The problem with Shouldice or The most dangerous phrase in the English language- “We’ve always done it this way.”

I have just been chastised online for daring to criticize the Shouldice clinic on Twitter.  So I’m going to outline some of my problems with the Shouldice clinic, which is held up around the world as a great Canadian healthcare success story.  I am not going to comment on specific cases, just generalities here.   I have never worked at, or been involved with the Shouldice clinic, so this blog comes from my own professional opinion as a general surgeon/hernia fixer and defender of evidence based medicine and socialized healthcare, discussions with many patients who have gone or are considering going to the Shouldice clinic, going to a talk some years back given by a surgeon who worked there, and the Shouldice clinic website.

The Shouldice Clinic is a private clinic operating in the Toronto area which has been open for decades.  It was originally founded during World War 2 to allow for young men to have their hernias repaired before going off to fight.  It was then allowed special licence by the Ministry of Health to continue operating.  It has been repairing hernias for decades.  It was recently taken over by a private company and is no longer in the hands of the original Shouldice family.  The clinic sits on luxurious grounds and offers one thing and one thing only.  Hernia repairs at the Shouldice are done with local anesthetic, no mesh insertion, and with a long stay in their hospital to recover.

Now as a confession of a conflict of interest here, I am a general surgeon who does lots of hernia repairs at a hospital about an hours drive from the Shouldice.   I think 3 or 4 tomorrow in fact.   The standard of care when the Shouldice was formed was a primary (suture) repair and lots of days in hospital recovering from the pain of having your own tissues reamed together to repair the hernia.  I really don’t want to get into a lot of detail about the complex world of hernia repair here, but the world surgical community has moved on from primary repair with lots of inpatient days and the Shouldice has not.  Is this because Shouldice thinks this is good care?  Is it because they make lots of money off the patients and the taxpayers?  Or is it because, here it comes, that dangerous phrase “We’ve always done it this way”?  Likely some of all three.   Another confession, I also make money doing hernia repairs, but I don’t make nearly as much as the Shouldice does off their patients.  The “standard of care” now is to do hernia repairs with mesh, a plastic like substance which allows for less pain (if inserted properly), earlier return to work, and decreased recurrence rates.  If I was doing the Shouldice repair with no mesh and keeping my patients in hospital for 5 days after hernia surgery, I would probably have my competence questioned, and with good reason.  I would also, I hope, be getting angry calls from our hospitals administrators asking what the hell I was doing keeping patients in hospital for so long after such a simple procedure.  Groin hernia repair is a day surgery procedure in Ontario (anywhere but the Shouldice clinic) with no overnight stay required, unless complications arise or in very frail or sick patients.  I cannot recall a patient ever having been in hospital for 5 days after elective hernia repair.  The Shouldice clinic admits patients the day BEFORE their surgery.  I find this mind boggling- this approach was abandoned in the rest of medicine decades ago.  I honestly cannot recall the last time I admitted a patient the night before surgery, except when I was a clinical clerk, and that is going back a long time now.  The vast majority of procedures are day surgery, or what we call same day admits, where they are admitted (usually after a lot more major surgery than hernia repair) after their operation.  Being in hospital has its own set of complications, with hospital acquired infections, pneumonias, blood clots in the legs or the lungs, and other problems.  But my main problem with this approach as a taxpayer is that this is a huge waste of healthcare dollars.  The Shouldice clinic charges patients for a private room for up to 5 days (this adds up to many hundreds of dollars).  Sometimes this cost is paid out by private insurance companies if the patient has a health benefits plan, or by the patients themselves.  The Shouldice then also bills the Ministry of Health for each inpatient day a patient stays overnight.  So yes, that is you, the taxpayer, footing the bill for unnecessary care being provided by a private company.  Now some of the Shouldice clinic patients come from out of country and should be paying for all of their care but what this percentage is, I do not know.  Shouldice also does not require a doctor’s referral to see patients and bill the Ontario health care system.  As a specialist, I am not allowed to bill OHIP to see patients without a referral from another doctor, and so we see the double standard growing.

Now the Shouldice clinic does do something I agree with in part.  Patients are required to be within 20 % of their ideal body weight, and are refused surgery at the Shouldice if they do not meet this criteria or lose the weight.  The average North American is gaining 1-2 lbs per year, and obesity is a clear risk factor in hernia recurrence.  The more you weigh and the more weight you gain after hernia repair, the more your risk of recurrence rises.   Now I do on call, a lot, at a smaller hospital, and it is not my practice to refuse hernia repair to overweight patients, unless it is a very large, recurrent hernia, in a very obese or frail patient, where there is little risk of bowel obstruction.  Odds are, I am going to be the one digging out a blocked or gangrenous piece of bowel from this hernia in the middle of the night if I do not fix it electively.  So while I agree with patients having to lose weight for some surgeries, I cannot on a practical level be that picky about it. Shouldice of course sends most of the patients it sees back to where they came from, and does not have to worry about complications or ongoing issues from their repairs.  They do not have to do emergency general surgery, ever, how convienient.  Most general surgeons will tell you that they cannot get patients to lose weight before surgery, and that has certainly been my experience.  Shouldice effectively skims off elective procedures in a very healthy, wealthy, and slim segment of the population that is extremely motivated to get their hernias repaired at this private clinic.  This makes any numbers they publish about their recurrence rates completely out of touch with the reality of what myself and other general surgeons are dealing with in our practices.  The other thing about hernia repairs is that recurrence rates have always been very hard to measure.  You have to follow patients for decades to know your real recurrence rate, and patients also are not likely to go back and see the same surgeon (or a clinic) once they have had a recurrence.  This makes anyone’s numbers on hernia repair difficult to interpret, but the Shouldice’s number in particular should be viewed with a grain of salt.  One patient told me he didn’t want to go back to Shouldice with his recurrence because he couldn’t afford it.  I wonder if they know about him, or does he go into their success pile?

