explaining the success of an authentic shouldice inguinal

EXPLAINING THE
SUCCESS OF AN
AUTHENTIC SHOULDICE
INGUINAL HERNIA
REPAIR
Dusseldorf, 2 April 2011
MICHAEL A. J. ALEXANDER
MB, BS, FRCSC, FACS, FASAS, FAIS
Chief Surgeon and Chief of Staff
Shouldice Hospital
Ontario, Canada
DISCLOSURE
No conflicts of interest
Dr. Byrnes Shouldice
Recurrence is still
a significant
complication of
hernioplasty
About 13% of the Shouldice
Hospital practice is repairing
recurrent hernias from other
institutions.
This has not changed over the years
in spite of the widespread use
elsewhere of artificial mesh
hernioplasty
What is the
Shouldice
Hernioplasty?
Tissue Repair in the Era of Mesh
Tension is the enemy of
hernia repairs
The Shouldice Repair works
Therefore
Must produce minimal tension
SKELETONISATION OF THE
CORD
Gorilla on the Ground
Gorilla in Tree
DIVIDE CREMASTERICS
•Lower recurrence
rate > 3%
•Enables an
unobstructed view
of the floor
•Simplifies the
repair
•Prevents disruption
of the reconstructed
internal inguinal
ring
Water erosion of Rock 1
Water erosion of Rock 2
INDIRECT SAC/PERITONEAL
PROTRUSION
• Peritoneum always
present on the cord
• Either as an indirect
sac or peritoneal
protrusion
• Peritoneal
protrusion is a
potential indirect
hernia
• Guarantees no
missed hernia at the
internal ring
DIRECT INGUINAL HERNIA
‫٭‬Peritoneal protrusion or sac
‫٭‬Location of direct - bulging
SPLITTING THE
TRANSVERSALIS FASCIA
• Not in children
• Rare in women
• Assures no
missed hernia or
defect
• Enables proper
viewing of tissue
to be sutured
• Space of Bogros
TRANSVERSALIS FASCIA
SPLIT
• Very good tissue
• Thickens
• It is used to enable
strong repair where
most recurrences
occur
• Initiation of repair
FIRST LINE OF THE REPAIR
What layers?
•Transversalis fascia
laterally to edge of
rectus medially
•Deep surface of
triple layer
•Establishing a flap
of tissue medially
FINISHING FIRST LINE OF
THE REPAIR
•Incorporates proximal
stump of cremasteric at
ring
•Replacing a ring with a
cylinder
•What to what?
•Medial flap to:
•Iliopubic tract
•Transversalis fascia
•Shelving border or
inguinal ligament
•Sutures placed deeper
near the bone
•No periosteum
SECOND LINE REPAIR
•Very strong
•Reinforces entire
transversalis
fascia layer
•Floor consists of
two layers not
one
THIRD LINE REPAIR
•Replaces external
oblique
•Particular attention
near bone
•Completes 3 layer
repair
FOURTH LINE
‫٭‬Continues replacement of external oblique
‫٭‬Forms flap to cover cord
‫٭‬Secures direct site of recurrence
‫٭‬Finalizes internal tube (ostomy) formation
RETURN CORD TO ANATOMICAL
POSITION
‫٭‬Incorporate distal stump of cremasteric
‫٭‬External ring loose - fascia
The Evolution of
Structural
Building
Techniques
Mud Brick Huts
“You are no longer to supply
the people with straw for
making bricks; let them go
and gather their own straw”
Pharaoh speaking to the slave
drivers of the israelite slaves
The Bible, Old Testament
EXODUS 5:7
Straw Reinforced Brick 1
Straw Reinforced Brick 2
Ziggurats
Walls of Jericho collapse
What happened to the Walls of
Jericho?
Walls of Jericho Today
Roman concrete Wall (detail)
Roman Structures
Roman Aqueduct
Skyscrapers
Reinforced Concrete
Burj Dubai Tower
Burj Dubai tower
WHY THE SHOULDICE REPAIR
WORKS 1
Hernia is a Biological, Metabolic Disease (Herniosis)
Wound Healing depends on Balance of
 Collagen Degradation
 Collagen Synthesis
Type I Collagen - STRONG (cross-linked)
Type III Collagen - WEAK (few cross linkages)
Normal Ratio I:III = 4:1
Hernia Patients from 1:1 to 1:3
Type III Collagen is Precursor of Type I
WHY THE SHOULDICE REPAIR
WORKS 2
Transversalis Fascia
 High in Protease Enzymes
 Very high Metabolic rate
Inguinal Ligament and Lateral Rectus Border
 Low in Protease Enzymes
 Low Metabolic rate
WHY THE SHOULDICE REPAIR
WORKS 3
An AUTHENTIC Shouldice INGUINAL Hernia
repair utilizes both
The Inguinal Ligament
And
The LATERAL Border of the Rectus Abdominis
This greatly reduces the BIOLOGIC role in failure
Relies instead on Mechanical Factors
 Strong Sutures
 Permanent Suture Material
 Good Surgical Technique
WHY THE SHOULDICE REPAIR
WORKS 4 (Construction analogy)
SUPERIOR BUILDING TECHNIQUE FOR
STRUCTURES
 Cement plus steel rod skeleton (rebar)
 REINFORCED CONCRETE
SHOULDICE TECHNIQUE
 Collagen plus permanent suture LATTICEWORK
(monofilament stainless steel wire)
 REINFORCED COLLAGEN (even in the presence of
large amounts of weak Type III collagen) (straw, rebar)
Showing Construction Analogy
Reinforced collagen
diaphragm in the posterior
inguinal wall
Reinforced concrete wall
In hernia repair
MESH
replaces a weakened area of
the abdominal wall
with a strong diaphragm-like
structure
or a plug
The Shouldice Inguinal
Hernioplasty
may be the first
Tension-free
Mesh-like repair
customized for individual patients
Artificial mesh repairs
were developed to
address problems not
common with the
Shouldice inguinal
hernioplasty
OPTIMIZE TISSUES FOR
REPAIR
Fatty infiltration weakens muscle
 If obese. Lose weight on low carbohydrate diet
Rapidly metabolizing tissue unsuitable for
repair
 If recurrent. Wait 1 year for repeat surgery
Follow-up Routine
After initial discharge examinations
Patients divided into COHORTS by
calendar year January – December
Attempts made to contact each patient
once a year for life
Each cohort followed as a group
Entire patient population also followed
3 of the initial 1945 cohort of 298 are still
alive and being followed
Shouldice Follow-up
Lifetime follow-up attempted
Lifetime exams. - free to patient
Questionnaire sent yearly to patient
Fee once yearly to any Physician in the
world for a Report
Recurrence redone at no charge to patient
96 % of procedures at the
Shouldice Hospital are performed
under conscious sedation and using
local infiltration anaesthesia
This greatly reduces the incidence of
systemic complications
Shouldice Complications 1994
as of 28 February 2011
6,393 Groin operations
 Superficial infections
 Hydroceles
 Testicular atrophy
 Recurrences



