalized Bassini’s original principals of inguinal hernia repair [19]. Using a local anaestheticShouldice dissected the structures of the groin including opening the posterior wall into the preperitonealspace. Differing from Bassini’s interrupted suture technique, Shouldice used continuous 34-gauge stainless steelwire to reconstruct the posterior wall and repair the hernia. The results of many-thousand repairs at the Shouldice hospitalare impressive. Shouldice championed using local anaesthesiaand insisted on patients ambulating early. His detailed dissection through the double layers of transversalis fascia, along with the contributions of Rives and Stoppa of Franceand Nyhus and Condon in the USA and the earlier work of Henry and Cheatle helped set the stage for the eventuality of posterior repairs."
                            There is more to read. This is the book:

                            Last edited by John Fortem; 06-30-2019, 12:29 PM.


                            • #15
                              I appreciate very much Fortem's reports and am happy he's doing well.

                              However, Bari's case can't be disregarded and there seems to have been not much dialogue there.

                              Shouldice Clinic is a reference in inguinal hernia. They're a highly trained team who only do that and they're as paranoid as people in Rolls Royce. So, one single doctor, however good he or she can be, will have a hard time formulating a sound argument they're wrong. If they say something is important, chances are more than 99% it is.


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