Now patients will generally think that more care is better care.  So five days in hospital must be better than no days in hospital, right?  We know that asking patients about their satisfaction with their care has nothing to do with the quality of care provided.  In fact, the most over investigated, over treated patients are likely to think they have great care, when the opposite is the truth.  The Shouldice clinic is a good example of that.  I am also not a fan of the idea of “Centres of Excellence.”  The idea that high volumes of doing one thing only makes you better at it.  I went into general surgery because it’s well, general.  I love doing a variety of different procedures in patients of all ages, sexes, shapes and sizes.  It’s one of the great things about my job.  If I was doing only one operation, the only thing I would be is bored. There is some evidence that using generalists is a cheaper, better way to run a health care system and I believe that.

This is a microcosm of what happens when you introduce private interests into a socialized health care system.  In Australia, the introduction of private healthcare has resulted in exactly what has happened here, albeit on a much larger scale.  A skim off of the healthy and the wealthy to the private system, leaving the public system to deal with the emergency, unhealthy, and poorer patients.  I do not believe in the argument that the Shouldice doing so many repairs allows for more hernias to be repaired in our public system.  The amount of money being drained away by this clinic from the public system is opportunity cost, not just for hernia repairs, but all healthcare spending.

So one last confession.  I had two hernias repaired in November last year.  I got a colleague to do it, with mesh, and a general anesthetic, as day surgery, in one of our local hospitals. I went back to work in less than 48 hours and I am very happy with my scar.  I would recommend this approach (and frequently do) to anyone, including my patients.

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54 thoughts on “The problem with Shouldice or The most dangerous phrase in the English language- “We’ve always done it this way.”

  1. Most patients I know of that go to Shouldice go there specifically for the expert all-tissue repair, the classic ‘old fashioned’ hernia repair sutured with their own tissues. That is, to avoid mesh and avoid any of the potential complications from mesh (primary fear usually is chronic pain in the groin, mesh migration, foreign body sensation from mesh, etc). Whether that fear of mesh is warranted, I do not know.

    There are definitely many who travel to Shouldice from the USA, where last I heard it runs somewhere around $6500 paid out of pocket for an inguinal hernia repair and the multiple night stay in a facility that supposedly feels collegiate. That may sound expensive to people from Canada or anywhere else with a cost effective health care system, but keep in mind that health care in the USA is extraordinarily expensive. Without insurance, an open hernia surgery is easily $20,000+ if not more in the states. Even with insurance in the USA, high deductibles and co-insurance means hernia surgery is still a very hefty expenditure well into the thousands, it could easily be the price of a Shouldice repair, but performed by someone with not nearly the expertise. On another topic, but those expenditures offer a glimpse as to why medical bills are the primary reason for personal bankruptcy in the USA.

    And yes, Shouldice cherrypicks their cases, perhaps because they can. They do not take overweight patients, they do not take complicated cases, and they do not take hernias that are not obviously visible right at the time of surgery itself. If you don’t have a very classic bulging abdominal or groin hernia, they are not going to operate.

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    1. You are correct, I lived in Australia and know even gap fees can bankrupt people with insurance. Mesh CAN be a nightmare if not inserted properly, and maybe I would be able to get away with not using in a very slim patient, but I consent patients thoroughly to all the risk factors. Hernias do just get larger, and there is also the issue of not being able to travel if you don’t get it fixed (pre-exisiting condition).
      Thanks for the comment and info. Very interesting.

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      1. I was suprised by your posting. While my knowledge of Shouldice is not direct, it is close to home, and entirely contrary to what you have said. My father, a neighbour, and a former co-worker have had hernia repairs in the last few years. I’m not a medical professional of any sort, but I’m capable at measuring time – the first two (father and neighbour), went to Shouldice and returned within 48 hours and their usual routines – somewhat ecstatic about the result, and with no need to revisit the surgeries since. This is why they went to Shouldice in the first place, in the Toronto area it has a kind of mythical acclaim. “Want fast and effectively perfect hernia repair? Shouldice” I learned the name even before it had become personally relevant and noted it.

        The example of my coworker is different. He had the choice of Shouldice or a Toronto area hospital. He chose the hospital. Why? Somehow he would be entitled to weeks of paid leave with the hospital option due to healing times for their style of treatment whereas with the Shouldice option he’d be back at work in a few days.

        I would love to see some frequency distributions for Shouldice repairs vs inpatient time and time back to work. This should be broken down into smaller samples to isolate by type of procedure or severity. Naturally I’d like to see the same for the hospital system. I’m sure there are anomalies in either system, but like I said, I’m rather surprised to hear that a place that is known for its speed (even among layfolk that have no business following the performance of hernia clinics) is being depicted as slower than public held alternatives.