0.27%
0.7%
0.1%
0.76%
No pulmonary, urinary, intra-abdominal problems
No persistent testicular, or transient or persistent leg
pain
SHOULDICE PAIN
PROBLEMS
1990
7,159 operations performed
Followed up to 31 Dec. 1993
(36 month follow up in >85% of patients)
22 pain problems
-0.3%
2 required intervention - 0.03%
Randomized Controlled Trials
and The Shouldice Technique
In trying to obtain informed consent for such
studies, the known good results of the
Shouldice Technique have to be disclosed
to the prospective patient
Since these can hardly be improved upon,
patients are reluctant to participate in case
they end up in the non-Shouldice cohort
RCT were done at the onset 1946-1952, in
developing the technique and culminating in
the ongoing high success rates
Shouldice Recs. % Overall - 1.11%
340,931 Hernia repairs.
3,783 have recurred over the past 65 years
As of 31 December 2010
25.00
20.00
%
15.00
10.00
5.00
0.00
YEAR
BEWARE!
It takes >20 years
for recurrence rates to
stabilize
The Shouldice Business Model
The Shouldice Hospital is also a business
No business can continue unless most of
its customers remain satisfied
We continue to perform 140 operations a
week
There are 700 surgeons in Ontario,
Canada performing 23,000 hernia
operations annually with 10 surgeons at
the Shouldice Hospital doing 7,000 of
these
Business Model 2
The hospital has operated on patients
from 104 different countries of the world
Physicians, chiropractors, nurses and
other personnel connected to the medical
field continue to form a fair number of our
patients
There are at present over 1,500 people on
our waiting list for surgery
Equipment for repair
Shouldice Efficiency

Cost of all medical supplies used/year
– surgical supplies, drugs, dressings etc.
Divided by total number of patients
managed
 = C$ 30.00 or Eur 22.00 per patient

THANK YOU!
DANKE
SCHÖN!