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      2. I guess my point is that everyone who goes to the Shouldice is going to have a good outcome, because they are doing the slim patients. I would love to see their numbers as well, but that is unlikely to happen soon. I would even love to go there and observe their technique, but they are not in the business of educating surgeons, just skimming off our business. Surgeons get really angry when people are allowed to do elective surgeries without providing on call services, which is essentially what the Shouldice is doing. I don’t know what the exact policy is on inpatient stay at Shouldice, the website said at least one day pre op, and an unspecified number post op. Possibly related to how much private insurance you carry. While I do like my patients to rest after surgery, they don’t need to do it in a hospital setting. As for speed, I think they say it takes around 30 minutes to do the surgery, and they have a short wait list. Not speed of hospital discharge. I always tell patients it takes as long as it takes to do a safe operation. Thanks for your comments.

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      3. I’d be curious to see some data comparing patient outcomes for slim patients at Shouldice vs the rest of the system. Lot of disparity in the anecdotal evidence (my understanding has been that in at least once instance a patient was offered a days long recovery at Shouldice vs weeks long at a hospital, and that has been constant with my knowledge of their reputation in general). Hard to be critical regarding matters of efficiency without data – descends into rhetoric pretty quickly.

        In general looking forward to a day when performance stats for regulated professionals and their related clinics/practices will be available for scrutiny – then we can all make decisions based on merit rather than hearsay or fuzzy notions of reputation etc.

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      4. You can travel with a hernia as long as it’s been 3 months since you were seen for it. After 3 months, 2 months with some insurance companies it is no longer considered a pre-existing condition. Also, you didn’t say if your two hernias were repaired laproscopically or open.

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    2. Hi, I am the “diabetic obese patient with an abdominal hernia”. I live in Montreal, soon to be living in Ontario. I’ve tried to get surgery twice. The first time I was sick with a high white blood cell count and they send me back home this was 5 years ago, 3 years ago I tried again and this time I had diabetes and they told me to go back home on the day of the surgery because I was coughing too much, the reason I was coughing was because of Ramipril a HBP medication. I since switched meds and lost a bit of weight but It’s so difficult to even move with a cantaloupe sized abdominal hernia. I wonder what steps should I take once I’m ready to see a new surgeon in Ontario? I’ve had this hernia since I gave birth to my child 9 years ago and my life has been very bad since. I can’t get a job people think I’m pregnant or will need a leave of absence. Should I wait or should I see a surgeon right away? Thanks.

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    3. Tell me about it..I had an accident at work. .1st operation to save my life. The huge incision ripped internally and of course I wanted to choose the BE ST surgery clinic to repair it so it would not happen again. I am now currently here in August 2016. .One year after this major Shouldice surgery in MAJOR pain EVERY day and night I NOW look like a fucking mutant due to their amazing technique over there at Shouldice and to no email at least 15 trips back there and numerous emergency visits and NO family doctor. .you should see the Gigantic infection I received from them and the sutures that were coming out of my incision

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  2. The Shouldice will not be handing over their data anytime soon, unless forced to, I can say that with confidence. Maybe a freedom of information request needs to be filed so accurate comparisons can be made. Anyone can look up what a surgeon in Ontario gets paid to fix a hernia. It’s not much. This clinic needs to keep people in hospital to make money. As I said at the beginning, this blog is my opinion and I have a conflict of interest BUT evidence based medicine would say you need to be doing hernia repairs with mesh. That is not my opinion, it is just a proven over and over medical fact. No public hospital in Ontario would be keeping groin hernia repair patients in hospital overnight without some underlying compelling reason. Large ventral/incisional hernia repair or complex abdominal wall reconstruction- different story. Of course, that is difficult work which the shouldice is not interested in.

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  3. I don’t know where you got your information that the Shouldice doesn’t use mesh but this is incorrect. I have had direct experience with Shouldice where my husband had a large abdominal hernia repair and they did use mesh and the head surgeon gave a long history of their use of mesh at one of our appoinments. Also, he only went there after years of being discouraged by general surgeons such as yourself but after multiple failed hernia surgeries by these same general surgeons. The last one before going there was a laproscopic surgery done by a cocky 40-something that failed before he even left the hospital & then turned into a fistuala which the surgeon was in denial about for months & could have killed him. Also, they don’t just do simple hernia surgeries on skinny people. My husband was asked to lose weight for the surgery but still was not “skinny”. They do this to improve success rates (which of course patients want too) to reduce fat in the tissues which, I imagine you know but others might not, is a factor with or without mesh. I don’t want to come off too confrontational but I am going to be blunt. We all want the best, most cost effective public system but critiques must look at the whole system. And I appreciate that is frustrating when Shouldice info is hard to get but I can tell you follow up & accurate reporting of success rates for the rest of the system is just as unreliable because of useless record keeping. I’m not happy about Shouldice being sold to a private company but I do not see that your critique of their prior history is based on any accurate or well-analysed information. Do you yourself know how many of your hernia surgeries fail? Have you or your staff followed up with all your patients? I would imagine a lot of people wouldn’t go back to someone who wasn’t successful with their surgery the first time unless it was very minor surgery. This is part of the problem with our record keeping.

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    1. You are correct, we should have much better reporting systems than we do. EMR should allow for reporting of all surgical complications and feedback to the surgeons on their complications, including how many of their hernias recur. This is so important, but our electronic medical records do not allow that to happen at this point in time. I do not feel Shouldice does an honest job of their success rate, but they are not the only place or surgeon to do that for sure. Sorry your husband had such a tough time with his hernia, hope he is doing well now. I absolutely follow up all my hernia patients. I do have recurrences, about 1 per year but I find since I have warned the patients about this they are usually pretty accepting of it and happy to come back to me for another repair. Informed consent is crucial. If I had an unhappy patient who did not want to have surgery with me again, I would refer them on for a second opinion. Most of my comments refer to groin hernia repair and as I said at the beginning, are based on my opinion as a medical expert and fixer of hernias, not on any raw data, which of course is not available.
      Lastly, I really feel strongly that clinics and surgeons which do not do emergency on call work should not be allowed to operate on an elective basis. On call is hard but necessary work and I , as a Royal College trained surgeon, would not be allowed elective operating time anywhere if I did not offer on call services.

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  4. I’m not sure what you mean by *elective* with regards to hernias except that I imagine they like many surgeries mostly don’t need to be done on an emergency basis. From a patient and voter point of view, I don’t see why all surgeons need to do emergency or on-call work. I can accept that this is work that should perhaps be compensated at a different level because of it’s extra demands. If this is an arguement that many surgeons feel should be addressed then of course I would be open to hearing the arguments for it but I believe our health care system should have a structure that’s based on requirements necessary for delivering good outcomes for patients at the best cost. I would have to see why, based on outcomes & diversity of treatments required, doctors/surgeons should have common requirements for their practice.

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    1. Surgeons need to do emergency work or perforated appendicitis, gangrenous gallbladders, and blocked bowels (sometimes stuck in hernias) would not be dealt with, and patients would die. In a socialized model of healthcare, allowing some hospitals and surgeons to absolve themselves of this emergency work is unfair and leads to their claiming to have better outcomes. No kidding Shouldice will have better results than me when they do not have to operate on an obese diabetic at midnight who is dying from a piece of blocked gangrenous bowel in his hernia which they wouldn’t fix electively because he was too heavy! It’s called cherry picking the easy cases and its exactly what Shouldice does. And it really annoys surgeons, including me. So you are absolutely right, there should be requirements for all surgeons and health care providers to follow evidence based medicine and try and make patients better.

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      1. I don’t understand why it should annoy you or any other surgeon if a place does *easier* surgeries that can be done efficiently. Does it annoy surgeons that many many *easy* abortions are done in clinics rather than hospitals? In any case my husband’s case is exactly the kind of many complicationes hernia that you are talking about although all his many failed hernias and the fistula repair that involved having a large part of his bowl removed were done at major hospitals. Shouldice, like you said, does not do that kind of thing. And I agree that we need to have tracking of surgical outcomes to verify the success of various techniques, whoever does them and whereever they are done, but making everybody do emergency & other more involved surgeries doesn’t address that. If someone has a hernia surgery at one hospital and then develops a complication they could easily end up at the emergency department of some other hospital having the repair done by a completely different surgeon. Success rates should indicate level of difficulty/complications/etc but why as a patient should I not be happy for surgeons to develop specialty areas or clinics for easier surgeries that do not need to be supported by the larger and more costly structure of a full hospital? I would like to see much more transparent reporting and rating of all surgeons & hospitals & clinics. There are certainly many issues to be factored in but as a patient my number 1 concern will always be having surgeons working in environments that are conducive to producing good outcomes for patients and I have not yet seen any convincing arguments for disallowing the development of specialties though I do have concerns about the influence of profit as a motivating factor. But the reality is that in Ontario anyway, major hospitals are getting as bad as any private clinic in letting cost considerations trump quality of patient care, but that’s a whole other topic.

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  5. Hi there – what do you believe offers the least chronic pain for hernia surgery (inguinal)? Mesh or the Shouldice method?
    From studies (which are few and far between), they both apparently have the same amount of chronic pain sufferers. I have an inguinal hernia which is more annoying than anything since I play a lot of sports (not painful), but more so I am afraid of chronic pain after the surgery.
    Any advice would be appreciated, I am athletic, non-smoker, late 20s.

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    1. Hi Tyler. Chronic groin pain after hernia repair is a concern, no question. A groin which has been operated on for hernia will never feel the same as before the hernia repair, but for the vast majority of patients they will be aware if their repair, or have to take medications for it. Chronic disabling pain which needs ongoing pain medication and/or other management (including mesh removal in the most severe cases) is thankfully extremely rare after groin hernia repair, be it with or without mesh. Your hernia will need to be fixed, no question. I would address your concerns with the operating surgeon. I discuss chronic pain issues with patients before surgery and try and make sure the nerves are away from the repair. I do believe mesh allows me as a surgeon to do a tension free repair which causes less pain, both acute and chronic, post op. You are correct though, there are not good studies comparing the two methods. Mesh has become widely adopted because it decreases recurrence rates of hernias, not due to concerns about chronic pain.

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      1. Thanks for getting back to me. I live in West GTA – if there’s any way for you to recommend me to be looked at by either yourself or a trusted colleague. I just want the best treatment possible with the lowest chronic pain! (As does everyone). I’ve read of issues with all repair methods except for TAPP laproscopic – have you heard of it?
        http://www.ncbi.nlm.nih.gov/m/pubmed/15243743/
        Study is here- older and from 2004.

        By the way, my sister is an RN at HHS who recommended Shouldice from what a Doc recommended to her. My email is attached here if you would like to email me! Thanks for such a great blog, very helpful and interesting.

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      2. Hi – thanks for your article. Two questions: (1) do you think a surgeon who did 30 laparoscopies in residency and 5 shortly after in private practice is sufficiently experienced to do bilateral inguinal hernia repair with the TEP method? He went to a top medical school and top intern in residency program. (2) do you know of the desarda method of no mesh surgery? It is supposed to be better than Shouldice. http://Www.desarda.com

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      3. So firstly, it is always hard in practice to know how many surgeries it takes to be competent? or skilled? Thirty five is a fair number if done completely by the surgeon in question I would think. Secondly, I have not heard of desarda method. I briefly looked at the website, and I would have the same concerns as with the Shouldice, namely that recurrence rates for hernia repairs without mesh would be unacceptably high unless in a highly selected (skinny) population in North America.

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  6. Very interesting and enlightening article for a soon-to-be operated-on groin-hernia sufferer like me.

    Your comment/reply from January 25, 2016 AT 11:14 PM says: ‘…for the vast majority of patients they will be aware if their repair, or have to take medications for it.’

    I am guessing that you probably meant:’…they will NOT be aware OF their repair, or have to take medications for it.’

    Thanks.

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  7. This is an excellent blog. It is virtually impossible to find any real data on Shouldice. I have a hernia (incisional/abdominal) that needs to be repaired, with several other smaller hernias, however, my visit to the Shouldice sent me searching for the right General Surgeon instead. The first consultation is “walk in” which for me meant a 3 hour wait in a run down old “estate” living room. I then met the doctor who told me to lose 25 pounds and return. Realistically, I am 50, 5’7″ and 163 pounds, am I really going to lose 30 pounds and keep it off for the rest of my life? And if not, would I need further surgery in my 60s if I gain a few pounds. I asked if he felt I would need mesh and he said he didn’t know (fair enough) however, I then asked what type of mesh is used and he said ,”mesh”. When staring down the prospect of putting a foreign substance in your body, as a patient you need to be treated with respect and provide knowledge and experience when asked. I then asked “where do patients go if an infection or problems arise after that are serious?” He said, “emergency.” So I arrived in emergency and drop a surgical problem on their doorstep with no follow up from the original surgeon? Too risky. Maybe if it’s a simple small hernia, Shouldice is a good choice, but otherwise, too clandestine for healthcare.

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  8. This is directed towards user, ‘Toronto’:

    I had my inguinal hernia operated on after much internal (and external debate with various health professionals) by the Shouldice clinic. I have to say, the experience was excellent. The surgeon who performed my surgery has successfully completed over 10,000 prior repairs. My hernia was considerably large and very uncomfortable (both surgeons recommended it get repaired soon as it was quite large and at risk for obstruction in the future) – in fact, I was no longer able to play sports anymore. I had little to no pain 4 days after the surgery, and other than a small scar, my groin has been perfect. I play sports 3 days a week, I run competitively, etc, and virtually no pain. Very very rarely will I feel a twinge of pain, but 99.5% of the time, I feel as good as new. I have only good things to say about the Shouldice! They actually recommended that my other hernia not get operated on as it was too small to be fixed (which was really impressive that they gave the correct advice, ‘watch and wait’). Yes, I’m not overweight, which helps, but others that had lost weight for their surgery I kept in touch with had great things to say about their experience as well. The fears of chronic pain and lack of research into Shouldice’s 99% effectiveness claim are overrated. From the group I saw (30 of us), virtually everyone was doing much better after the surgery. Go for the weight loss and then go for the surgery!!

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    1. I have been there two times for both right and left side repairs. Mid 30s in age… As with Tyler excellent experience both times with100 percent results. I have 5 years on one and one year on the latest already… Also agree out of the 30 or so both times there were next to no pain or issues just days later.. Your kidding yourself trying to talk anyone into not going here for a repair… Both the surgeons i had had well over 10000 repairs and the first one was nearing 30000. Straight truth from the USA here folks…

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      1. Thanks for sharing your positive experience Kram. I am scheduled to have a right side repair done at Shouldice next week. I’m traveling from the US and paying the entire bill myself (my insurance does not cover non-emergency out of country surgery).

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      2. Absolutely not. The reason my wife and I offer the Shouldice op in Kent UkK is the very high incidence of chronic pain after open mesh repair.
        Less with lap but google complications of lap inguinal hernia repairs and you wouldn’t touch it with a barge pole.
        In our small study no patient had any pain after 6 weeks. We take meshes out for pain on a weekly basis. over 30 years and thousands of repairs we have redone 3 for pain The last was 2 weeks ago and already he is pain free.
        Pain clinics are full of patients who have had open mesh repairs.
        We were guests at the Shouldice Hospital last year. They have permanent audit staff and know their outcome details. The problem is that the mesh industry is so powerful it is impossible to get anything published that doesn’t involve a mesh.
        To see how we do a Modified Shouldice visit http://www.herniaoperation.co.uk
        We have just reviewed 400 consecutive patients from 4 years ago and our recurrence rate is 2%.
        The NHS website now warns of a 10% rate after open mesh here in the UK

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    2. I agree with “Toronto” that it is hard to find any real data on the Shouldice clinic. People seem to either love it or hate it. My biggest concern is chronic pain, and the medical papers I have found do not give the Shouldice method the best score. It seems to be the same, or slightly worse than the common open mesh repair. Laparoscopic repairs are reported to have the lowest occurrence of chronic pain in the papers that I read. My biggest concern with the Shouldice clinic is that you might get a very experienced surgeon, or you might get a surgeon that is quite inexperienced (relative to the rest of the staff). It seems like a roll of the dice.

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      1. Best of luck Dean. I would suspect you will look back at the experience with a fondness when it is all over even… I also drove up both times. First time insurance paid 80 pecent… That was 5 years ago and as you know us health care has changed dramatically… Laat June when I had my second side done I was told nothing.. I had should ice give me the paperwork anyway and submitted it 2 times to my insurance and went thru an appeals process… Finally I did get about a 60 percent payment back… Think they got tired of me.. Haha. It’s worth a try on the appeal process though….. Again best of luck.. I know 2 other people who have gone up for repair both of which are now we’ll over 30 years on the repair without issue also….. Take care safe travels

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  9. Thanks Kram. I had my surgery done at Soldice 5 days ago. They don’t call it the “Shouldice Experience” for nothing. It’s certainly an interesting place. The grounds were beautiful and interior spaces quite nice. The nursing staff was a mixed bag, as would be expected anywhere. The food was better than I expected. The place isrun a bit like a hernia “boot camp”, which I really had no issue with. Sharing the experience with a bunch of other patients was a big plus in my opinion. Most patients never met their surgeons before surgery, or saw them afterwards. Many didn’t even know their surgeon’s name. That was a bit odd. It may be in part an attempt to keep a surgeon ratings list from being established, as patients are not allowed to pick a surgeon. But it might also just be for efficiency. Five days after surgery I’m still in quite a bit of pain, and I’m finding Tylenol to still be a must. A very hard ridge is forming under the incision, which the patient discharge sheet says should be expected. The sheet says this ridge will last for several months (oh joy). My biggest concern is chronic pain, and of course it will be quite some time before I know if that’s going to be an issue. Based on my experience thus far, I would recommend Shouldice to those who are considering it.

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  10. The biggest problem with the Shouldice hospital is you cannot choose your surgeon and like anywhere there are good ones and bad ones. Would you go to a dentist or have any other surgicla procedure done without knowing a thing about the surgeon? So why would you do so for an inguinal hernia repair, a surgery that is far from simple and fraught with potential serious complications, mesh or no mesh.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2727805/

    It doesn’t matter what method you have these days the recurrence rates are all about the same,…low. The data we need are the rates for chronic pain which is very hard to come across for any of these techniques. I’d stick to an open or lap repair with mesh applied externally. Choose your surgeon carefully.

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    1. Good points John. I would not that in Canada most people are referred to a surgeon they do not really know for most procedures. The vast majority will accept the surgeons advice and do not seek out second opinions or options for their surgery. It is nice to have met your surgeon before any surgical procedure though. And yes chronic pain is an issue which needs to be better studied in terms of techniques to prevent it and treatments.

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  11. I higly recommend Shouldice Hospital. I had my hernia repaired there on Nov 2nd. It went well. All Drs are well experienced and trained. They give you good care. The place is charming. You share good times with the people you meet there. I traveled from NY TRYING TO AVOID the horrors of the mesh repairs. The mesh industry is too powerful and monopolize the medical society. I think is a matter of profit from this industry. You dont find Drs in NY doing hernia repairs without the mesh. Thinking logically, implanting foreign materials in your body is a matter of concern.

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    1. So the idea that you think there some sort of mesh industry monopoly is concerning to me. It smacks of the sort of paranoid anti-science conspiracy theory sentiment which we are seeing rise around other health issues such as vaccinations and water fluoridation. There are many companies which manufacture mesh (hundreds) and yes they like to make money. That is simply how medical innovation for medical products in our capitalist society works. One might wonder why you could not find a surgeon in New York willing to do a repair without mesh- are all of these surgeons incompetent, immoral, or both? I doubt it- they are simply following “standard of care” which they are required to do by their licensing bodies. I have acknowledged in the comments above the rare but real risks of mesh insertion.
      The benefits of mesh far outweigh the risks for the vast majority of adult hernia patients. Cataract implants, joint implants, tubal ligation clips are all examples of other extremely safe foreign materials we implant in patients for their benefit.

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    2. Would you please share with me what kind of hernia you had. I have a rather large incisional hernia and am considering a trip to Shouldice. But I wonder if I will be told I need to have mesh after all.

      If that is the case, I would rather stay in NYC but I guess I will have to make the trip to find out.

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      1. My hernias were small (umbilical and femoral) and related to pregnancies and not a previous incision. The literature on incisional hernias is where the use of mesh was first tested. The recurrence rate for incisional hernia repair without mesh would approach 100 % for a large incisional hernia, so I (and most other general surgeons) would likely not recommend repair without the use of mesh.

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  12. Thank you for your knowledge and insights re hernia repairs. I have recently had a consult at Shouldice and had some concerns. Reading your comments put some things into perspective for me.
    Having to go in the day before surgery and staying 4 nights seemed odd in this day and age.
    I think I am going to stick with a repair by a general surgeon at my local hospital.

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  13. I am debating on having surgery on my right inguinal hernia and whether to do it at Shouldice or at my local hospital. My hernia is very small and only appears after I have been working-out or stand for a long period of time however I have a constant dull pain in the groin area/lower abdomen area (heaviness feeling) My fiancé and I also love to travel and travel insurance seems to be an issue. I am a 36 year old female (very slim and healthy) and hoping to start a family in the near future. My biggest concern is chronic pain and it seems there is a lack of research reporting on chronic pain and pregnancy. Also, I find there is a lack of information on hernias in fertile women and how to treat. I’m left asking the question do I fix it now or after pregnancy? Which method is the best option considering I want to get pregnant? I got three different answers from Shouldice on how long I should wait to try and conceive after surgery (4 weeks, 3 months and 1 year). The general surgeon I seen advised 6 weeks.

    Also, Shouldice website and the doctor I seen reports their procedure is tension-free however from what I read on different techniques the “Shouldice repair” is tension method???Does this matter?

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    1. So this is a tricky situation. Certainly your hernia is symptomatic and should be repaired. I would think you could fix it now and get pregnant right away without worry. I tell women who may get pregnant after a repair that there is a higher risk of recurrence of the hernia because of the stretching of the abdominal wall with pregnancy. Having said that, the risk of recurrence is much higher with umbilical and epigastric hernias in pregnancy than with groin hernias. You are right, there is not a lot of good information for women in your situation. As for tension free vs not, as I said in my blog, standard of care for most institutions is tension free (ie using mesh)

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  14. Can I please get the name of the hospital an hours drive from Shouldice and your name if possible? My father needs a hernia operation. Thank you.

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    1. Mr Dedes- there are many fine surgeons and hospitals in the GTA area which fix hernias. In fact, the vast majority of hospitals would offer hernia repair. I would encourage you to have your father see his family doctor to refer to the hospital and surgeon which are closest to you.

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  15. My son who is 17 years old has an inguinal hernia that needs to be repaired. More and more often, he’s having flare ups where the blood supply to his groin is being blocked. My concern is with the use of mesh on a growing teenage boy. He’s certainly not done growing. Is this a factor?

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    1. So that is a great question. The risks and benefits of mesh should be discussed with a general surgeon. Sounds like he needs a repair, although you don’t need to worry about blood supply usually.

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  16. Thanks for your blog. I have a right side inguinal hernia that needs fixing. I’ve had it for about 1.5 yrs now and because it’s not painful and really just a small bump I’ve not bothered with it until last fall when I saw a local general surgeon about it and scheduled the surgery for May as I go away in the winter. I’m 60 and 5’11” @ 180lbs, so not overweight and in good health. I had the left side done 11 yrs ago @ Shouldice and have had no issues with pain or recurrence and I don’t avoid any activity, including heavy lifting. I’m on the fence with going back to Shouldice or going with the local doctor. I’m about 2hrs from Shouldice. As anybody else, my concern is long term pain or discomfort and recurrence.

    I see that you are anti-Shouldice but wonder how much of that is based on procedure/method and how much is related to you not liking that they get to do only elective and cherry pick. I also saw the ambulance chasing lawyer ads in the US regarding mesh failures.

    Steve

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  17. I had an inguinal hernia repair at Shouldice 4 days ago. I had an inguinal (opposite side) and umbilical hernia repairs done using mesh two years ago. Three surgeries at two different facilities using different techniques – by no means expertise in either technique.

    Having been an aircraft accident investigator I provide this comparison/critique in a strictly evidentiary way based on my experiences and observations from having had both procedures. For personal comparisons I am a 50+ year old male in average/above average health.

    – 2015 surgeries (inguinal, umbilical) performed at local Ottawa hospital by general surgeon, with some specialization in hernia repair. Day surgeries – admitted in the morning released that afternoon. Fully sedated for duration of procedure. Recovery done at home, pain meds prescribed, incisions very tidy, standard sutures, little to no swelling or bruising. Discomfort for 3-4 days but quite tolerable. Ten days after surgery I taught a two week long course requiring standing for 10-12 hours per day and golfed the day after the course. Have no perceptible issues with umbilical repair but under strain do feel some discomfort at the lower end of inguinal repair. Have had it checked and been informed that it is not at the point where a repair is required. Pain is tolerable(sensation of burning/stabbing in groin) that subsides quickly with reduction of effort/strain.
    – Inguinal surgery 4 days ago at Shouldice performed by surgeon with 10,000+ hernia surgeries performed. Standard Shouldice methodology – admitted day before (process long, repetitive, old school “handdraulic” vice electronic). Placed in a room with patient who had surgery the day prior. Standard “rubberized” hospital bed and pillow. Bed manually adjustable by hand crank at foot of bed – not comfortably or easily done post surgery. Poor night’s sleep (roommate having pain, snoring, up through the night for pain meds, temperature check by nurse at some point, etc). Standard and mandatory wake up is 0530 for all. Showered and dressed first thing. First scheduled patients moved to pre-surgery prep. Personally, put in a holding pattern until surgery in the afternoon. Awake and aware during surgery, no pain but the feeling of pressure and intense tugging. Though a significantly smaller hernia than the 2015 inguinal hernia the incision was two inches longer (6″) and the incision was closed by puckering/pinching the skin on either side by 1/4″-5/16″ and secured with stainless steel staples, i.e. 1/2″-5/8″ of flesh mounded above the underlying muscular tissue fix. The staples are removed (one half at a time) over the two following days. This wound closure and stapling technique are a significant source of discomfort and pain for all patients. The collegial environment of you and your co-wounded seems to be a plus for most.

    At this stage I cannot guage the quality or durability of the underlying repair. Following this summer’s logging and landscape work I will report the status of all three repaired hernias.

    At this point I am out $980.00, I am more sore than I was at the same time following two mesh repairs, the in-hospital conditions/regimen were not as conducive to recovery as being at home. In summary, I have to agree with lesmcc1: the technique, the hospital/facility itself, the four day stay, the old equipment, i.e., bed, the wound closure method, etc, all point to a “we have always done it this way” mindset. The rigidity of the program is old school military in nature and does not seem to be keeping pace with evolution. Seventy years of existence can be touted as a measure of success and justification for the status quo – Smith-Corona felt the same way about the typewriter.

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  18. For Michael:Google search “Shouldice hernia failures”. Look for nih data. I think the most recent data is from 2012 and shows a higher failure rate at Shouldice than mesh. I am quite disappointed in myself for not having done a thorough investigation prior to my Shouldice fix. Based on what I know now I wouldn’t do it again.

    As for my health state, today is two weeks and I am still having significant pain from the muscle lump. A tearing feeling (like being stabbed) from bowel movements is prevalent; on the positive side, I had my first pain free sneeze this morning.

    Do your homework and make an informed decision…good luck.

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    1. I did that search, and I’m not sure if I saw exactly what you saw, but yes even though Shouldice method (performed at the Shouldice hospital specifically) has a very low recurrence rate, certainly mesh will have the lowest recurrence rate. It is almost impossible for a hernia to recur through a piece of mesh. This is why mesh is now preferred.
      However there is more to it. Myself, and others who are wary of mesh, are reacting to the very real possibility of chronic severe pain, and other complications like erosion, migration, and neuroma that can come from mesh. There have been many mesh products that have been recalled over the years.
      I haven’t made the decision yet myself, Shouldice or mesh. There are many reasons why mesh is used and many people do fine with it.
      One thing I’ll add, is a problem with the Shouldice technique is that it’s complicated for a surgeon who is not very experienced with it. An article I just read after using your suggested search term called “Inguinal Hernias: A Current Review of an Old Problem” mentions recurrence rate at a specialized center (Shouldice hospital) being 0.7% to 1.7%, but Shouldice technique done at a general hospital with a general surgeon was as high as 15%. I have seen these numbers elsewhere also.
      That is an important distinction.
      I would say you will very likely be fine, I wouldn’t worry about your decision at this point.

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  19. I have put off surgery for four years because of concerns with mesh.

    I can NOT for the life of me understand the following:
    Mesh is known to have a potential side effect of chronic, possibly serious pain, and potential difficult mesh removal later which leaves the person changed for the worse. The rate of this risk varies, you say it is low, but the risk exists. Anecdotal reports from those who have had this problem make it sound like a real living hell.
    Pure tissue technique, according to yourself and other general surgeons, has the risk of recurrence. Meaning the hernia comes back, requiring a second repair.

    Why is recurrence the worst that can happen here? Given the choice, I’d choose a hernia comeback. I have had one for four years and besides some soreness at the end of the day, I am not in constant terrible pain. I feel like patient quality of outcome should be the deciding factor, not just whether the original hernia was handled.
    In addition, in my case I’m 41 and 168 lbs. I seem to be a good candidate for pure tissue. Has mesh been inside anyone for 40-50 years? I don’t think it has been around that long. To me, mesh is the risk here, not hernia recurrence with pure tissue. We know how to fix recurrence, but fixing mesh complications is a difficult procedure.

    Please tell me what I am missing here.

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  20. I had my first one done at Shouldice (10 yrs ago) and no issues with it unless I do a lot of hiking or lifting and then maybe a bit of soreness in the left groin. I’ll lift 100+ pounds while working around the house without thinking about it. I have had a right side inguinal hernia for 1.5 yrs and am scheduled for mesh repair locally end of May (bumped from mid-May). I find it hard to get solid information of one method vs the other, maybe because there really isn’t any. Shouldice would take me again, the surgeon I’m scheduled with said “ideal patient”, all these things mean is low risk for the actual surgery, doesn’t mean it’ll work or not give you issues down the road.

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